Accuracy of ultrasonography for the diagnosis of intussusception in infants in Vietnam

Development and evaluation of an artificial intelligence system for children intussusception diagnosis using ultrasound images

Accurate identification of intussusception in children is critical for timely non-surgical management. We propose an end-to-end artificial intelligence algorithm, the Children Intussusception Diagnosis Network (CIDNet) system, that utilizes ultrasound images to rapidly diagnose intussusception. 9999 ultrasound images of 4154 pediatric patients were divided into training, validation, test, and independent reader study datasets. The independent reader study cohort was used to compare the diagnostic performance of the CIDNet system to six radiologists. Performance was evaluated using, among others, balance accuracy (BACC) and area under the receiver operating characteristic curve (AUC). The CIDNet system performed the best in diagnosing intussusception with a BACC of 0.8464 and AUC of 0.9716 in the test dataset compared to other deep learning algorithms. The CIDNet system compared favorably with expert radiologists by outstanding identification performance and robustness (BACC:0.9297; AUC:0.9769). CIDNet is a stable and precise technological tool for identifying intussusception in ultrasound scans of children.

The diagnosis and treatment of retrograde intussusception: a single-centre experience

Background/Purpose

To investigate the clinical manifestations, treatments of retrograde intussusception and summarize the experience.

Methods

Children with retrograde intussusception treated in our hospital from January 2011 to January 2021 were retrospectively analysed. Demographics, clinical manifestations, preoperative colour Doppler ultrasound (CDU) findings, findings during surgery and follow-up results were collected.

Results

A total of 4719 cases of intussusception were treated in our department, including 12 cases of retrograde intussusception (0.25%). There were 8 males and 4 females.The age ranged from 4.1 to 14.3 months, with an average of (8.3 ± 2.8) months.; The weight ranged from 5.5 to 12.6 kg, with an average of (9.4 ± 2.3) kg; The onset time ranged from 6 to 15 h, with an average of (10.0 ± 2.4) h. All the children received CDU examination before surgery, and in one case, the possibility of 2 intussusception masses was considered. Emergency surgical exploration was performed after the failure of air enema reduction. During the operation, multiple types of intussusception were found (coincidence of anterograde and retrograde intussusception). The pattern of anterograde intussusception was all ileo-ileo-colic variety and the retrograde intussusception was proximal sigmoid colon into descending colon. All the children were successfully reduced by manual reduction without intestinal necrosis or intestinal malformation. All children were discharged 6–7 days after surgery, and had no recurrence after 3–6 months of follow-up.

Conclusions

Retrograde intussusception is easily misdiagnosed before surgery. During air enema, if the intussusception mass was fixed and did not move with increasing pressure, we should be aware of the possibility of retrograde intussusception, and the enema pressure should not be too large to avoid intestinal perforation. If the intraoperative position of the intussusception mass was not consistent with that of the preoperative enema, it was recommended to use bimanual examination to explore whether there was still a mass in the abdominal cavity to avoid misdiagnosis.

Evaluation of bedside sonography performed by emergency physicians to detect intussusception in children in the emergency department

OBJECTIVE

The aim of our study was to evaluate the test characteristics of point-of-care ultrasound (POCUS) performed by emergency physicians with varying levels of experience among children having undergone diagnostic radiology ultrasound for intussusception in a pediatric emergency department (PED).

METHODS

This was a subanalysis of a prospective cohort study conducted at a tertiary care PED. The study population was a sample of children younger than 5 years old who required an abdominal ultrasound for suspected intussusception. Participating physicians had varying levels of POCUS experience. They received a 1-hour didactic and practical training session on intussusception ultrasound. All POCUS was performed following the initial physical examination and prior to further radiologic evaluation. The final outcome was determined by radiologic evaluation performed by a pediatric radiologist. Test characteristics were calculated for POCUS compared with the criterion standard of ultrasound read by a pediatric radiologist. A secondary analysis compared test characteristics of POCUS performed by physicians with different level of POCUS training.

