Abdominal Radiology

, Volume 44, Issue 3, pp 821–827 | Cite as

Radiographic stool quantification: an equivalence study of 484 symptomatic and asymptomatic subjects

  • Omar Khan
  • Prasad R. ShankarEmail author
  • Adish D. Parikh
  • Richard H. Cohan
  • Nahid Keshavarzi
  • Shokoufeh Khalatbari
  • Richard J. Saad
  • Matthew S. Davenport
Hollow Organ GI



To determine if symptomatic patients referred for radiographic stool quantification have equivalent stool burden to asymptomatic patients.


This was an IRB-approved HIPAA-compliant retrospective equivalence cohort study. An a priori equivalence power calculation was performed. Consecutive abdominal radiographs performed in adult outpatients with bloating, constipation, diarrhea, or abdominal pain to assess “fecal loading” [n = 242 (fecal cohort)] were compared to those performed in asymptomatic adult outpatients to assess “renal stones” [n = 242 (renal cohort)]. Radiographs were randomized and reviewed by two blinded independent abdominal radiologists. Exclusion criteria, designed to avoid unblinding, included urinary tract calculi ≥ 0.5 cm, multiple urinary tract calculi, and ureteral stent(s). Readers scored all radiographs (n = 484) for stool burden using validated Leech criteria [scale: 0 (none) to 15 (extreme diffuse)]. Mean Leech scores and 95% confidence intervals were calculated. Multivariable generalized linear modeling was performed to adjust for baseline medication use, age, and gender. The adjusted parameter estimate was used to test for equivalence in the mean difference between cohorts using Schuirmann’s method of two one-sided t-tests. Inter-reader agreement was assessed with intraclass correlation coefficients.


Overall mean Leech scores for fecal [6.9 (95% CI 6.7, 7.2)] and renal [7.3 (95% CI 7.1, 7.5)] cohorts were equivalent within a margin of 0.75 (adjusted mean difference: − 0.4 [90% CI − 0.7, − 0.04]; p value = 0.02). Inter-reader agreement was good [ICC: 0.62 (95% CI 0.56, 0.68)].


Radiographic stool quantification produces equivalent results in symptomatic and asymptomatic adults and is of uncertain value.


Constipation Fecal loading Utilization Abdominal radiograph Value 



Unfunded study.

Supplementary material

261_2018_1869_MOESM1_ESM.docx (12 kb)
Supplementary material 1 (DOCX 11 kb)
261_2018_1869_MOESM2_ESM.doc (87 kb)
Supplementary material 2 (DOC 87 kb)


