NIV Congres

Moderator:
Mw. dr. H.A.H. Kaasjager, Arnhem

Panelleden
Mw. dr. P.C. Oldenburg, Amersfoort
Mw. W.E.M. Schouten, Amsterdam
Dr. F.L.J. Visseren, Utrecht

Introduction: Digital rectal examination (DRE) is traditionally recommended to evaluate patients with abdominal pain. This recommendation is based on the theory that DRE irritates the inflamed peritoneum and thus helps to distinguish serious from non-serious causes of abdominal pain. Even some well-known and highly respected textbooks (recent versions included) proclaim that DRE is mandatory in every patient with abdominal pain.[1] Because DRE is (meant to be) part of the standard physical examination, we often forget that DRE is considered (very) inconvenient by many patients (and doctors), especially in the emergengy department, where an atmosphere needed for mutual trust cannot easily be built up.[2,3,4]

There is reasonable doubt about the use of DRE and in this time of evidence based medicine (EBM) we already excluded DRE to be part of standard physical examination in children, because of discomfort and disappointing diagnostic value.[5] Why do we not apply EBM to adults?

Because there is a continuing and lively debate on this topic, we wanted to end this discussion for once and for all at the 2013 Internistendagen. We investigated the diagnostic utility of DRE for abdominal pain and assessed its necessity.

Clinical Question: Is DRE indicated in every patient with abdominal pain in the emergency department?

This clinical question was critically appraised using the following PICO:

- Patient: Patients in the emergency department presenting with abdominal pain.

- Intervention: Performing DRE.

- Control: Not performing DRE.

- Outcome: 1) Diagnostic value of DRE in differentiating between causes of abdominal pain, 2) DRE leading to correct decisions in the diagnostic process.

Search strategy: A literature search of PubMed was performed. Search terms were: Digital Rectal Examination AND Abdominal pain. There were 13 hits and after screening abstracts and titles, 6 articles seemed useful to answer the clinical questions.

Results: Concerning the diagnostic value of DRE in the assessment of right lower quadrant abdominal pain, Bonello et al. retrospectively showed low predictive values (PPV =  0.43, NPV = 0.50) for DRE in diagnosing appendicitis. DRE was considered positive if there was generalized rectal tenderness when performing DRE. Appendicitis was diagnosed during surgery. They also showed that the positive predicitive value of DRE was only 0.48 when performed in patients with appendiceal perforation.[6]

Likewise, Sedlak et al. found low predictive values (PPV = 0.45 (95% CI 0.39-0.50), NP V= 0.54 (95% CI 0.51-0.57)) and odds ratio (OR = 0.95) for positive DRE in diagnosing appendicitis in a group of patients admitted to the emergency department with pain in the right-lower-quadrant of the abdomen.[7]

Dixon et al. showed approximately the same odds ratios for positive DRE (OR = 1.03 when generalized rectal tenderness on DRE and OR = 1.34 when right-sided rectal tenderness on DRE) in a prospective study diagnosing appendicitis in adults. They included 1028 consecutive patients admitted to hospital with pain in the right lower quadrant of the abdomen. Patients were assessed by a surgeon. The odds ratios for the findings right-lower-quadrant pain (OR = 5.09), guarding (OR = 3.07), rebound tenderness (OR = 3.34) and abdominal rigidity (OR = 5.03) however, were much higher and thus of more diagnostic value than DRE.[8]

Concerning the diagnostic value of DRE in undifferentiated abdominal pain Quaas et al. prospectively studied the use of DRE in the emergency department to determine its value in decision making.[9] In total, 528 DREs were performed of which 494 (92%) were classified as not being useful. The remaining 8% of all DREs were just as often classified as helpful (= indicating correct diagnosis) as harmful (= indicating incorrect diagnosis or rejecting correct diagnosis).

Likewise, Manimaran et al. prospectively showed that DRE did not change the diagnostic process or initial management of acute abdominal pain in 100/100 consecutive patients referred to the emergency surgical unit. Additionally, DRE did not reveal any other (unrelated) pathology, colorectal cancer in particular.[4]

The above-mentioned studies were elegantly reviewed in three studies, all of which came to the same conclusion as we: DRE in patients with acute abdominal pain does not add to or aid in diagnosing appendicitis and peritonitis.[3,10,11]

Conclusion: DRE is of very little use in diagnosing appendicitis. Additionally, DRE does not play a role in differentiating between causes of undifferentiated abdominal pain. The above- summarized studies also show that DRE only rarely changes the diagnostic process, and if so, it seems to be as potentially helpful as harmful.

Appraising these studies and weighing the certainly present discomfort for both patient and doctor caused by DRE, we plead against routine DRE in people with abdominal pain and thus DRE should not be used as a diagnostic or decisive instrument in the assessment of abdominal pain at the emergency department.

References

1. Kasper DL, et al. Harrison’s principles of internal medicine (18th ed.). New York: McGraw-Hill Medical Publishing Division. 2011. ISBN 978-0-07-1748896.
2. Macias DJ, et al. Male discomfort during the digital rectal examination: does examiner gender make a difference? Am J Emerg Med. 2000;18:676-8.
3. Werner J, et al. Sinnhaftigkeit der digital-rektalen untersuchung bei akutem abdomen in der notfallaufnahme. Zentralbl Chir. 2011:5.
4. Manimaran N, et al. Significance of routine digital rectal examination in adults presenting with abdominal pain. Ann R Coll Surg Engl. 2004;86:292-5.
5. Naheed N. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: digital rectal exams in children who present with constipation. Emerg med J. 2010;27:394-5.
6. Bonello JC, et al. The significance of a “positive”rectal examination in acute appendicitis. Dis Colon Rectum. 1979;22:97-101.
7. Sedlak M, et al. Is there still a role for rectal examination in suspected appendicitis in adults? Am J Emerg Med. 2008;26:359-60.
8. Dixon JM, et al. Rectal examination in patients with pain in the right lower quadrant of the abdomen. BMJ. 1991;302:386-388.
9. Quaas J, et al. Utility of the digital rectal examination in the evaluation of undifferentiated abdominal pain. Am J Emerg Med. 2009;27:1125-9.
10. Moll van Charante EP, et al. Physical examination of patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2011;155:A2658.
11. Kessler C, et al. Utility of the digital rectal examination in the emergency department: A review. J Emerg Med. 2012:7.