Pediatric GI exam for reflux - huh?

Just to be clear: Yes, my child is under medical care. No, I am not asking for medical advice, merely for observations or (perhaps) insight from someone in the field.

Background: 6 months ago, my 6 year old child began throwing up in the mornings. We tried feeding her before bed, and as soon as she just woke up in the morning (on the theory that perhaps it was low blood sugar). It didn’t help. We took her to our PCP, who diagnosed reflux and began treating with Zantac 2X/day. The vomiting stopped.

But, if we miss 2 doses, she gets horrible stomach pain and throws up again. Further discussion with her Ped, when this continued after so many months (I mean, if we missed a dose or two, she’d throw up), led to the Ped sending us to the local Children’s Hospital to see a specialist.

We got there, and the first thing the nurse did was warn me that the GI doc would probably want to do a rectal exam. And I thought “Huh? A rectal exam on a 6 year old kid with reflux?”

So he came in. and I had the impression he had a diagnosis already decided before he ever looked at her. He decided she must be constipated. He said 90% of the kids who come into his office are constipated, and she must be, too. Every question he asked was a leading question: “Does your stomach ever hurt?” “Do you have to strain to go poop?” He told me Zantac has a mild laxative effect, so missing a dose would naturally make her …constipated. Then he said he wanted to do a rectal exam to confirm it. I refused. He said that was fine, but the treatment would be the same regardless: 4 months of a prescription laxative, Miralax (nasty possible side effects).

He dismissed all my thoughts and observations, including things like “if congenital hiatal hernia like her ID twin, why didn’t it show up until now?” and “test for H. Pylori?” and everything I said, like “she tells me several times a week that she has to swallow down stomach contents which have suddenly come up into her mouth”. Either they were irrelevent or they confirmed…constipation.

Look. I’m no doctor, but I’m reasonably sure that my Ped is smart enough to have a) diagnosed or at least suspected constipation and prescribed a laxative herself and b) done a rectal exam herself if she felt it necessary. There was hardly a need to send us to the hospital for this.

Also, unless there was an impaction in the sigmoid colon itself (which, being home with my child 24/7, I’m sure I would have heard about before now from my child), a digital rectal exam would not find it.

And there’s this warning from the nurse. If she saw fit to warn me, this doc must do this as a routine. Yet I consider this quite an invasive and potentially traumatic exam (and moreso since at the time, my child was nearly hysterical at the thought of having to have a blood draw). I would no more permit it to be done to a young child as a matter of routine than I would permit a vaginal exam.

Is it normal for a pediatric GI doc to expect to do such an exam as a matter of routine? My gut feeling at the time was that he gets some sort of jollies from it, or some kind of feeling of power…but he’s an employee of an elite children’s hospital, so that would seem out of character for the institution.

(For the record, we do also have an upper-GI study (barium swallow) scheduled, which should tell hopefully tell us a lot about the reflux. But we also have a follow-up appointment with this man, and I’d rather see ANYBODY else in his office than him, just now. And expect to change our followup appointment after consulting with the Ped on Monday. I’m extremely uneasy about giving a small child a lengthy course of laxatives, which can mess up her electrolytes and the natural flora in her gut, when I am by no means convinced she is or ever was constipated at all.)

I’m not a medical person, but my son had to be seen last year by a pediatric gastroenterologist for a similar reason and you son’s. There was no rectal exam or any suggestion of doing one. He did have other exams done, such as upper GI and endoscopy.

My take based on being seen as an (adult) patient for stomach problems a fair amount. I think you’re right to be concerned the constipation diagnosis was a little pat, and seek a second opinion.

I do, however, think you may be over-reacting to the rectal exam. Pretty much every visit I made related to stomach problems involved such an exam (various doctors, male and female). It was brief (1 minute) not a big deal, not nearly as invasive as an OB/GYN exam. If your kid has bad stomach problems, I’d think you should probably get her used to that type of exam. If your attitude is that the exam is traumatic and perverse, your kid will pick up on that. Find a doctor you trust, then treat the rectal exam just like the doctor looks in the ears and the throat. If your kid has questions, explain the parts of the digestive system and how they are connected so she understands why she needs the exam.

I’ve had stomach trouble since about the same age, and had to see a specialist at around 7-8.

My symptoms were vomiting weekly (always on Wednesday, I’d wake up early thinking I had to have a BM, then directly afterwards I’d vomit every half hour for about 4 hours.)

My first exam with a specialist included x-rays and a rectal exam. I’m not entirely sure what happened, but I seem to recall that she inserted something resembling cardboard litmus paper to see if I was bleeding inside.

Turns out I had impacted constipation.

Treatment was a daily mild laxative, two doses of mineral oil per day, and (this is way, way TMI) milk and mollassus enemas (3 total). I’d go back every week for another abdominal film. It took a while, maybe a month total, but it did work…fortunately on the visit before I’d have had to have an endoscopy.

Having said that, I had a family history of ulcers, as my sister had a perforated ulcer at age 16, and they got that out of the way before moving on. My mother requested the H. Pylori test, though I’m not sure I ever got it. Since then I’ve not had the same problem, just my good old gastritis and IBS. I’d certainly seek a second opinion, but the rectal exam is par for the course.

I have had reflux problems for years. Not on any medication now BUT the head of the bed is raised approx 3." Nothing to eat within four hours of bed time and nothing to drink within 2 hours of bed time. No problems.

