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{{Constipation}}
{{Constipation}}
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==Overview==
==Overview==
An [[abdominal X-ray]] may be helpful in the [[diagnosis]] of constipation. Findings on an [[X-ray]] suggestive of constipation is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems. Barr scoring system is the first scoring method used to interpret [[abdominal X-ray]] suggestive of constipation. The total score of more than 10 was postulated as [[diagnosis]] of constipation. The revised scoring system of Blethyn (simplified version of Barr scoring system) is based on the amount of remained [[feces]] in [[large bowel]]. The Blethyn scoring system consists of 4 grades of [[fecal]] retention in [[bowels]]. The most progressed and organized scoring system for diagnosis of constipation is Leech method. The score of more than 8 is considered as constipation.
An [[abdominal X-ray]] may be helpful in the [[diagnosis]] of constipation. Findings on an [[X-ray]] suggestive of constipation is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems. Barr scoring system is the first scoring method used to interpret [[abdominal X-ray]] suggestive of constipation. The total score of more than 10 was postulated as [[diagnosis]] of constipation. The revised scoring system of Blethyn (a simplified version of Barr scoring system) is based on the amount of remained [[feces]] in [[large bowel]]. The Blethyn scoring system consists of 4 grades of [[fecal]] retention in [[bowels]]. The most studies and organized scoring system for diagnosis of constipation is Leech method. The score of more than 8 is considered as constipation.


==Abdominal X-ray==
==Abdominal X-ray==
*An [[abdominal X-ray]] may be helpful in the [[diagnosis]] of constipation.  
{| align="right"
*Findings on an [[X-ray]] suggestive of constipation is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems.
|{{#ev:youtube|UboRPFBZ9rE|500}}
|}
*An [[abdominal X-ray]] may be helpful in the [[diagnosis]] of constipation. The most common method to [[diagnose]] constipation is using Sitzmarks®.  
*Findings on an [[X-ray]] suggestive of constipation in children is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems.
 
 
=== Sitzmarks ===
* Sitzmarks are [[Radio-opaque|radioopaque]] markers which are plastic beads or rings are been contained in a edible [[capsule]].
* There are 20-50 rings in each [[capsule]]. There are two methods of [[diagnosis]]:
** Serial [[Abdominal X-ray|abdominal X-rays]] are taken after ingestion of the Sitzmarks [[capsule]], until all the rings become cleared from [[bowels]].
** Single [[abdominal X-ray]] on the day 5 (after 120 hours) ['''preferred method due to less [[radiation]] exposure'''].
* On the day 5, more than 20% of markers remaining within [[bowels]] is diagnostic of delayed colonic transit.<ref name="pmid22323993">{{cite journal| author=Kim ER, Rhee PL| title=How to interpret a functional or motility test - colon transit study. | journal=J Neurogastroenterol Motil | year= 2012 | volume= 18 | issue= 1 | pages= 94-9 | pmid=22323993 | doi=10.5056/jnm.2012.18.1.94 | pmc=3271260 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22323993  }}</ref>
<br>
<br>


