Is an upper GI (gastrointestinal) with small bowel follow-through indicated for evaluating chronic constipation?

Upper GI with Small Bowel Follow-Through is NOT Indicated for Chronic Constipation Evaluation

An upper GI with small bowel follow-through is not indicated for the evaluation of chronic constipation and should not be performed for this purpose. 1

Appropriate Diagnostic Approach for Chronic Constipation

Initial Evaluation

• Complete history focusing on:

  • Stool frequency, consistency, and size
  • Straining during defecation
  • Sensation of incomplete evacuation
  • Need for manual maneuvers to facilitate defecation
  • Duration of symptoms (>3 months)
  • Medication review (opioids, calcium channel blockers, antidepressants)

• Physical examination including:

  • Abdominal examination
  • Digital rectal examination to assess for:
    • Fecal impaction
    • Rectal tone
    • Pelvic floor dyssynergia

First-Line Testing

• Basic laboratory tests:
  • Complete blood count
  • Serum chemistries
  • Thyroid function tests
  • Stool for occult blood 1

Diagnostic Algorithm Based on Symptom Pattern

1. For patients with alarm features (weight loss, rectal bleeding, family history of colorectal cancer):

   • Colonoscopy is recommended, especially for patients >50 years 1

2. For patients without alarm features:

   • Trial of fiber supplementation and/or osmotic laxatives 2
   • If symptoms persist, proceed to specialized testing:
     • Colonic transit time study using radiopaque markers
     • Anorectal manometry with balloon expulsion test 3, 4

Specialized Testing for Refractory Cases

• Defecatory disorders: Anorectal manometry, balloon expulsion test, defecography
• Slow transit constipation: Colonic transit study

Why Upper GI with Small Bowel Follow-Through is Inappropriate

The ACR Appropriateness Criteria explicitly states that "there are no data to support the use of fluoroscopy upper GI series with small bowel follow-through" for evaluating chronic constipation 1. This imaging modality focuses on the upper gastrointestinal tract and small bowel, while constipation is primarily related to colonic and anorectal function.

Multiple guidelines confirm that upper GI with small bowel follow-through has no role in constipation evaluation:

1. The ACR Appropriateness Criteria specifically notes that fluoroscopy upper GI series with small bowel follow-through is not supported by current literature for evaluating patients with abdominal complaints related to constipation 1.

2. Current diagnostic approaches for chronic constipation focus on:

   • Colonic transit time assessment
   • Anorectal function evaluation
   • Defecatory dynamics 3, 4, 2

Appropriate Imaging for Constipation (When Indicated)

When imaging is needed for constipation evaluation, more appropriate options include:

• Defecography (conventional or MR): To evaluate pelvic floor dysfunction
• Colonic transit studies: Using radiopaque markers to assess colonic motility
• Colonoscopy: For patients with alarm symptoms or >50 years of age

Common Pitfalls to Avoid

1. Ordering inappropriate imaging studies like upper GI with small bowel follow-through, which exposes patients to unnecessary radiation without diagnostic benefit
2. Failing to categorize constipation into subtypes (normal transit, slow transit, or defecatory disorder)
3. Neglecting to perform anorectal function testing in patients with refractory constipation
4. Overlooking medication-induced causes of constipation

Upper GI with small bowel follow-through has been largely replaced by cross-sectional imaging techniques for most gastrointestinal conditions, and it has no established role in the evaluation of chronic constipation.