Plain abdominal radiography in suspected intussusception: a reassessment

Yield of abdominal radiographs in children with suspected intussusception; rate of pneumoperitoneum and other abdominal pathology

OBJECTIVES

Ultrasound is the criterion standard imaging modality for the diagnosis of intussusception. However, to our knowledge the utility of abdominal radiographs to concurrently screen for pneumoperitoneum or other abdominal pathology that could have a similar presentation has not been studied. Our institutional protocol requires the performance of AP supine and left lateral decubitus views of the abdomen prior to ultrasound evaluation for intussusception, providing an opportunity to examine the yield of abdominal radiographs in this setting. Our primary objective was to determine the rate of pneumoperitoneum on screening abdominal radiographs in children undergoing evaluation for intussusception. Our secondary objective was to determine the rate that other clinically significant pathology is found on these screening abdominal radiographs.

METHODS

We performed a retrospective chart review of all patients under 6 years of age who had any imaging ordered in our large urban pediatric emergency department to evaluate for suspected intussusception during the calendar years 2018-2020.

RESULTS

1115 patient encounters met our inclusion criteria. Among 1090 who had screening abdominal radiographs, 82 (8%) had findings concerning for intussusception. Of those not concerning for intussusception, 635 (58%) were read as normal, 263 (24%) showed moderate to large stool burden, 107 (10%) showed generalized bowel distention, and 22 (2%) showed abnormal gastric distention. Individually the remainder of all other findings compromised <1% of encounters and included radiopaque foreign body (8), intraabdominal calcification (4), pneumonia/effusion (3), pneumatosis intestinalis, abdominal mass (2), diaphragmatic hernia (1), rib fracture (1), appendicolith (1), feeding tube malposition (1), and bowel wall thickening (1). In one encounter the patient had a bowel perforation with pneumoperitoneum present secondary to ingestion of multiple magnets.

CONCLUSIONS

Our study indicates that radiograph-detected pneumoperitoneum is rare in children with suspected intussusception. Constipation is the most common abnormal finding on screening radiographs. Other findings occur in approximately 15% of total cases, some of which require further workup.

Current diagnosis and image-guided reduction for intussusception in children

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

Neonatal and Pediatric Bowel Obstruction: Imaging Guidelines and Recommendations

Pediatric bowel obstructions are one of the most common surgical emergencies in children, and imaging plays a vital role in the evaluation and diagnosis. An evidence-based and practical imaging approach to diagnosing and localizing pediatric bowel obstructions is essential for optimal pediatric patient care. This article discusses an up-to-date practical diagnostic imaging algorithm for pediatric bowel obstructions and presents the imaging spectrum of pediatric bowel obstructions and their underlying causes.

Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians

BACKGROUND

Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists.

OBJECTIVE

Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT.

METHODS

We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P-and radiology-performed US (RPUS) results was assessed.

RESULTS

One hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51-99%; specificity 98%; 95% CI 92-100%; positive predictive value 80%; 95% CI 44-96%; negative predictive value 99%; 95% CI 93-100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07-162.36) and with a negative POCUS was 0.11 (95% CI 0.02-0.72).

CONCLUSIONS

POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department-performed POCUS is a rapid and accurate method for diagnosing INT.

Deep learning algorithms for detecting and visualising intussusception on plain abdominal radiography in children: a retrospective multicenter study

This study aimed to verify a deep convolutional neural network (CNN) algorithm to detect intussusception in children using a human-annotated data set of plain abdominal X-rays from affected children. From January 2005 to August 2019, 1449 images were collected from plain abdominal X-rays of patients ≤ 6 years old who were diagnosed with intussusception while 9935 images were collected from patients without intussusception from three tertiary academic hospitals (A, B, and C data sets). Single Shot MultiBox Detector and ResNet were used for abdominal detection and intussusception classification, respectively. The diagnostic performance of the algorithm was analysed using internal and external validation tests. The internal test values after training with two hospital data sets were 0.946 to 0.971 for the area under the receiver operating characteristic curve (AUC), 0.927 to 0.952 for the highest accuracy, and 0.764 to 0.848 for the highest Youden index. The values from external test using the remaining data set were all lower (P-value < 0.001). The mean values of the internal test with all data sets were 0.935 and 0.743 for the AUC and Youden Index, respectively. Detection of intussusception by deep CNN and plain abdominal X-rays could aid in screening for intussusception in children.

Radiographic findings predictive of irreducibility and surgical resection in ileocolic intussusception

BACKGROUND

Ileocolic intussusception is a common cause of intestinal obstruction in young children. Radiographs may be of limited value in the diagnosis of intussusception and are sometimes utilized primarily to exclude pneumoperitoneum before therapeutic enema reduction.

OBJECTIVE

The goal of this study was to determine if radiographic findings in ileocolic intussusception can offer prognostic information regarding the outcome of therapeutic air enema and, for those requiring surgical intervention, surgical outcomes and/or complications.