RESULTS

A total of 131 children were evaluated by POCUS, of whom 45 (34%) had an intussusception. Twenty-four physicians performed between one and 25 POCUS procedures. POCUS identified 39 of 45 intussusception cases, with a sensitivity of 0.87 (95% confidence interval [CI] = 0.74 to 0.94). A normal or inconclusive POCUS was reported for 83 of the 86 negative studies, with a specificity of 0.97 (95% CI = 0.90 to 0.99). When excluding the 28 patients for whom the physician reported an inconclusive examination, the sensitivity improved to 0.98 (95% CI = 0.97 to 1.00) and the specificity to 0.94 (95% CI = 0.85 to 0.99). The accuracy of diagnosis using POCUS was 42 of 43 (98%) for experienced sonographers in comparison to 81 of 88 (92%) for novices.

CONCLUSION

This study demonstrated a very good sensitivity and specificity of POCUS for intussusception in children when performed by multiple emergency physicians with varying POCUS experience.

Ultrasonographic Diagnosis of Intussusception in Children: A Systematic Review and Meta-Analysis

Ultrasonography offers a unique advantage in the clinical diagnosis of intussusception. We aimed to evaluate the diagnostic accuracy of ultrasonography in pediatric intussusception. The PubMed, Embase, Web of Science, Cochrane Library databases, and African Journals Online database were searched for studies pertaining to ultrasonographic diagnosis of intussusception in children. Finally, 14 studies (combined n = 2367) were found eligible for inclusion. Pooled sensitivity and specificity were 0.94 (95% confidence interval: 0.91-0.96) and 0.96 (95% confidence interval: 0.93-0.98), respectively. In conclusion, ultrasonography has high sensitivity and specificity in the diagnosis of intussusception.

Point-of-Care Ultrasound May Reduce Misdiagnosis of Pediatric Intussusception

Aim: Intussusception, the most common abdominal emergency in early childhood, is frequently misdiagnosed at initial presentation. The effect of using point-of-care ultrasonography (POCUS) by emergency medicine physicians on pediatric intussusception misdiagnosis rate remains unclear. Here, we summarize outcomes and misdiagnoses before and after training junior and senior physicians on using POCUS for diagnosing intussusception and compared their performance levels. Materials and Methods: This observational cohort analysis included patients with suspected intussusception who visited a pediatric emergency department (ED) between January 2017 and December 2019. All enrolled patients were evaluated by junior (<10-year experience) or senior attending physicians. Misdiagnosis was defined as a finding of negative air reduction or confirmation of diagnosis on ED revisit or admission. The misdiagnosis rates and outcomes before and after POCUS training for intussusception diagnosis were evaluated and performance of the junior and senior physicians was compared. Results: Of the 167 enrolled patients, 130 were confirmed to have intussusception by air reduction. Misdiagnosis rate was significantly lower in the post-training patient group after training than in the pre-training patient group (43.7 vs. 12.7%, P < 0.001). After training, fewer misdiagnoses were made by the junior (59.1 vs. 25.9%, P = 0.003) and senior (31.7 vs. 0%, P < 0.001) physicians. In the post-training patient group, the door-to-reduction time and rate of ultrasonography consultation with an expert also decreased significantly (118.2 ± 124.5 vs. 198 ± 250.2 min, P = 0.006). Abdominal pain (80.9%) was the most common symptom of intussusception, followed by vomiting (58.3%), fever (17.8%), bloody stool (15.4%), and diarrhea (14.2%). Even after training, the presenting symptoms of intussusception often leading junior physicians to misdiagnosis were diarrhea and fever. Conclusions: A brief POCUS training leads to decreased misdiagnosis rates in both the senior and junior physicians. Junior physicians should increase their awareness regarding diarrhea and fever being the presenting symptoms of intussusception, particularly in early childhood. Combining clinical judgment and POCUS results forms the core principle of the evaluation of children with intussusception.

