Rectal Exam in the Neutropenic Patient
A question from last shift that had me deep diving.
Question: Can I do a rectal exam in a neutropenic patient?
What is neutropenia? It’s defined by the ANC.
Neutropenia: Neutrophil count <1.5 x 109 cells/L (1500/microL)
Severe Neutropenia: Neutrophil count <0.5 x 109 cells/L (500/microL)
Patients with neutropenia will get sick fast and have blunted immune responses.
The theory behind the controversy:
The neutropenic state leads to an increased risk for bacterial invasion during rectal manipulation.
Most consensus recommendations advise against performing the DRE in neutropenic patients due to concern for bacterial translocation of gram negative microbes.
A 2009 guideline (updated in 2010) cosponsored by the IDSA and CDC noted “the use of rectal thermometers, enemas, or suppositories; internal rectal exams; and sexual practices involving anal penetration are contraindicated among neutropenic patients to avoid skin or mucosal breakdown, which can introduce pathogens“
This recommendation was based on expert opinion
There is no direct research that exists to support this recommendation. However, no society has been published in the interim to refute this initial recommendation.
Now—the DRE can provide a quick and inexpensive way to evaluate for anorectal pathology, prostatic abnormalities, fecal impaction, neurologic deficits, and GI bleeding. Rectal thermometers are favored in certain situations, and can be more accurate than oral, otic, or temporal thermometers. Increased accuracy may be helpful if you are concerned for neutropenic fever.
While a certain diagnosis is essential in many cases, the DRE is one of many available tools. CT or MRI could get you to the diagnosis without causing rectal mucosal trauma. Believing someone when they say they have rectal bleeding is probably good enough. A foley or esophogeal thermometer are other methods of getting a core temperature.
Conclusion:
Basically, there is no data to suggest there is a risk to performing a DRE. However, you probably can answer clinical questions without it. And to be honest—the yield of the DRE for most conditions is pretty slim.
Cheers,
Dillon
Source:
Mosby, Chad et al. “Can I Do a Rectal Exam in a Neutropenic Patient?” Gastrointestinal Emergencies. Cham: Springer International Publishing, 2019. 405–406.