  1. 1.
    Lacy BE, Levenick JM, Crowell M (2012) Chronic constipation: new diagnostic and treatment approaches. Therapeutic advances in gastroenterology 5 (4):233-247. CrossRefGoogle Scholar
  2. 2.
    Vazquez Roque M, Bouras EP (2015) Epidemiology and management of chronic constipation in elderly patients. Clinical interventions in aging 10:919-930. Google Scholar
  3. 3.
    Higgins PD, Johanson JF (2004) Epidemiology of constipation in North America: a systematic review. The American journal of gastroenterology 99 (4):750-759. CrossRefGoogle Scholar
  4. 4.
    Lacy BE, Mearin F, Chang L, Chey WD, Lembo AJ, Simren M, Spiller R (2016) Bowel Disorders. Gastroenterology 150 (6):1393-1407.e1395. CrossRefGoogle Scholar
  5. 5.
    Simren M, Palsson OS, Whitehead WE (2017) Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Current gastroenterology reports 19 (4):15-15. CrossRefGoogle Scholar
  6. 6.
    National Collaborating Centre for Ws, Children’s H (2010) National Institute for Health and Clinical Excellence: Guidance. In: Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care. RCOG Press. National Collaborating Centre for Women’s and Children’s Health., LondonGoogle Scholar
  7. 7.
    Cowlam S, Vinayagam R, Khan U, Marsden S, Minty I, Moncur P, Bain I, Yiannakou YJ (2008) Blinded comparison of faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation. Clinical radiology 63 (12):1326-1331. CrossRefGoogle Scholar
  8. 8.
    Reber J, McGauvran A, Froemming A (2018) Abdominal radiograph usage trends in the setting of constipation: a 10-year experience. Abdominal radiology (New York) 43 (9):2231-2238. CrossRefGoogle Scholar
  9. 9.
    Reuchlin-Vroklage LM, Bierma-Zeinstra S, Benninga MA, Berger MY (2005) Diagnostic value of abdominal radiography in constipated children: a systematic review. Archives of pediatrics & adolescent medicine 159 (7):671-678. CrossRefGoogle Scholar
  10. 10.
    Hanauer DA, Mei Q, Law J, Khanna R, Zheng K (2015) Supporting information retrieval from electronic health records. J of Biomedical Informatics 55 (C):290-300. CrossRefGoogle Scholar
  11. 11.
    The Big List of Narcotic Drugs. (2018) American Addiction Centers. Accessed October 23 2018
  12. 12.
    Medical Imaging Resource Community (MIRC). (2018) Radiological Society of North America. Accessed 10/23/18 2018
  13. 13.
    Leech SC, McHugh K, Sullivan PB (1999) Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children. Pediatric radiology 29 (4):255-258. CrossRefGoogle Scholar
  14. 14.
    van den Bosch M, Graafmans D, Nievelstein R, Beek E (2006) Systematic assessment of constipation on plain abdominal radiographs in children. Pediatric radiology 36 (3):224-226. CrossRefGoogle Scholar
  15. 15.
    Rezazadeh A, Javaherizadeh H, Chahardahcherik F, Yavarahmadi MH, Sadjadei N, Tahmasebi M (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. CrossRefGoogle Scholar
  16. 16.
    de Lorijn F, van Rijn RR, Heijmans J, Reitsma JB, Voskuijl WP, Henneman OD, Taminiau JA, Benninga MA (2006) The Leech method for diagnosing constipation: intra- and interobserver variability and accuracy. Pediatric radiology 36 (1):43-49. CrossRefGoogle Scholar
  17. 17.
    Schuirmann DJ (1987) A comparison of the two one-sided tests procedure and the power approach for assessing the equivalence of average bioavailability. Journal of pharmacokinetics and biopharmaceutics 15 (6):657-680CrossRefGoogle Scholar
  18. 18.
    Shankar PR, Kaza RK, Al-Hawary MM, Masch WR, Curci NE, Mendiratta-Lala M, Sakala MD, Johnson TD, Davenport MS (2018) Impact of Clinical History on Maximum PI-RADS Version 2 Score: A Six-Reader 120-Case Sham History Retrospective Evaluation. Radiology 288 (1):158-163. CrossRefGoogle Scholar
  19. 19.
    Landers R (2015) Computing Intraclass Correlations (ICC) as Estimates of Interrater Reliability in SPSS. The Winnower . Google Scholar
  20. 20.
    Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychological bulletin 86 (2):420-428.CrossRefGoogle Scholar
  21. 21.
    Cicchetti D (1994) Guidelines, Criteria, and Rules of Thumb for Evaluating Normed and Standardized Assessment Instrument in Psychology, vol 6. Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of RadiologyMichigan MedicineAnn ArborUSA
  2. 2.Michigan Radiology Quality Collaborative, Michigan MedicineAnn ArborUSA
  3. 3.University of Michigan Medical SchoolAnn ArborUSA
  4. 4.Michigan Institute for Clinical and Health Research (MICHR)University of MichiganAnn ArborUSA
  5. 5.Department of GastroenterologyMichigan MedicineAnn ArborUSA
  6. 6.Department of UrologyMichigan MedicineAnn ArborUSA
  7. 7.Department of RadiologyUniversity Hospital, University of MichiganAnn ArborUSA

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