Does sequential balloon expulsion test improve the screening of defecation disorders

BACKGROUND A defecation disorder (DD) is a difficulty in evacuation documented by physiological exams. However, this physiological evaluation can be cumbersome, inaccessible and costly. Three "low-cost" tools to evaluate DD-a clinical DD score, the balloon expulsion test (BET) and a digital rectal examination (DRE) score were evaluated as separate or combined tests for DD screening. METHODS This prospective study occurred between January 2015 and March 2019 in the Gastroenterology Department of a tertiary hospital. Besides the gold standard physiological tests, constipated patients answered the clinical DD score and were evaluated by DRE and BET [standard and variable volume (VV)]. RESULTS From 98 constipated patients, 35 (38.9%) were diagnosed with DD according to Rome IV criteria, mainly female (n = 30, 86%) with a median age of 60 years old. The clinical DD score revealed an AUC of 0.417 (SE = 0.07, p = 0.191). The DRE score displayed an AUC of 0.56 (SE = 0.063, p = 0.301). The standard BET displayed a sensitivity of 86%, specificity of 58%, positive predictive value (PPV) of 57% and negative predictive value (NPV) of 86%. The sequential VVBET followed by standard BET improved the BET performance regarding the evaluation of DD, with a sensitivity of 86%, specificity of 67%, PPV of 63% and NPV of 87%. The sequential BET had an OR 8.942, p > 0.001, CI 3.18-25.14, revealing to be the most significant predictor for DD screening. CONCLUSION The sequential BET is a low cost, well-performing DD screening tool, appropriate to the Primary Care Setting.