MATERIALS AND METHODS

A single institution retrospective study was performed including all enemas for intussusception performed during a 5-year period from September 2012 to August 2017. Radiographs obtained before therapeutic enema, including our institution radiographs, outside facility radiographs, or scout images obtained during fluoroscopy or computed tomography (CT), were independently scored by two pediatric radiologists for normal bowel gas pattern, soft-tissue mass, paucity of bowel gas, meniscus sign and bowel obstruction. The reviewers were blinded to enema and surgical outcomes at the time of review. Differences were resolved by consensus. Cases were excluded in which there was no adequate pre-procedure radiograph. In total, 182 cases were reviewed. The medical records were reviewed for enema and surgical outcomes.

RESULTS

Radiographic findings included normal bowel gas pattern in 13%, soft-tissue mass in 26%, paucity of bowel gas in 65%, meniscus sign in 12% and obstruction in 10% of the cases, with 17.5% of patients having more than one finding. In patients with bowel obstruction on radiographs, there was a statistically significant decrease in success of therapeutic enema (83% vs. 21%, P=0.0001), increase in complicated surgical reductions (47% vs. 4%, P=0.0012), and increase in bowel resection (42% vs. 4%, P=0.003) compared to patients with normal bowel gas pattern.

CONCLUSION

Radiographs can offer prognostic information regarding the potential for therapeutic enema success, as well as potential surgical outcomes in patients failing enema reduction. Particularly, bowel obstruction significantly decreases the success of therapeutic enema and increases the need for bowel resection.

Comparison of Lactic Acid Levels in Children with Suspected and Confirmed Intussusception

BACKGROUND

Currently, no laboratory test can identify children with intussusception. Lactic acid is a marker of ischemia in gastrointestinal emergencies.

OBJECTIVES

We present a case series comparing lactic acid levels in children with suspected and confirmed intussusception.

METHODS

This is a prospective single case series of 39 patients who had suspected intussusception. Patients were eligible if they underwent abdominal ultrasound screening for suspected intussusception. Blood collected at the time of peripheral intravenous line placement was analyzed for lactic acid levels before ultrasound.

RESULTS

Thirty-nine patients were enrolled; 16 were diagnosed with intussusception. Mean (± standard deviation) lactic acid levels were not significantly different between children with suspected (1.7 ± 0.69 mmol/L) and confirmed intussusception (1.93 ± 1.13 mmol/L).

CONCLUSIONS

Lactic acid levels cannot identify children with intussusception.

Intussusception: past, present and future

Intussusception is a common etiology of acute abdominal pain in children. Over the last 70 years, there have been significant changes in how we diagnose and treat intussusception, with a more recent focus on the role of ultrasound. In this article we discuss historical and current approaches to intussusception, with an emphasis on ultrasound as a diagnostic and therapeutic modality.

Intussusception in childhood: role of sonography on diagnosis and treatment

OBJECTIVE

The aim of this study was to determine the role of ultrasound in the diagnosis and treatment of pediatric patients with acute abdominal pain caused by intussusceptions.

MATERIALS AND METHODS

We performed a retrospective study of all pediatric patients with acute abdominal pain caused by intussusceptions and that underwent ultrasound examination at the emergency service of the Radiology Department between November 2007 and June 2013. The role of ultrasonography in the diagnosis of intussusceptions has been assessed by comparing the echographic presumptive diagnosis with the final diagnosis of discharge. Its importance in the treatment has been assessed by determining the value of ultrasound findings in the choice of the best treatment.

RESULTS

The ultrasound examination was positive in 16/18 patients with a final diagnosis of intussusception. Some sonographic findings seemed to be able to predict the opportunity to resort to non-surgical therapeutic options like hydrostatic or pneumatic reduction of the intestinal segments invaginated. In our casuistry, five children presented characteristics typical of this subgroup and underwent barium enema which provided the reduction of the intestinal segments involved. The future challenge will be to perform non-surgical ultrasound-guided reductions to avoid the exposure of the infants to ionizing radiations.

CONCLUSIONS

Ultrasonography is essential not only in the diagnosis, but also it adds important elements in the therapeutic choice and could play in the future an important role in non-surgical reduction of intestinal intussusceptions in pediatric patients.

Inter-rater agreement in the evaluation of abdominal radiographs for necrotizing enterocolitis

PURPOSE

Abdominal radiographs are frequently employed in the surveillance of patients with necrotizing enterocolitis (NEC), with typical findings well described. Clinicians interpret and act upon these films at different intervals, however, and inter-rater agreement has not been evaluated to date.

METHODS

Thirty abdominal radiographs of premature infants were distributed to attending radiologists (4), pediatric surgeons (4), and trainees (4), who evaluated for findings of NEC from a list of eight potential choices (1=normal, 8=perforation). Fleiss's Kappa (FK) was used to evaluate concordance between multiple raters with 0-0.2=slight association and 0.8-1=almost perfect agreement.

RESULTS

Practicing surgeons had an FK of 0.77 overall (95% CI: 0.67-0.87), but demonstrated poor agreement when evaluating decubitus films (FK: 0.39, 95% CI:0.12-0.65). Radiologists had excellent inter-rater agreement (FK: 0.81, 95% CI: 0.74-0.88), but had only modest agreement with surgeons (FK: 0.59, 95% CI: 0.56-0.63) and poor agreement for decubitus films (FK: 0.15, 95% CI: 0.47-0.26). Surgical and radiology trainees had fair agreement with their respective attendings (0.60, 95% CI: 0.55-0.65 and 0.64, 95% CI: 0.60-0.69, respectively).