{| align="right"
|[[image:Constipation-with-sitz-markers.jpg|thumb|350px|Constipation with Sitzmarks-Case courtesy of Dr Matt A. Morgan, via Radiopaedia.org<ref name="https://radiopaedia.org/">Radiopaedia.org. From the case <"https://radiopaedia.org/cases/37754">rID: 37754</ref>]]
|}
=== Barr scoring system ===
=== Barr scoring system ===
* Barr scoring system is the first scoring method used to interpret [[abdominal X-ray]] suggestive of constipation.
* Barr scoring system is the first scoring method used to interpret [[abdominal X-ray]] suggestive of constipation.
* The main identifier in Barr system is [[stool]] retention severity in [[bowels]] seen on [[abdominal X-ray]].
* The main identifier in Barr system is [[stool]] retention severity in [[bowels]] seen on [[abdominal X-ray]].
* The total score of more than 10 was postulated as [[diagnosis]] of constipation.<ref name="pmid498690">{{cite journal |vauthors=Barr RG, Levine MD, Wilkinson RH, Mulvihill D |title=Chronic and occult stool retention: a clinical tool for its evaluation in school-aged children |journal=Clin Pediatr (Phila) |volume=18 |issue=11 |pages=674, 676, 677–9, passim |year=1979 |pmid=498690 |doi=10.1177/000992287901801103 |url=}}</ref>
* The total score of more than 10 was postulated as [[diagnosis]] of constipation.<ref name="pmid498690">{{cite journal |vauthors=Barr RG, Levine MD, Wilkinson RH, Mulvihill D |title=Chronic and occult stool retention: a clinical tool for its evaluation in school-aged children |journal=Clin Pediatr (Phila) |volume=18 |issue=11 |pages=674, 676, 677–9, passim |year=1979 |pmid=498690 |doi=10.1177/000992287901801103 |url=}}</ref>
{| class="wikitable"
{|
!Scoring elements
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring elements
!Scores
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scores
|-
|-
|The quantity of [[stool]] in [[ascending colon]]  
| style="background:#DCDCDC;" align="center" + |The quantity of [[stool]] in [[ascending colon]]  
|0-1-2 points
| style="background:#F5F5F5;" align="center" + |0-1-2 points
|-
|-
|The quantity of [[stool]] in [[transverse colon]]  
| style="background:#DCDCDC;" align="center" + |The quantity of [[stool]] in [[transverse colon]]  
|0-2-5 points
| style="background:#F5F5F5;" align="center" + |0-2-5 points
|-
|-
|The quantity of [[stool]] in [[descending colon]]  
| style="background:#DCDCDC;" align="center" + |The quantity of [[stool]] in [[descending colon]]  
|0-3-4 points
| style="background:#F5F5F5;" align="center" + |0-3-4 points
|-
|-
|The quantity of [[stool]] in [[rectum]]
| style="background:#DCDCDC;" align="center" + |The quantity of [[stool]] in [[rectum]]
|0-2-5 points
| style="background:#F5F5F5;" align="center" + |0-2-5 points
|-
|-
|The quality of the retained [[stool]] is expressed in scybala
| style="background:#DCDCDC;" align="center" + |The quality of the retained [[stool]] is expressed in scybala
|0-1-2-3 points
| style="background:#F5F5F5;" align="center" + |0-1-2-3 points
|-
|-
|The quality of the retained [[stool]] is expressed in granular [[feces]]
| style="background:#DCDCDC;" align="center" + |The quality of the retained [[stool]] is expressed in granular [[feces]]
|0-2-4-5 points
| style="background:#F5F5F5;" align="center" + |0-2-4-5 points
|}
|}