Ultrasonography for the Diagnosis of Intussusception in Children: An Experience From Pakistan

INTRODUCTION

Intussusception can lead to small bowel obstruction in children, hence the early diagnosis of this condition is very important. The purpose of this study is to evaluate the accuracy of sonography in the diagnostic work-up of children with suspected intussusceptions in the emergency setting, keeping surgical findings as the gold standard.

METHODS AND DESIGN

Two hundred patients with classical presentation of intussusceptions, who were diagnosed either by barium enema or CT scan, were included in this study. Patients with irreducible intussusceptions on color Doppler were followed after surgery.

RESULTS

The average age of the patients was 6.7 ± 2.8 years, and the study population consisted of 115 (57.5%) boys and 85 (42.5%) girls. One hundred forty-three patients were confirmed to have intussusception on ultrasonography, of whom 117 (81.8%) were confirmed to have intussusception after surgery while 26 (18%) were not diagnosed with intussusception during surgery. Despite the clinical presentation of intussusceptions, ultrasonography was not diagnostic in 57 patients, of whom 28 were confirmed to have intussusception after surgery and 29 were not found to have the disease.

CONCLUSION

Use of ultrasonography in cases with intussusception has proven to be a reliable and accurate method for diagnosing intussusception and provides an advantage over unnecessary radiological or surgical procedures being performed.

Variation in the Presentation of Intussusception by Age

OBJECTIVE

To compare the clinical presentation of intussusception among children younger and older than 24 months of age.

DESIGN/METHODS

We performed a retrospective cross-sectional cohort study of children treated in the emergency department, aged 1 month to 6 years, who had an abdominal ultrasound to evaluate for intussusception over a 5-year period. After stratifying by an age cut-point of 24 months, univariate and multivariate analyses were performed.

RESULTS

One thousand two hundred fifty-eight cases of suspected intussusception were studied; median age was 1.7 years (interquartile range, 0.8, 2.9 years), and 37% were female. Intussusception was identified in 176 children (14%); 153 (87%) were ileocolic, and 23 were ileoileal. Abdominal pain (odds ratio, 4.0; 95% confidence interval [CI], 1.5-10.5), emesis (OR, 3.5; 95% CI, 1.8-6.7), bilious emesis (OR, 2.9; 95% CI, 1.5-5.7), lethargy (OR, 2.3; 95% CI, 1.3-5.7), rectal bleeding (OR, 2.8; 95% CI, 1.4-5.7), and irritability (OR, 0.4; 95% CI, 0.2-0.8) were found to be predictors in those younger than 24 months. In children older than 24 months, male sex was the only predictor identified (OR, 2.0; 95% CI, 1.1-3.7). In cases where abdominal radiographs were obtained (n = 1212), any abnormality on abdominal radiograph was found to be predictive in both age groups (OR, 7.8; 95% CI, 3.8-25.7; and OR, 3.1; 95% CI, 1.8-5.2, respectively).

CONCLUSIONS

Intussusception presents differently in children younger than 24 months compared with older children. "Traditional" clinical predictors of intussusception should be interpreted with caution when assessing children older than 2 years.

Positive guaiac and bloody stool are poor predictors of intussusception

BACKGROUND

Currant jelly stool is a late manifestation of intussusception and is rarely seen in clinical practice. Other forms of GI bleeding have not been thoroughly studied and little is known about their respective diagnostic values.

OBJECTIVE

To assess the predictive value of GI bleeding (positive guaiac test, bloody stool and rectal bleeding in evaluation of intussusception.

METHODS

We performed a retrospective cross-sectional study cohort of all children, ages 1month-6years of age, who had an abdominal ultrasound obtained evaluating for intussusception over 5year period. We identified intussusception if diagnosed by ultrasound, air-contrast enema or surgery. Univariate and a multivariate logistic regression analysis were performed.