CONCLUSIONS

While inter-rater agreement was good-excellent among attending staff, it was only moderate between radiologists and surgeons and between trainees and their attendings. This highlights the importance of inter-disciplinary and hierarchical communication to optimize clinical decision-making. Decubitus films may be of limited value in evaluating patients with NEC.

Renal cell carcinoma presenting as small bowel obstruction secondary to a metastatic ileal intussusception

We report a rare clinical presentation of renal cell carcinoma in the form of small bowel obstruction which was secondary to a metastatic ileal intussusception. Intussusception in the elderly is most commonly due to an underlying neoplasm, however metastases from a renal cell carcinoma is very uncommon. We present clinical details, radiological and pathological findings of the case followed by a discussion of the diagnosis and management of intussusception in the adult population.

Evaluating pediatric intussusception using 24-hour ultrasound

BACKGROUND

Although ultrasound is often the preferred pediatric imaging modality for the evaluation of intussusception in children, many institutions lack access to ultrasound at night. This study characterized the day- and nighttime use of radiographic imaging for evaluation of intussusception.

METHODS

The charts of pediatric patients evaluated for intussusception between January 2010 and December 2010 were reviewed retrospectively to evaluate the day- and nighttime use of radiographic imaging. Patients were stratified into day and night groups according to when the imaging studies were performed, and differences in the clinical characteristics, imaging studies, cost, and final diagnosis were compared.

RESULTS

Pediatric consultations were performed for 86 suspected intussusceptions: 40 (46.5%) during the day [38 (95%) ultrasounds and 33 (82.5%) plain abdominal X-rays] and 46 at night [3 (6.5%) computed tomography and 39 (84.7%) plain abdominal X-rays]. The rate of positive enemas was significantly higher during the day than at night (97.5% vs. 52.2%, p < 0.001). The radiation dose during the initial survey was significantly lower during the day than at night (0.63 ± 0.48 vs. 2.06 ± 1.48 mSv, p < 0.001).

CONCLUSION

Radiographic imaging at night results in higher radiation exposure and negative enema findings. Twenty-four-hour ultrasound availability would decrease the radiation exposure and unnecessary enemas for intussusceptions suspected clinically.

Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound

BACKGROUND

During the past decade, point-of-care ultrasound (POC US) has been increasingly performed in emergency medicine for a variety of indications. However, pediatric emergency physicians have been slower to understand the importance of POC US in the diagnosis of critical care cases.

OBJECTIVE

This study aimed to illustrate the usefulness of POC US in improving workflow in the emergency department (ED) with an early diagnosis in a critically ill child by a pediatric emergency attending physician.

CASE

On arrival to the ED, an early diagnosis of intussusception was made using real-time POC US by a pediatric emergency medicine attending physician well trained in pediatric US.

CONCLUSIONS

This report illustrates the impact that POC US can make during an early diagnosis of intussusception. With thorough knowledge of the US features characteristic of intussusception, its accurate diagnosis using POC US has the potential to reduce morbidity and mortality as well as improve patient flow and throughput time in the ED.

Comparison of 2-view abdominal radiographs with ultrasound in children with suspected intussusception

BACKGROUND

The clinical presentation of intussusception is variable; therefore, screening with either abdominal radiography (AXR) or abdominal ultrasound (US) is often used, although the optimal method is not known.

PURPOSE

This study aimed to compare the utility of AXR with that of the US in children with suspected intussusception.

METHODS

Retrospective cohort of children age 3 months to 3 years presenting to a pediatric emergency department (ED) between 2007 and 2009. Inclusion criteria were as follows: (1) presentation to the ED for suspected intussusception and (2) both 2-view AXR and US performed during the ED visit. An AXR was deemed negative for intussusception if air was visualized in the ascending colon on 2 views and transverse colon on the supine view; US results were obtained from the radiologist report at the time of presentation. Criterion standard measures for intussusception were contrast enema, operative report, or follow-up.

RESULTS

A total of 286 children were included, with mean (SD) age 16.1 (9.1) months; 62.2% were male, and 43.7% were African American. Intussusception was present in 61 subjects (21.3%). Abdominal radiography had sensitivity of 62.3% (95% confidence interval [CI], 50.1%-74.5%) and specificity of 86.7% (95% CI, 82.2%-91.1%), whereas US had a sensitivity of 98.4% (95% CI, 95.2%-100.0%) and specificity of 96.4% (95% CI, 94.0%-98.9%). Ultrasound had a greater negative predictive value (99.5%; 95% CI, 98.6%-100.4%) compared with AXR (89.4%; 95% CI, 85.4%-93.5%). Abdominal radiography had a greater false-positive rate (13.3% vs 3.6%) and greater false-negative rate (37.8% vs 1.6%), compared with US.

CONCLUSIONS

Ultrasound is superior to AXR as a screening method for establishing and excluding the diagnosis of intussusception. The poor test characteristics of 2-view AXR suggest that it should not be used as a primary screening method in cases of suspected intussusception.

Japanese guidelines for the management of intussusception in children, 2011

BACKGROUND

The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death.

METHODS

Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels.

RESULTS

Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable.

CONCLUSIONS

The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.