Line 40: Line 56:
* The revised scoring system of Blethyn (simplified version of Barr scoring system) is based on the amount of remained [[feces]] in [[large bowel]].
* The revised scoring system of Blethyn (simplified version of Barr scoring system) is based on the amount of remained [[feces]] in [[large bowel]].
* The Blethyn scoring system consists of 4 grades of [[fecal]] retention in [[bowels]].<ref name="pmid8546512">{{cite journal |vauthors=Blethyn AJ, Verrier Jones K, Newcombe R, Roberts GM, Jenkins HR |title=Radiological assessment of constipation |journal=Arch. Dis. Child. |volume=73 |issue=6 |pages=532–3 |year=1995 |pmid=8546512 |pmc=1511442 |doi= |url=}}</ref>
* The Blethyn scoring system consists of 4 grades of [[fecal]] retention in [[bowels]].<ref name="pmid8546512">{{cite journal |vauthors=Blethyn AJ, Verrier Jones K, Newcombe R, Roberts GM, Jenkins HR |title=Radiological assessment of constipation |journal=Arch. Dis. Child. |volume=73 |issue=6 |pages=532–3 |year=1995 |pmid=8546512 |pmc=1511442 |doi= |url=}}</ref>
{| class="wikitable"
{|
!Scoring element
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring element
!Grade
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Grade
!Constipation severity
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Constipation severity
|-
|-
|''F''eces in [[rectum]] and [[caecum]] only
| style="background:#DCDCDC;" align="center" + |''F''eces in [[rectum]] and [[caecum]] only
|0
| style="background:#F5F5F5;" align="center" + |0
|Normal
| style="background:#F5F5F5;" align="center" + |Normal
|-
|-
|Feces in [[rectum]] and [[caecum]] and discontinuous elsewhere
| style="background:#DCDCDC;" align="center" + |Feces in [[rectum]] and [[caecum]] and discontinuous elsewhere
|1
| style="background:#F5F5F5;" align="center" + |1
|Mild
| style="background:#F5F5F5;" align="center" + |Mild
|-
|-
|Feces in [[rectum]] and [[caecum]], continuous and affecting all segments
| style="background:#DCDCDC;" align="center" + |Feces in [[rectum]] and [[caecum]], continuous and affecting all segments
|2
| style="background:#F5F5F5;" align="center" + |2
|Moderate
| style="background:#F5F5F5;" align="center" + |Moderate
|-
|-
|Feces in [[rectum]] and [[caecum]], continuous elsewhere and dilated [[colon]] and impacted [[rectum]]
| style="background:#DCDCDC;" align="center" + |Feces in [[rectum]] and [[caecum]], continuous elsewhere and dilated [[colon]] and impacted [[rectum]]
|3
| style="background:#F5F5F5;" align="center" + |3
|Severe
| style="background:#F5F5F5;" align="center" + |Severe
|}
 
{| align="right"
|[[image:Leech scoring areas.jpg|thumb|350px|Leech scoring areas-By Mikael Häggström and Nevit Dilmen, via Wikimedia Commons<ref name="https://creativecommons.org/licenses/by-sa/3.0"><CC BY-SA 3.0> <"https://commons.wikimedia.org/wiki/File%3ALeech_scoring_areas.jpg"></ref>]]
|}
|}
{|align:"right"
|[[image:Leech scoring areas.jpg|thumb|350px|Leech scoring areas-By Mikael Häggström and Nevit Dilmen, via Wikimedia Commons<ref name="https://creativecommons.org/licenses/by-sa/3.0">CC BY-SA 3.0> <"https://commons.wikimedia.org/wiki/File%3ALeech_scoring_areas.jpg"></ref>]]