Ask you ped. about the above three items. Upper GI & endoscopy were done.

Chotii, I see you live in the Pacific NW. Are you being seen at Seattle Children’s, or Mary Bridge?
I know nothing about Mary Bridge, but if it’s the GI clinic at Children’s, they do have several doctors. Asking to see someone else is in no way out of line, if he makes you or your child uncomfortable.
Occult (that means hidden) constipation (this is a PDF Here it is in HTML) in children isn’t uncommon. A rectal exam isn’t too traumatic for a 6 year old as long as it’s explained well. I’m not sure it would be all that helpful in his diagnosis, however. Usually occult constipation is much higher in the colon. There may be some liquid stool in the rectal vault, but that isn’t conclusive by any means. Here is a discussion from the Children’s GI team about the subject.
He would want to check for occult blood in the stool as well, so that may be what he was looking for. Getting a small sample with a digital exam is a much quicker and less unpleasant than having you collect a stool at home, then sending it back for testing.

I don’t know much about the GI docs. They don’t have much reason to hang around the ICU, since the GI team from the UW oversees the liver transplants. So I can’t say they have any perverts on staff, but I doubt it very much. It may be a big hospital, but it’s really a small town.

I hope this helps.

Nothing to add except that the possibilities for punk band names abound in the previous post.

The thing is, she was already on the verge of hysteria because it had been decided she would have a blood draw. She had just had one 2 days before, had hyperventilated during and throw up after, and even if I’d agreed the rectal exam was a good idea, there was no way to explain it to her - she was beyond logical discussion at that point. Remember, she’s only 6. As bright and lively as she is, she’s just not rational yet, half the time, and certainly not when she’s out of her head with anxiety.

We had already done a test for occult blood, at home. 2 tests in 2 days; 1st was negative, second positive (but she also had food poisoning overnight and had nasty diarrhea; I expect blood would not be unusual with that going on.) I showed him the result of that. He still wanted to do the exam.

He said nothing about getting a stool sample. He just wanted to feel for constipation, apparently.

I posited this same question to a list of parents of kids with G-tubes, all of whom of course must deal with GI clinics and doctors all over the country. Of the 6 people who took time to respond, none of them had ever heard of a digital rectal exam for symptoms of reflux or even constipation. So I’m at a loss to know how it could be a routine method of diagnosis?

At any rate, we’ll see our Ped on Monday morning. Maybe she’ll confess she overlooked something completely obvious and easily treated for the last 6 months, and she’ll apologise. Or maybe she’ll agree with me that the diagnosis doesn’t fit the facts, and we’ll continue our pursuit of the cause of the vomiting. I admit, I wish I thought it were something as simple as constipation, occult or otherwise, because that can be cleared up and the kid maybe won’t have to take Zantac forever and aye, like I do for my reflux.

I don’t think a rectal exam would be inappropriate under the circumstances. I’d switch doctors if you feel uncomfortable, though.

I do understand that she was beyond the pale at that time. The doctor should has seen that too.
If she continues to be afraid, you could ask about getting something to calm her you can give before you leave home. Not to sedate her, but just to take the edge off.
I’m pretty sure the GI clinic at Children’s has a nurse practicitioner that you can talk to about your concerns.

Did you tell her peds and/or the GI guy, that you have GERD? If you aren’t old, not an alcoholic, or morbidly obese, GERD could be familial.

You said she’s scheduled for an upper GI series. right? Do they plan to do an endoscopy too? Have you ever had an endoscopy?
Rysdad, and what might they be? Remember, I’m old and clueless :cool:

Versed is useful at times. And I would certainly consider asking for it.

My mom has it. I have it. At least 2 of my brothers suffer from heartburn (and I just don’t know about the other). None of us are alcoholics, old, nor morbidly obese. Okay, mom’s getting a little bit old, but 65 isn’t “old”. One ID twin was born with a congenital deformity at the top of her stomach (hiatal hernia?) and had so much reflux that she became orally aversive and was g-tube fed until the age of 4 1/2 (and had surgery to repair it)… This other child, the other ID twin, seems to me to be following the family trend.

And yes, I did tell the GI doctor this. And the Ped also knows, because she’s also my family doctor. This may be why the Ped leans toward GERD. But the GI doc seemed to dismiss it as irrelevent.

The plan seemed to go like this: Upper GI series, concurrent with 4-month course of laxatives. Depending on what the GI series shows, and if the laxative course doesn’t stop the vomiting/remove the need for Zantac, then an endoscopy.

I have had an endoscopy, yes. Nasty affair, I woke up during the procedure and had awful trouble with my stomach/throat for days afterward. I am hoping we don’t have to resort to that, because I know the recovery really sucks, but it can be a useful diagnostic tool. The other twin had one too, a couple of years ago. She had a miserable couple of days afterward (and we learned what we needed to know).

IMHO, drawing blood requires a needle, which is way scarier than a finger.

Not necessarily. My husband has a phobia of needles. I don’t mind them at all. I have given gallons of blood over the years. It’s just no big deal to me.

I find a pelvic exam to be roughly as invasive as a rectal exam, each requiring the same degree of of voluntary submission in a highly vulnerable position. I find them each to be equally uncomfortable.

And I have not exactly noticed men being overjoyed at their yearly prostate exam, so cleary, even adult men can find a digital rectal exam unpleasant - with the size differential between body and finger being considerably smaller, when it’s an adult man getting the exam.