RESULTS

During the study period 1258 cases met the study criteria; median age was 1.7years (IQR 0.8, 2.9) and 37% were females. Overall 176 children had intussusception; 153 (87%) were ileo-colic and 23 were ileo-ileal. Univariate risk ratio and adjusted Odds ratio were 1.3 (95% CI, 0.8, 2.0) and 1.3 (0.7, 2.4) for positive guaiac test, 1.1 (0.6, 2.1) and 0.9 (0.3, 3.0) for bloody stool, and 1.7 (1.02, 2.8) and 1.3 (0.5, 3.1) for rectal bleeding .

CONCLUSION

Blood in stool, whether visible or tested by guaiac test has poor diagnostic performance in the evaluation of intussusception and is not independently predictive of intussusception. If the sole purpose of a rectal exam in these patients is for guaiac testing it should be reconsidered.

Point-of-Care Ultrasonography for the Rapid Diagnosis of Intussusception: A Case Series

We present a case series describing an infant and a child who presented with abdominal discomfort and their conditions were diagnosed with intussusception by point-of-care ultrasound. These cases illustrate how point-of-care ultrasound led to the expeditious diagnosis of intussusception.

The role of US in finding intussusception and alternative diagnosis: a report of 100 pediatric cases

BACKGROUND

The clinical diagnosis of intussusception remains challenging, because many children with intussusception may present with non-specific signs and symptoms, which overlap with other conditions. Therefore imaging, in particular ultrasonography (US), plays a significant role in the management of these patients.

PURPOSE

To evaluate how US can contribute to the diagnosis in clinically suspected intussusception and finding alternative diagnosis.

MATERIAL AND METHODS

We retrospectively reviewed reports of US examinations and medical records of 100 patients (51 boys, 49 girls; mean age, 23.0 ± 12.1 months) who underwent abdominal US for clinically suspected intussusception. Each US study was assessed for the presence or absence of intussusception and for a possible alternative diagnosis in cases interpreted as negative for intussusception.

RESULTS

Thirty-seven patients had US findings consistent with intussusception, which was confirmed by air enema. In seven patients, US studies were normal. Alternative diagnoses were identified by US for each of the remaining 56 patients, including ileocolitis (n = 20), terminal ileitis (n = 18), mesenteric lymphadenitis (n = 13), choledochal cyst (n = 1), accessory spleen torsion (n = 1), small bowel ileus (n = 1), midgut volvulus with bowel ischemia (n = 1), and hydronephrosis (n = 1).

CONCLUSION

With the high sensitivity and specificity of this study we conclude that US is valuable in detecting intussusception and finding the alternative diagnosis.

Incidence and Epidemiology of Intussusception among Infants in Ho Chi Minh City, Vietnam

OBJECTIVE

To evaluate rates of intussusception hospitalization among infants in Vietnam before the introduction of rotavirus vaccine.

STUDY DESIGN

Between 2009 and 2011, we identified intussusception hospitalizations among infants using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification code K56.1 at 2 large pediatric hospitals in Ho Chi Minh City, Vietnam that treat most of the intussusception cases in the city. We reviewed all medical records to confirm a Brighton level 1 case definition for intussusception.

RESULTS

We identified a total of 869 intussusception cases in Ho Chi Minh City during the 3-year study period, for an annual rate of 296 per 100,000 infants. The mean age of intussusception was ∼ 37 weeks (8.6 months), with <2% of the cases occurring before age 15 weeks. Cases of intussusception were observed year-round in these hospitals with no evident seasonal pattern. Ultrasonography was used to diagnose most cases (97%), and reduction was performed by air enema in >95% of the cases, with only 1% of cases at 1 hospital and 5% at the other hospital requiring surgical intervention. Ultrasound diagnosis was confirmed by an independent radiologist in 94% of a randomly selected group of intussusception cases at 1 of the 2 hospitals. No mortality was reported.

CONCLUSION

Vietnam has a substantially higher rate of intussusception in children aged >15 weeks compared with most other regions of the world. Most of our cases were diagnosed by ultrasound, and only a small proportion required surgical intervention with no fatalities, suggesting that the higher rates may be related in part to better and earlier detection of intussusception.

