Does sequential balloon expulsion test improve the screening of defecation disorders?
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RESEARCH ARTICLE
Does sequential balloon expulsion test improve the screening of defecation disorders? A. C. Caetano1,2,3* , D. Costa1,2,3, R. Gonçalves1, J. Correia‑Pinto2,3 and C. Rolanda1,2,3
Abstract Background: A defecation disorder (DD) is a difficulty in evacuation documented by physiological exams. However, this physiological evaluation can be cumbersome, inaccessible and costly. Three “low-cost” tools to evaluate DD—a clinical DD score, the balloon expulsion test (BET) and a digital rectal examination (DRE) score were evaluated as sepa‑ rate or combined tests for DD screening. Methods: This prospective study occurred between January 2015 and March 2019 in the Gastroenterology Depart‑ ment of a tertiary hospital. Besides the gold standard physiological tests, constipated patients answered the clinical DD score and were evaluated by DRE and BET [standard and variable volume (VV)]. Results: From 98 constipated patients, 35 (38.9%) were diagnosed with DD according to Rome IV criteria, mainly female (n = 30, 86%) with a median age of 60 years old. The clinical DD score revealed an AUC of 0.417 (SE = 0.07, p = 0.191). The DRE score displayed an AUC of 0.56 (SE = 0.063, p = 0.301). The standard BET displayed a sensitivity of 86%, specificity of 58%, positive predictive value (PPV) of 57% and negative predictive value (NPV) of 86%. The sequential VVBET followed by standard BET improved the BET performance regarding the evaluation of DD, with a sensitivity of 86%, specificity of 67%, PPV of 63% and NPV of 87%. The sequential BET had an OR 8.942, p > 0.001, CI 3.18–25.14, revealing to be the most significant predictor for DD screening. Conclusion: The sequential BET is a low cost, well-performing DD screening tool, appropriate to the Primary Care Setting. Keywords: Constipation, Defecation disorders, Low-cost tools Background A defecation disorder (DD) is defined as a difficulty in evacuation or emptying the rectum. DD may result from impaired anorectal function or rectal structural disturbances in patients with complaints of Chronic Constipation (CC) [1–3]. DD was recently defined by the Rome IV criteria, based on symptoms and objective physiological criteria—Table 1 [4, 5]. Therefore, the diagnosis of DD is established when a patient with functional chronic *Correspondence: [email protected] 1 Department of Gastroenterology, Hospital of Braga, Sete Fontes – São Victor, 4710‑243 Braga, Portugal Full list of author information is available at the end of the article
constipation (CC) or irritable bowel syndrome with constipation (IBS-C) has impaired evacuation as demonstrated by 2 of 3 types of tests—balloon expulsion test (BET); imaging (conventional defecography, dynamic ultrasound or dynamic magnetic resonance); anorectal manometry (ARM) or electromiography (EMG). This physiological evaluation is not always easily accessible, moreover it can be long and costly [3, 6, 7]. American studies report costs of healthcare utilization for CC as high as 500 dollars-patient-year while the exac
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