=== Leech scoring system ===
=== Leech scoring system ===
*The most progressed and organized scoring system for diagnosis of constipation is Leech method.
*The most studied and organized scoring system for diagnosis of constipation is Leech method.
*Leech divided the [[colon]] to 3 different regions in plain [[abdominal X-ray]], include:
*Leech divided the [[colon]] to 3 different regions in plain [[abdominal X-ray]], include:
*#[[Ascending colon]] and proximal [[transverse colon]]
*#[[Ascending colon]] and proximal [[transverse colon]]
Line 71: Line 89:
*#Rectosigmoid
*#Rectosigmoid
*The scoring is based on the amount of [[feces]] remained in each section (0-5 points).
*The scoring is based on the amount of [[feces]] remained in each section (0-5 points).
*The score of more than 8 is considered as constipation.<ref name="pmid10199902">{{cite journal |vauthors=Leech SC, McHugh K, Sullivan PB |title=Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children |journal=Pediatr Radiol |volume=29 |issue=4 |pages=255–8 |year=1999 |pmid=10199902 |doi=10.1007/s002470050583 |url=}}</ref>
*The score of more than 8 is considered as diagnostic of constipation.<ref name="pmid10199902">{{cite journal |vauthors=Leech SC, McHugh K, Sullivan PB |title=Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children |journal=Pediatr Radiol |volume=29 |issue=4 |pages=255–8 |year=1999 |pmid=10199902 |doi=10.1007/s002470050583 |url=}}</ref>
{| class="wikitable"
{|
!Scoring element
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring element
!Scores
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scores
|-
| style="background:#DCDCDC;" align="center" + |No [[feces]] visible
| style="background:#F5F5F5;" align="center" + |0
|-
| style="background:#DCDCDC;" align="center" + |Scanty [[feces]] visible
| style="background:#F5F5F5;" align="center" + |1
|-
| style="background:#DCDCDC;" align="center" + |Mild [[fecal]] loading
| style="background:#F5F5F5;" align="center" + |2
|-
| style="background:#DCDCDC;" align="center" + |Moderate [[fecal]] loading
| style="background:#F5F5F5;" align="center" + |3
|-
| style="background:#DCDCDC;" align="center" + |Severe [[fecal]] loading
| style="background:#F5F5F5;" align="center" + |4
|-
| style="background:#DCDCDC;" align="center" + |Severe [[fecal]] loading with [[bowel]] dilatation
| style="background:#F5F5F5;" align="center" + |5
|}
=== Sensitivity and specificity ===
*[[Sensitivity]] and [[specificity]] of scoring systems for diagnosing constipation are as following:
{|
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Author
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Year
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring system
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Sensitivity (%)
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Specificity (%)
|-
| style="background:#DCDCDC;" align="center" + |Barr<ref name="pmid498690" />
| style="background:#F5F5F5;" align="center" + |1979
| style="background:#F5F5F5;" align="center" + |Barr
| style="background:#F5F5F5;" align="center" + |80
| style="background:#F5F5F5;" align="center" + |90
|-
|-
|No [[feces]] visible
| style="background:#DCDCDC;" align="center" + |Leech<ref name="pmid10199902" />
|0
| style="background:#F5F5F5;" align="center" + |1999
| style="background:#F5F5F5;" align="center" + |Leech
| style="background:#F5F5F5;" align="center" + |76
| style="background:#F5F5F5;" align="center" + |75
|-
|-
|Scanty [[feces]] visible
| style="background:#DCDCDC;" align="center" + |Benninga<ref name="pmid7607277">{{cite journal |vauthors=Benninga MA, Büller HA, Staalman CR, Gubler FM, Bossuyt PM, van der Plas RN, Taminiau JA |title=Defaecation disorders in children, colonic transit time versus the Barr-score |journal=Eur. J. Pediatr. |volume=154 |issue=4 |pages=277–84 |year=1995 |pmid=7607277 |doi= |url=}}</ref>
|1
| style="background:#F5F5F5;" align="center" + |1995
| style="background:#F5F5F5;" align="center" + |Barr
| style="background:#F5F5F5;" align="center" + |60
| style="background:#F5F5F5;" align="center" + |43
|-
|-
|Mild [[fecal]] loading
| style="background:#DCDCDC;" align="center" + |Beckmann<ref name="pmid11315444">{{cite journal |vauthors=Beckmann KR, Hennes H, Sty JR, Walsh-Kelly CM |title=Accuracy of clinical variables in the identification of radiographically proven constipation in children |journal=WMJ |volume=100 |issue=1 |pages=33–6 |year=2001 |pmid=11315444 |doi= |url=}}</ref>
|2
| style="background:#F5F5F5;" align="center" + |2001
| style="background:#F5F5F5;" align="center" + |Barr
| style="background:#F5F5F5;" align="center" + |77
| style="background:#F5F5F5;" align="center" + |35
|-
|-
|Moderate [[fecal]] loading
| style="background:#DCDCDC;" align="center" + |Pensabene<ref name="pmid20453675">{{cite journal |vauthors=Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S |title=Lack of utility of abdominal x-rays in the evaluation of children with constipation: comparison of different scoring methods |journal=J. Pediatr. Gastroenterol. Nutr. |volume=51 |issue=2 |pages=155–9 |year=2010 |pmid=20453675 |pmc=2910825 |doi=10.1097/MPG.0b013e3181cb4309 |url=}}</ref>
|3
| style="background:#F5F5F5;" align="center" + |2010
| style="background:#F5F5F5;" align="center" + |Leech
| style="background:#F5F5F5;" align="center" + |57
| style="background:#F5F5F5;" align="center" + |74
|-
|-
|Severe [[fecal]] loading
| rowspan="3" style="background:#DCDCDC;" align="center" + |Rezazadeh<ref name="REZAZADEHJAVAHERIZADEH2016">{{cite journal|last1=REZAZADEH|first1=Afshin|last2=JAVAHERIZADEH|first2=Hazhir|last3=CHAHARDAHCHERIK|first3=Farzaneh|last4=YAVARAHMADI|first4=Mohammad Hossein|last5=SADJADEI|first5=Nooshin|last6=TAHMASEBI|first6=Morteza|title=RELIABILITY OF BARR, LEECH, AND BLETHYN SCORE IN USING OF PLAIN RADIOGRAPHY IN DETERMINING FECAL IMPACTION IN CHILDREN WITH AND WITHOUT CONSTIPATION|journal=Arquivos de Gastroenterologia|volume=53|issue=3|year=2016|pages=141–145|issn=0004-2803|doi=10.1590/S0004-28032016000300004}}</ref>
|4
| rowspan="3" style="background:#F5F5F5;" align="center" + |2014
| style="background:#F5F5F5;" align="center" + |Barr
| style="background:#F5F5F5;" align="center" + |83
| style="background:#F5F5F5;" align="center" + |79
|-
|-
|Severe [[fecal]] loading with [[bowel]] dilatation
| style="background:#F5F5F5;" align="center" + |Leech
|5
| style="background:#F5F5F5;" align="center" + |92
| style="background:#F5F5F5;" align="center" + |80
|-
| style="background:#F5F5F5;" align="center" + |Blethyn
| style="background:#F5F5F5;" align="center" + |79
| style="background:#F5F5F5;" align="center" + |92
|}
|}
<br>
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 21:07, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

