Pediatric Radiology

, 39:664

Diagnostic accuracy of the Barr and Blethyn radiological scoring systems for childhood constipation assessed using colonic transit time as the gold standard

  • Claire R. Jackson
  • Richard E. Lee
  • Anna B. Z. Wylie
  • Charlotte Adams
  • Bruce Jaffray
Original Article



Constipation is a common childhood symptom and abdominal radiography is advocated in diagnosis and management.


To assess the reproducibility and diagnostic accuracy of the Barr and Blethyn systems for quantifying constipation on abdominal radiographs in children.

Materials and methods

Radiographs were scored by three observers of increasing radiological experience (student, junior doctor, consultant). Abdominal radiographs produced during measurement of colonic transit time (CTT) were classified as constipated or normal based on the value of the transit time, and were scored using both systems by observers blinded to the CTT. Abdominal radiographs obtained in children for reasons other than constipation were classed as normal and similarly scored. Reproducibility was measured using the kappa statistic. Diagnostic accuracy was measured using the area under the curve (AUC) for the receiver operator characteristic (ROC) curve.


Using either system, scores were higher for constipated children (P<0.01). The consultant produced higher scores than the other observers (P<0.01). Interobserver reproducibility was moderate with the best kappa value only 0.48. The best correlation between score and CTT was 0.51 (junior doctor scores). Diagnostic accuracy of the scores was only moderate, with the largest AUC for a ROC curve of 0.84 for the consultant using the Barr score.


Scoring of abdominal radiographs in the assessment of childhood constipation should be abandoned because it is dependent on the experience of the observer, is poorly reproducible, and does not accurately discriminate between constipated children and children without constipation.


Abdomen Constipation Radiograph Children 


  1. 1.
    Loening-Baucke V (1993) Constipation in early childhood: patient characteristics, treatment, and longterm follow up. Gut 34:1400–1404PubMedCrossRefGoogle Scholar
  2. 2.
    Baker SS, Liptak GS, Colletti RB et al (1999) Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 29:612–626PubMedCrossRefGoogle Scholar
  3. 3.
    Rockney RM, McQuade WH, Days AL (1995) The plain abdominal roentgenogram in the management of encopresis. Arch Pediatr Adolesc Med 149:623–627PubMedGoogle Scholar
  4. 4.
    Barr R, Levine M, Wilkinson R et al (1979) Chronic and occult stool retention. Clin Pediatr (Phila) 18:674–686CrossRefGoogle Scholar
  5. 5.
    Blethyn AJ, Verrier Jones K, Newcombe R et al (1995) Radiological assessment of constipation. Arch Dis Child 73:532–533PubMedCrossRefGoogle Scholar
  6. 6.
    van den Bosch M, Graafmans D, Nievelstein R et al (2006) Systematic assessment of constipation on plain abdominal radiographs in children. Pediatr Radiol 36:224–226PubMedCrossRefGoogle Scholar
  7. 7.
    Benninga MA, Buller HA, Staalman CR et al (1995) Defaecation disorders in children, colonic transit time versus the Barr-score. Eur J Pediatr 154:277–284PubMedCrossRefGoogle Scholar
  8. 8.
    The Royal College of Radiologists (2007) Making the best use of clinical radiology services, 6th edn. The Royal College of Radiologists, LondonGoogle Scholar
  9. 9.
    Metcalf AM, Phillips SF, Zinmeister AR et al (1987) Simplified assessment of segmental colonic transit. Gastroenterology 92:40–47PubMedGoogle Scholar
  10. 10.
    Zaslavsky C, da Silveira TR, Maguilnik I (1998) Total and segmental colonic transit time with radio-opaque markers in adolescents with functional constipation. J Pediatr Gastroenterol Nutr 27:138–142PubMedCrossRefGoogle Scholar
  11. 11.
    de Lorijn F, van Rijn RR, Heijmans J et al (2006) The Leech method for diagnosing constipation: intra- and interobserver variability and accuracy. Pediatr Radiol 36:43–49PubMedCrossRefGoogle Scholar
  12. 12.
    Altman D, Machin D, Bryant T et al (2000) Statistics with confidence. BMJ, LondonGoogle Scholar
  13. 13.
    Cohen J (1960) Coefficient of agreement for nominal scales. Electroencephalogr Clin Neurophysiol 20:37–46Google Scholar
  14. 14.
    Sackett D, Haynes R, Guyatt G et al (1991) The clinical examination. Clinical epidemiology: a basic science for clinical medicine, 2nd edn. Williams and Wilkins, Philadelphia, p 30Google Scholar
  15. 15.
    Collinson P (1998) Of bombers, radiologists, and cardiologists: time to ROC. Heart 80:215–217PubMedGoogle Scholar
  16. 16.
    Benninga MA, Buller HA, Tytgat GN et al (1996) Colonic transit time in constipated children: does pediatric slow-transit constipation exist? J Pediatr Gastroenterol Nutr 23:241–251PubMedCrossRefGoogle Scholar
  17. 17.
    Leech SC, McHugh K, Sullivan PB (1999) Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children. Pediatr Radiol 29:255–258PubMedCrossRefGoogle Scholar
  18. 18.
    de Lorijn F, van Wijk MP, Reitsma JB et al (2004) Prognosis of constipation: clinical factors and colonic transit time. Arch Dis Child 89:723–727PubMedCrossRefGoogle Scholar
  19. 19.
    Boccia G, Manguso F, Coccorullo P et al (2007) Functional defecation disorders in children: PACCT criteria versus Rome II criteria. J Pediatr 151:394–398PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Claire R. Jackson
    • 1
  • Richard E. Lee
    • 2
  • Anna B. Z. Wylie
    • 1
  • Charlotte Adams
    • 1
  • Bruce Jaffray
    • 3
  1. 1.Department of Paediatric SurgeryThe Royal Victoria InfirmaryNewcastle upon TyneUK
  2. 2.Department of RadiologyThe Royal Victoria InfirmaryNewcastle upon TyneUK
  3. 3.School of Clinical Medical Sciences (Child Health), Sir James Spence InstituteUniversity of Newcastle upon TyneNewcastle upon TyneUK

Personalised recommendations