Recurrent Intussusception: when Should Surgical Intervention be performed?

OBJECTIVE

To determine the optimal timing of surgery for recurrent intussusception.

METHODS

We retrospectively reviewed medical records of patients aged from 0 to 18 years old with diagnosis of intussusception in the Pediatric Department at Mackay Memorial Hospital between January 1995 and May 2010.

RESULTS

During the study period, there were 686 children (divided into three age groups: 367 < 2 years, 289 aged 2 to 5 years, 30 > 5 years) with diagnoses of intussusception. Eighty-five of the 686 patients had recurrent intussusception, of whom 56 had two, 16 had three, 11 had four, and 2 had five episodes. The recurrence rate after the first, second, third, and fourth barium enema reductions were 15.7%, 37.7%, 68.4%, and 100.0%, respectively. The incidence of recurrence and failure rate of barium enema reduction did not differ significantly among these three age groups. Surgery was performed in 177 children (146 during the first episode and 31 in recurrent cases). The probability of eventual surgery after first enema reduction was 21.8%, after the second 35.7%, and after the third 70.0%. Lead points were found in 15 children, and all of them were found during surgery for the first episode of intussusception.

CONCLUSION

The probability of recurrence was 100% after the fourth episode of intussusception in our study. After the third episode of intussusception, the probability of recurrence and eventual surgery were 68% and 70%, respectively. From this study, surgical intervention should be considered at the third episode of intussusception.

Accuracy of plain radiographs to exclude the diagnosis of intussusception

OBJECTIVES

To prospectively determine the test characteristics of the 3-view abdominal radiograph to decrease the likelihood of ileocolic intussusception.

METHODS

We conducted a prospective cross-sectional study of children aged 3 months to 3 years suspected of having intussusception at a children's hospital emergency department. Clinicians obtained supine, prone, and left lateral decubitus radiographs. We determined the presence or absence of intussusception by air enema, ultrasound, operative report, or clinical follow-up. A masked pediatric radiologist reviewed all radiographs. The criteria evaluated were whether air was visualized in the ascending colon on each view and in the transverse colon on the supine view.

RESULTS

Nineteen (14.8%) of 128 patients had intussusception. Using air in the ascending colon on all 3 views as the diagnostic criteria, the test characteristics of the 3-view radiograph were sensitivity, 100% (95% confidence interval [CI], 79.1-100); specificity, 17.4% (95% CI, 11.1-26.1); negative predictive value, 100% (95% CI, 79.1-100); and likelihood ratio of a negative test, 0. When 2 or more of 3 views had air in the ascending colon, sensitivity decreased to 89.5% (95% CI, 75.7-100) and specificity improved to 45.0% (95% CI, 35.6-54.3). Air in the transverse colon had moderate sensitivity, 84.2% (95% CI, 67.8-100), but further improved specificity, 63.3% (95% CI, 54.2-72.4).

CONCLUSIONS

The presence of air in the ascending colon on the 3-view abdominal radiograph can decrease the likelihood of or exclude intussusception. When clinical suspicion is low, the presence of specific criterion on a 3-view abdominal radiograph series may obviate the need for further studies.

Emergent pediatric US: what every radiologist should know

Appendicitis, intussusception, and hypertrophic pyloric stenosis (HPS) are three of the most common reasons for emergent abdominal imaging in pediatric patients. Although the use of computed tomography has risen dramatically over the past 2 decades, children are particularly at risk for the adverse effects of ionizing radiation, and even low-dose radiation is associated with a small but significant increase in lifetime risk of fatal cancer. In most emergency departments, the use of magnetic resonance (MR) imaging as a primary modality for the evaluation of a child with abdominal pain remains impractical due to its high cost, its limited availability, and the frequent need for sedation. Ultrasonography (US) does not involve ionizing radiation and, unlike MR imaging, is relatively inexpensive, is widely available, and does not require sedation. Another major advantage of US in abdominal imaging is that it allows dynamic assessment of bowel peristalsis and compressibility. Delayed diagnosis of any of the aforementioned disease processes can lead to serious morbidity and, in some cases, death. The ability to diagnose or exclude disease with US should be part of a core radiology skill set for any practice that includes a pediatric population.

The role of plain radiography in assessing intussusception with vascular compromise in children

INTRODUCTION

The diagnostic value of colour Doppler sonography for the detection of blood flow in intussusception is questionable. The purpose of this study was to evaluate plain radiography in the assessment of vascular compromise in children with intussusception.

MATERIAL AND METHODS

The hospital notes of 1,119 paediatric cases of intussusception who presented between January 2007 and February 2008 were retrospectively analysed. Informed consent was given by the parents before the air enema and this study was approved by the hospital ethics committee. Overall, the plain abdominal X-rays of 190 cases were assessed independently by two experienced radiologists, and disagreements were settled by discussion. Symptom profiles, operative notes and pathological records were compared to plain radiography. SAS V8.1 was used for the analysis.