An abdominal X-ray may be helpful in the diagnosis of constipation. Findings on an X-ray suggestive of constipation is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems. Barr scoring system is the first scoring method used to interpret abdominal X-ray suggestive of constipation. The total score of more than 10 was postulated as diagnosis of constipation. The revised scoring system of Blethyn (a simplified version of Barr scoring system) is based on the amount of remained feces in large bowel. The Blethyn scoring system consists of 4 grades of fecal retention in bowels. The most studies and organized scoring system for diagnosis of constipation is Leech method. The score of more than 8 is considered as constipation.

Abdominal X-ray

UboRPFBZ9rE|500}}
  • An abdominal X-ray may be helpful in the diagnosis of constipation. The most common method to diagnose constipation is using Sitzmarks®.
  • Findings on an X-ray suggestive of constipation in children is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems.


Sitzmarks

  • Sitzmarks are radioopaque markers which are plastic beads or rings are been contained in a edible capsule.
  • There are 20-50 rings in each capsule. There are two methods of diagnosis:
  • On the day 5, more than 20% of markers remaining within bowels is diagnostic of delayed colonic transit.[1]



Constipation with Sitzmarks-Case courtesy of Dr Matt A. Morgan, via Radiopaedia.org[2]

Barr scoring system

  • Barr scoring system is the first scoring method used to interpret abdominal X-ray suggestive of constipation.
  • The main identifier in Barr system is stool retention severity in bowels seen on abdominal X-ray.
  • The total score of more than 10 was postulated as diagnosis of constipation.[3]
Scoring elements Scores
The quantity of stool in ascending colon 0-1-2 points
The quantity of stool in transverse colon 0-2-5 points
The quantity of stool in descending colon 0-3-4 points
The quantity of stool in rectum 0-2-5 points
The quality of the retained stool is expressed in scybala 0-1-2-3 points
The quality of the retained stool is expressed in granular feces 0-2-4-5 points

