Abdominal X-ray in constipation in children

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Author: Mikael Häggström [notes 1]

Projectional radiography ("X-ray") of the abdomen in children for signs of constipation:



There is substantial evidence that abdominal X-ray should not be used in the diagnosis of constipation in children having symptoms thereof.[1] According to a guideline from the Netherlands in 2014, colonic transit time is indicated far down the management algorithm, after for example gastroenterologist evaluation and initial treatment.[1]


Colon diameters

Leech score

Areas used for the Leech system of constipation grading.

For children, the degree of constipation may be scored by the Leech or the Barr systems:

  • The Leech system assigns a score of 0 to 5 based on the amount of feces:[3]
  • 0: no visible feces
  • 1: scanty feces visible
  • 2: mild fecal loading
  • 3: moderate fecal loading
  • 4: severe fecal loading
  • 5: severe fecal loading with bowel dilatation
These score are assigned separately for the right colon, the left colon and the rectosigmoid colon, resulting in a maximum score of 15. A Leech score of 9 or greater is regarded as positive for constipation.[3]
  • The Barr system rates both the amount and consistency of the faeces, and assigns a score separately for the ascending colon, transverse colon, descending colon and rectum. Its maximum score is 22, and a score of 10 or greater is regarded as positive for constipation.[4]

Air content

The colon normally contains air, but the small intestine usually only contains minimal air.[5]

Transit time

In case of lower gastrointestinal series, a rather arbitrary cutoff has been suggested that children with symptoms of constipation with a colonic transit time of over 100 hours are categorized as having slow-transit constipation, and a colonic transit time of less than 100 hours as normal- or delayed-transit constipation.[6]


  • Any colon dilation, and maximal diameter, preferably qualitatively such as "mild"/"moderate"/"severe" because of geometric magnification
  • Amount of fecal loading.
See also: General notes on reporting


  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.


  1. 1.0 1.1 Tabbers, M.M.; DiLorenzo, C.; Berger, M.Y.; Faure, C.; Langendam, M.W.; Nurko, S.; Staiano, A.; Vandenplas, Y.; et al. (2014). "Evaluation and Treatment of Functional Constipation in Infants and Children ". Journal of Pediatric Gastroenterology and Nutrition 58 (2): 265–281. doi:10.1097/MPG.0000000000000266. ISSN 0277-2116. 
  2. 2.0 2.1 Koppen, Ilan J. N.; Yacob, Desale; Di Lorenzo, Carlo; Saps, Miguel; Benninga, Marc A.; Cooper, Jennifer N.; Minneci, Peter C.; Deans, Katherine J.; et al. (2016). "Assessing colonic anatomy normal values based on air contrast enemas in children younger than 6 years ". Pediatric Radiology 47 (3): 306–312. doi:10.1007/s00247-016-3746-0. ISSN 0301-0449. Archived from the original. . 
  3. 3.0 3.1 Leech, Susan C.; McHugh, Kieran; Sullivan, P. B. (1999). "Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children ". Pediatric Radiology 29 (4): 255–258. doi:10.1007/s002470050583. ISSN 0301-0449. 
  4. G., Anthony; H., Kathleen (2012). The Role of Diagnostic Tests in Constipation in Children . doi:10.5772/29213. 
  5. Dr Mike Cadogan. AXR Interpretation. lifeinthefastlane.com. Last updated May 24, 2016
  6. "Colonic transit time in constipated children: does pediatric slow-transit constipation exist? ". J. Pediatr. Gastroenterol. Nutr. 23 (3): 241–51. October 1996. PMID 8890073. Archived from the original. .