RESULTS

Of the 190 patients, 30 cases had vascular compromise on plain films, as shown by the "coffee-bean" sign or "banana" sign. There was a paucity of gas in 36 cases, a quadrant-specific gas pattern in 51 cases, and the film showed a mass in 73 cases. Statistical analysis that compared signs on plain radiography signs and symptom onset showed a significant difference. Ninety-five cases were irreducible by air enema and required surgical intervention. The location of these intussusceptions were ileo-ileal-colic (n = 44), ileo-colic (n = 25), ileo-ileal (n = 14), ileo-caecal (n = 10), and ileo-colic-colic (n = 2). Eleven cases had intestinal necrosis and underwent resection of the necrotic bowel.

CONCLUSIONS

The signs of intussusception on plain radiography were significant during the clinical assessment of children with secondary ischaemic bowel. The radiological findings were shown to have a high concordance with pathology in the assessment of intussusception.The diagnostic value of colour Doppler sonography for the detection of blood flow in intussusception is questionable. The purpose of this study was to evaluate plain radiography in the assessment of vascular compromise in children with intussusception.

Perforated appendicitis and appendicolith in a child presenting as intussusception: a case report

Simultaneous diagnoses of intussusception and appendicitis in the same patient have rarely been described in the pediatric literature. A case of a 30-month-old boy is presented with an initial diagnosis of intussusception that was successfully reduced by air contrast enema. When the patient's condition deteriorated, a diagnostic search surprisingly revealed a missed perforated appendicitis with an appendicolith that had been part of the intussusception. The patient's hospitalization and surgical course is described along with a discussion of the intermingling of intussusception and appendicitis in a young child. This case illustrates the need to consider alternative diagnoses when a patient's course takes an unexpected and confusing turn.

Risk stratification of children being evaluated for intussusception

CONTEXT

Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation.

OBJECTIVE

To determine predictive clinical criteria and develop a decision tree to risk-stratify children with possible intussusception.

DESIGN/METHODS

This is a prospective observational cohort study of children aged 1 month to 6 years who presented with possible intussusception. A data-collection form was completed before knowledge of any advanced imaging. Univariate analysis was performed, and decision trees were developed using recursive partitioning.

RESULTS

In the study, 310 patients were enrolled, including 38 (12.3%) with intussusception. The median age was 21.1 months and 61% were male. Univariate predictors of intussusception included age older than 6 months (P = 0.04), male gender (P = .007), history of lethargy (P = .001), and abnormal plain x-ray (P = .0001). Multivariate analysis through recursive partitioning identified decision trees (with and without the result of a plain abdominal x-ray) and allowed identification of patients at low risk. The decision tree based on the results of an abdominal x-ray (negative or positive), age (≤ 5 or >5 months), diarrhea (present or absent), and bilious emesis (present or absent) had the best test performance (sensitivity: 97% [95% confidence interval (CI): 86-100]; negative predictive value: 99% [95% CI: 93-100]; negative likelihood ratio: 0.08 [95% CI: 0.01-0.6]).

CONCLUSIONS

Among children who were being evaluated for intussusception, we prospectively determined clinical criteria and developed a decision tree to risk-stratify children with possible intussusception.

The role of abdominal radiography in the diagnosis of intussusception when interpreted by pediatric emergency physicians

OBJECTIVE

To evaluate the sensitivity and specificity of abdominal x-rays in the diagnosis of intussusception when interpreted by pediatric emergency physicians.

STUDY DESIGN

This was a prospective experimental study. Participants were board-certified/eligible pediatric emergency physicians. They evaluated a module containing radiographs of 50 cases of intussusception and 50 controls, matched for age and sex. For each x-ray, the physicians stated whether the x-ray increased, decreased or did not affect suspicion of intussusception. The primary outcome was the percentage of cases for which physicians stated that the x-ray increased their level of suspicion (sensitivity). Secondary outcomes included the proportion of false-negative results and specificity.

RESULTS

Fourteen of 15 eligible physicians participated in the study. Overall, abdominal radiography increased the index of suspicion of intussusception in 48% of cases (sensitivity) and 21% of controls; however, in 11% of cases, the abdominal x-rays were incorrectly interpreted as being reassuring. The specificity was 21%. The radiographs were deemed equivocal for 41% of cases and 58% of controls.

CONCLUSIONS

Abdominal x-rays have a low sensitivity and specificity for diagnosing intussusception when interpreted by pediatric emergency physicians.

Idiopathic cecocolic intussusception in a 16-year-old boy

Intussusception is a relatively common problem requiring evaluation and treatment by pediatric surgeons and radiologists. While ileocolic and small bowel intussusceptions are frequently observed, cecocolic intussusception is a rare event, most commonly occurring as a result of a pathologic lead point. To our knowledge, this is the first reported case of cecocolic intussusception occurring without an identifiable pathologic lead point or intestinal infection.

Diagnosis of pediatric intussusception by an emergency physician-performed bedside ultrasound: a case report

The past decade has seen a rapid evolution in the use of bedside ultrasound (BUS) in the emergency department (ED). In addition, it has been increasingly used in the pediatric population for a variety of indications. As ED BUS is a relatively new modality in pediatric emergency medicine, novel indications are increasingly being recognized. We report a case of a 9-month-old infant who presented with signs and symptoms suggestive of intussusception, whose diagnosis was made using ED BUS in the pediatric ED. Knowledge of the sonographic appearance of intussusception can aid the emergency physician in the prompt diagnosis of this condition while potentially minimizing complications that may result from a delay in diagnosis.