Blethyn scoring system

  • The revised scoring system of Blethyn (simplified version of Barr scoring system) is based on the amount of remained feces in large bowel.
  • The Blethyn scoring system consists of 4 grades of fecal retention in bowels.[4]
Scoring element Grade Constipation severity
Feces in rectum and caecum only 0 Normal
Feces in rectum and caecum and discontinuous elsewhere 1 Mild
Feces in rectum and caecum, continuous and affecting all segments 2 Moderate
Feces in rectum and caecum, continuous elsewhere and dilated colon and impacted rectum 3 Severe
Leech scoring areas-By Mikael Häggström and Nevit Dilmen, via Wikimedia Commons[5]

Leech scoring system

Scoring element Scores
No feces visible 0
Scanty feces visible 1
Mild fecal loading 2
Moderate fecal loading 3
Severe fecal loading 4
Severe fecal loading with bowel dilatation 5

Sensitivity and specificity

Author Year Scoring system Sensitivity (%) Specificity (%)
Barr[3] 1979 Barr 80 90
Leech[6] 1999 Leech 76 75
Benninga[7] 1995 Barr 60 43
Beckmann[8] 2001 Barr 77 35
Pensabene[9] 2010 Leech 57 74
Rezazadeh[10] 2014 Barr 83 79
Leech 92 80
Blethyn 79 92

References

  1. ↑ Kim ER, Rhee PL (2012). "How to interpret a functional or motility test - colon transit study". J Neurogastroenterol Motil. 18 (1): 94–9. doi:10.5056/jnm.2012.18.1.94. PMC 3271260. PMID 22323993.
  2. ↑ Radiopaedia.org. From the case <"https://radiopaedia.org/cases/37754">rID: 37754
  3. ↑ 3.0 3.1 Barr RG, Levine MD, Wilkinson RH, Mulvihill D (1979). "Chronic and occult stool retention: a clinical tool for its evaluation in school-aged children". Clin Pediatr (Phila). 18 (11): 674, 676, 677–9, passim. doi:10.1177/000992287901801103. PMID 498690.
  4. ↑ Blethyn AJ, Verrier Jones K, Newcombe R, Roberts GM, Jenkins HR (1995). "Radiological assessment of constipation". Arch. Dis. Child. 73 (6): 532–3. PMC 1511442. PMID 8546512.
  5. ↑ <CC BY-SA 3.0> <"https://commons.wikimedia.org/wiki/File%3ALeech_scoring_areas.jpg">
  6. ↑ 6.0 6.1 Leech SC, McHugh K, Sullivan PB (1999). "Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children". Pediatr Radiol. 29 (4): 255–8. doi:10.1007/s002470050583. PMID 10199902.
  7. ↑ Benninga MA, Büller HA, Staalman CR, Gubler FM, Bossuyt PM, van der Plas RN, Taminiau JA (1995). "Defaecation disorders in children, colonic transit time versus the Barr-score". Eur. J. Pediatr. 154 (4): 277–84. PMID 7607277.
  8. ↑ Beckmann KR, Hennes H, Sty JR, Walsh-Kelly CM (2001). "Accuracy of clinical variables in the identification of radiographically proven constipation in children". WMJ. 100 (1): 33–6. PMID 11315444.
  9. ↑ Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S (2010). "Lack of utility of abdominal x-rays in the evaluation of children with constipation: comparison of different scoring methods". J. Pediatr. Gastroenterol. Nutr. 51 (2): 155–9. doi:10.1097/MPG.0b013e3181cb4309. PMC 2910825. PMID 20453675.
  10. ↑ REZAZADEH, Afshin; JAVAHERIZADEH, Hazhir; CHAHARDAHCHERIK, Farzaneh; YAVARAHMADI, Mohammad Hossein; SADJADEI, Nooshin; TAHMASEBI, Morteza (2016). "RELIABILITY OF BARR, LEECH, AND BLETHYN SCORE IN USING OF PLAIN RADIOGRAPHY IN DETERMINING FECAL IMPACTION IN CHILDREN WITH AND WITHOUT CONSTIPATION". Arquivos de Gastroenterologia. 53 (3): 141–145. doi:10.1590/S0004-28032016000300004. ISSN 0004-2803.

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