Radiographic evaluation of intussusception: utility of left-side-down decubitus view

PURPOSE

To assess the incremental value of the left-side-down decubitus view in radiographic evaluation of ileocolic intussusception.

MATERIALS AND METHODS

The institutional review board approved this retrospective investigation with waiver of informed consent. Between February 24, 2002, and January 25, 2007, 304 studies (300 patients; mean age, 1.3 years; range, 0.1-3.9 years) met the following inclusion criteria: kidney ureter bladder (KUB) and decubitus views obtained, with subsequent proof of diagnosis. Using a consensus approach, two pediatric radiologists evaluated KUB and decubitus views for four variables: (a) discrete mass and (b) small-bowel obstruction (positive criteria); (c) air or stool in ascending colon and (d) cecal air or stool (negative criteria). On the basis of these criteria, each study was graded as negative, positive, or indeterminate for intussusception. Diagnostically determinate studies and the ability to visualize or exclude intussusception were calculated to determine sensitivity and specificity. The difference between proportions was calculated, along with 95% confidence intervals. Agreement between the supine KUB view and supine KUB plus left-side-down decubitus views was tested with the McNemar test.

RESULTS

Intussusception was present in 58 of 304 studies (19%). Adding the decubitus view to the KUB view increased the number of determinate studies from 110 of 304 (36.2%) to 205 of 304 (67.4%) (difference, 31.2 percentage points; P < .001). Intussusception was correctly identified with KUB view alone in 35 of 58 studies (60.3%); this value increased to 43 of 58 (74.1%) with KUB plus decubitus views (P = .0215). Intussusception was correctly excluded with the KUB view alone in 63 of 246 studies (25.6%); this increased to 143 of 246 studies (58.1%) with addition of the decubitus view (P < .0001).

CONCLUSION

The addition of decubitus views increased the number of diagnostically determinate studies and increased the ability to diagnose or exclude intussusception. The authors believe that a left-side-down decubitus view should be included in the initial evaluation of patients suspected of having intussusception, particularly when the supine view is diagnostically indeterminate.

[Ultrasound-guided water enema for reduction of childhood intussusception]

INTRODUCTION

Intussusception is a common abdominal emergency in infants and children. Ultrasonography and barium enema are very useful in diagnosis and treatment of this condition. The aim of the study was to assess the accuracy of ultrasound-guided saline enema for intussusception and to determine if some factors may improve the outcome of this technique.

MATERIAL AND METHODS

Intussusception was diagnosed in 63 patients at the Clinic of Pediatric Surgery in Novi Sad. The study period was divided into two 2-year phases: phase I, from 2001 through 2002, and phase II, from 2003 through 2004. During phase I, besides barium enema and fluoroscopy, we started using ultrasonography and ultrasound-guided hydrostatic saline enema in the diagnosis and reduction of intussusception. In phase II, this method of reduction was routinely used in all cases. Our technique of ultrasonic reduction was similar to the conventional hydrostatic barium reduction, except the reservoir was higher than that of barium, analgosedation of patients was performed and in case of difficult and prolonged reduction, gentle manual pressure to the abdomen at right lower quadrant was used.

RESULTS

In phase I the diagnostic accuracy of ultrasonography in detecting intussusception was 53.8%, and 100% in phase II. The success rate of ultrasound-guided saline enema was 55.5% in phase I, and 83.8% in phase II. Only 6 patients (16.2%) underwent operative manual reduction of intussusception in phase II. There were no cases with boewl gangrene or perforations in both groups.

CONCLUSIONS

Ultrasonography is a useful screening tool in the diagnosis of intussusception. Tme main advantage of hydrostatic reduction with ultrasound guidance is avoidance of ionizing radiation. The success rate of this method of reduction may be increased with an integrated team approach to the management and with modifications of the technique.

Test characteristics of the 3-view abdominal radiograph series in the diagnosis of intussusception

OBJECTIVES

To determine the test characteristics of the 3-view abdominal radiograph series to exclude intussusception in children presenting to the pediatric emergency department.

METHODS

We performed a single-center retrospective review of children for whom supine, prone, and lateral decubitus abdominal radiographs were performed as part of our standard diagnostic evaluation for intussusception. A pediatric radiologist masked to the patient's clinical data and outcome reviewed all radiographs. The criterion evaluated was whether air was visualized in the ascending colon on each of the 3 radiograph views. We determined the presence or absence of intussusception hierarchically by definitive radiological study report, surgical operative note, or clinical outcome.

RESULTS

We analyzed 179 patients, of whom 27 (15.1%) were diagnosed with intussusception. The test characteristics of the 3-view radiograph series in the diagnosis of intussusception when all 3 views had air in the ascending colon were sensitivity of 100% (95% confidence interval [CI] 87-100), specificity of 18.4% (95% CI, 12.3-24.6), likelihood ratio for a negative test of 0 (95% CI, 0.01-1.53), and negative predictive value (NPV) of 100% (lower bound 95% CI, 98%). When at least 2 views had air in the ascending colon, the test characteristics were sensitivity of 96.3% (95% CI, 89.2-100), specificity of 41.4% (95% CI, 33.6-49.3), likelihood ratio for a negative test of 0.09 (0.01-0.62), and NPV of 98.4 (95% CI, 95.2-100).

CONCLUSIONS

Using specific criteria, the presence of air in the ascending colon on 2 or 3 abdominal radiograph views has the potential to substantially decrease the likelihood of or exclude intussusception.

[Ultrasonography in the diagnosis of hypertrophic pyloric stenosis and intussusception--emergency conditions in pediatric gastroenterology]

Hypertrophic pyloric stenosis (HPS) is the most common abdominal surgical condition in newborns and infants, while intussusception is the most frequent problem in children between the ages of 6 months and 2 years. The aim of this study was to show the advantages of ultrasonography in diagnosis of hypertrophic pyloric stenosis and intussusception and also to point out the efficiency of ultrasound guided hydrostatic reduction of childhood intussusception, as a nonoperative therapeutic option.

MATERIAL AND METHODS

This study had a prospective design and included 208 patients in a 2-year period (2004-2005). Both US examinations were done using a linear 7.5 MHz probe, and the main ultrasound criteria for HPS were increased pyloric muscle thickness of 3 mm and over, as well as pyloric length over 15 mm, typical ultrasonic findings of intussusception included a target sign or a pseudokidney sign. Sonographically guided hydrostatic reduction of intussusceptions was also performed.

RESULTS

HPS was predominant in male infants, and the mean age was 40 days. The mean pyloric muscle thickness was 4.95 mm in infants with HPS, and the average length of the antroplyloric canal was 19.26 mm. In patients with intussusception, male predominance was also observed and the mean age was 1 year and 79 days. The intussusceptum was most often located in the cecoascending (53.6%) and transverse colon (21.4%). US-guided hydrostatic reduction of intussusception was successful in 82.14% of all cases.

DISCUSSION

Our findings are in absolute agreement with literature data regarding the average age of patients, both with HPS and intussusception, thickness of the muscular layer, length of the antropyloric canal, and extremely successfid US-guided hydrostatic reduction of intussusceptions.

CONCLUSION

Ultrasonography has proved to be a remarkably precise diagnostic modality in diagnosing HPS and intussusception, but also makes nonoperative treatment of intussusceptions possible in extremely high percentage.

Current radiological management of intussusception in children

Intussusception is the most common abdominal emergency situation in infants and small children. There has been great progress in diagnostic and therapeutic management of intussusception. Ultrasound (US) has been shown to be the first-choice imaging technique in diagnosing intussusception for reasons of high accuracy, simultaneous exclusion of differential diagnoses, and disclosure of additional pathologies. Controversial opinions exist worldwide concerning the nonoperative treatment of intussusception in infants and children. Pneumatic reduction under fluoroscopic guidance and hydrostatic reduction under US monitoring are the preferred techniques. The aim should be a success rate of at least 90% in idiopathic intussusception. This review summarizes different types of intussusception and outlines diagnostic aspects as well as several treatment concepts.

Success with hydrostatic reduction of intussusception in relation to duration of symptoms

BACKGROUND

It is widely believed that hydrostatic reduction of intussusception is less successful in children with prolonged symptoms prior to presentation.

AIM

To prospectively evaluate success in relation to duration of symptoms.

METHODS

Prospective study in which children, regardless of symptom duration, underwent an attempt at hydrostatic reduction.

RESULTS

Of 113 children presenting with intussusception, 16 had peritonitis and required immediate laparotomy. A hydrostatic reduction was attempted in 97 and was successful in 77 (79%). There were 26 successful reductions with symptoms <12 hours (81%), 30 with symptoms for 12-24 hours (81%), and 21 with symptoms >24 hours (75%).

CONCLUSION

The success rate with hydrostatic reduction was not significantly influenced by symptom duration.

Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module

OBJECTIVE

This article uses case examples to review the current evidence for the management of children with clinically suspected intussusception.

CONCLUSION

In this educational module, we review the evidence for diagnostic and management strategies in children with clinically suspected intussusception.

Intussuscepção em crianças: avaliação por métodos de imagem e abordagem terapêutica

A intussuscepção, uma emergência médica, ocorre com maior freqüência em crianças com idade abaixo dos dois anos. A tríade clássica de dor abdominal, fezes avermelhadas "em geléia" e massa abdominal palpável é observada em menos de 50% dos casos, tornando difícil seu diagnóstico clínico. Todavia, o diagnóstico de intussuscepção pode ser efetuado com radiografia simples, ultra-sonografia, tomografia computadorizada e enema baritado ou com gás/solução salina, com variável acurácia. Alguns destes métodos de imagem também proporcionam valiosa utilidade à terapia desta condição. Os autores fazem uma revisão da literatura, com ensaio iconográfico dos achados em pacientes com intussuscepção, e discutem os conceitos atuais e tópicos controversos relacionados ao seu tratamento.

The imaging of intussusception

Intussusception is defined as the telescoping of one segment of the gastrointestinal tract into an adjacent one. It is relatively common in children and is the second most common cause of an acute abdomen in this age group. It is much less common in adults and accounts for less than 5% of cases of mechanical small bowel obstruction. Whereas the diagnosis is usually already suspected in children before imaging, it is often made unexpectedly in adults. In addition, although in children there is usually no specific underlying cause, an underlying lead point is often present in adults. Plain film radiography, barium studies and ultrasound imaging play major roles in both the diagnosis and management of this condition, and it is increasingly common for the diagnosis to be made by CT and MRI, particularly in adults. This pictorial essay reviews the imaging features that may be found in patients with bowel intussusception. As well as describing the imaging features of the more commonly used tests, we also stress the role of emerging technologies such as MRI using ultrafast half-fourier sequences with single shot turbo spin echo.

Ultrasound evaluation of acute abdominal emergencies in infants and children

Ultrasound is extremely beneficial in the evaluation of acute pediatric abdominal disease, such as HPS, intussusception, and acute appendicitis. As techniques and equipment improve, its role in the evaluation of infants and children continues to increase.

Validity of plain films in intussusception

The aim of this study was to re-evaluate the specificity of plain film findings in intussusception. The plain film findings in 80 cases of proven intussusception were reviewed. Findings documented were: (1) presence or absence of small bowel obstruction, (2) paucity of right lower quadrant gas, (3) presence of an intracolonic mass, (4) presence of a rim or target sign, and (5) presence of the classic triad of intestinal obstruction, intracolonic mass, and paucity of right lower quadrant gas. Intestinal obstruction was present in 54% of patients. In 19 patients (24%) the abdominal films were completely normal. Paucity of right lower quadrant gas was seen in 10% of patients, while specific findings of a mass or a target (rim) sign were seen in 29% of patients. The classic triad of an intracolonic mass, obstruction, and paucity of gas in the right lower quadrant occurred in only 1 patient (1%). Plain films of the abdomen were diagnostic of intussusception in only 29% of cases. A completely normal gas pattern was seen in one-quarter of our patients. This being the case, most patients with suspected intussusception will require further imaging, either by ultrasound or contrast enema. In our institution we favor the ultrasound study.

The diagnosis of intussusception

The aims of this study were to identify features in the history, physical examination, and radiologic studies that were associated with the diagnosis of intussusception and to determine if there was a subset of patients being evaluated for intussusception who can be spared from undergoing a contrast enema based on a combination of historical, clinical, and radiographic findings. A retrospective cohort study at a regional children's hospital emergency department (ED) was conducted. Mean age was 1.2 years among both those with and without intussusception. Predictors of intussusception in the univariate analysis included history of vomiting (P=0.02), abdominal pain (P=0.1), and rectal bleeding (P=0.003); physical examination findings of abdominal mass (P<0.001), abdominal tenderness (P=0.02), and guiac positive stool (P=0.004); and plain radiograph finding of the absence of stool in the ascending colon (P<0.05). We were unable to develop a prediction model that would reliably identify all patients with the diagnosis of intussusception. Previously identified predictors of intussusception remain important in increasing suspicion of this important diagnosis. At this point there is no reliable prediction model that can accurately identify all patients with intussusception. A prospective study may aid in the development of a clinically more useful model.

Contemporary imaging of the child with abdominal pain or distress

As technological advances in the field of diagnostic imaging progress rapidly, there is increasing confusion as to how to utilize these resources efficiently in the evaluation of the child with acute abdominal pain. The history and physical examination become extremely important to help guide the subsequent imaging protocol. Plain films have limited value. Sonographic technology is particularly well suited to the child for the initial imaging investigation because the sonographic examination can demonstrate excellent sensitivity and specificity for some disease entities. Computed tomography is a useful adjunctive imaging modality, while magnetic resonance imaging for abdominal pain is still in its infancy. Nuclear medicine isotope studies will not be addressed in this review.

Investigation in vomiting children

This article discusses how to investigate various surgical causes of vomiting. Particular emphasis is placed on plain radiographic, ultrasound, and contrast study findings. The article touches upon nineteen different diseases, and encompasses diseases found in neonates to adolescents.

Imaging in acute abdomen

OBJECTIVE

The present study aims at establishing the exact role and limitation of ultrasound in pediatric acute abdomen.

METHODS

Fifty children less than 14 years of age presenting with acute abdomen were evaluated by US and other imaging modalities. The mean age of presentation was 3 1/2 years. Maximum number of cases were seen in less than two years of age. There were 17 cases of intussusception with US sensitivity and specificity of 88.2% and 100% respectively and positive and negative predictive values of 100% and 94.5% respectively. There were 13 cases of appendicitis. US was diagnostic in 11 with sensitivity and specificity of 91.6% and 97%; the positive and negative predictive values were 91.6% and 97% respectively.

RESULTS

There were two cases each of congenital bands, adhesive intestinal obstruction, malrotation of bowel with volvulus, incarcerated inguinal hernia, hypertrophic pyloric stenosis, duplication cyst and pseudopancreatic cyst, one case each of trichobezoar, Meckel's diverticulum, ureteric calculus and worms as a cause of intestinal obstruction. The sensitivity of US for diagnosing specific cause of acute abdomen was found to be 77.5%. The main limitation of US was in the diagnosis of acute intestinal obstruction such as congenital bands and adhesions.

CONCLUSION

US should now be considered as imaging modality of choice in pediatric acute abdomen. However, at times, plain radiography, conventional contrast studies and CT may be vital to reach the true diagnosis.