Childhood intussusception: a literature review

Background

Postlicensure data has identified a causal link between rotavirus vaccines and intussusception in some settings. As rotavirus vaccines are introduced globally, monitoring intussusception will be crucial for ensuring safety of the vaccine programs.

Methods

To obtain updated information on background rates and clinical management of intussusception, we reviewed studies of intussusception in children <18 years of age published since 2002. We assessed the incidence of intussusception by month of life among children <1 year of age, seasonality, method of diagnosis, treatment, and case-fatality.

Findings

We identified 82 studies from North America, Asia, Europe, Oceania, Africa, Eastern Mediterranean, and Central & South America that reported a total of 44,454 intussusception events. The mean incidence of intussusception was 74 per 100,000 (range: 9–328) among children <1 year of age, with peak incidence among infants 5–7 months of age. No seasonal patterns were observed. A radiographic modality was used to diagnose intussusception in over 95% of the cases in all regions except Africa where clinical findings or surgery were used in 65% of the cases. Surgical rates were substantially higher in Africa (77%) and Central and South America (86%) compared to other regions (13–29%). Case-fatality also was higher in Africa (9%) compared to other regions (<1%). The primary limitation of this review relates to the heterogeneity in intussusception surveillance across different regions.

Conclusion

This review of the intussusception literature from the past decade provides pertinent information that should facilitate implementation of intussusception surveillance for monitoring the postlicensure safety of rotavirus vaccines.

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.

Review: indications for ultrasound use in low- and middle-income countries

OBJECTIVE

To determine the indications for using ultrasound, in low- and middle-income countries (LMICs) and to assess whether its use alters clinical management.

METHODS

Literature review. We conducted a Pubmed search on the clinical use of ultrasound in LMIC for articles published between January 2000 and December 2010, recording country of origin, speciality and whether ultrasound use led to a change in management.

RESULTS

Fifty-eight articles were identified from 32 countries and represented nine specialties. Ultrasound was most commonly used for assisting with the diagnosis of obstetrical conditions, followed by intra-abdominal conditions such as liver abscesses and intussusceptions. Clinical management was altered in >30% of cases.

CONCLUSION

Ultrasound is a highly valuable diagnostic tool in LMICs and its use should be considered essential for all district medical facilities. The use could be applied more widely, eg., for tropical and non-communicable diseases. Additional research is needed to further characterize the impact of task shifting on ultrasound use in LMICs.

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.

Intussusception in infants younger than 3 months: a single center's experience

BACKGROUND

The diagnosis and treatment of intussusception is often confusing in infants aged younger than 3 months. This study aimed to discuss the particularity of diagnosis and treatment of intussusception in this age group.

METHODS

From April 1983 to June 2008, 39 infants aged 3 months or younger who had been diagnosed with intussusception were treated and their clinical data were analyzed retrospectively.

RESULTS

Of the 39 infants (29 boys and 10 girls), ages ranged from 12 hours to 3 months, with a mean age of 52.6 days. The duration from onset to admission ranged from 7 to 142 hours (mean 39.6 hours). Three infants had intrauterine intussusception and 36 postnatal intussusception. The 3 infants with intrauterine intussusception had typical presentations of complete ileus after birth. Gap type ileal atresia was found in surgery in 2 of the 3 infants and primary anatomosis was performed therapeutically. The other infant was found to have ileal separation and a patent proximal end with diffused meconium peritonitis. The patient died 2 days after primary anastomosis. Most infants with postnatal intussusception had two or more manifestations of the tetralogy, namely intermittent screaming, vomiting, bloody stool, and abdominal mass. In 23 infants who underwent pneumatic reduction, 17 had a successful reduction and 6 converted to open surgery. Surgery was indicated for 19 infants, with maneuver procedure in 14. Meckel's diverticulum was noted as a leading cause in 2 infants, ileal duplication in 1 with necrosis of intussusceptum, and primary intussusception with lead point necrosis in 2. The 5 infants, on whom segmental resection was performed, underwent primary anastomosis. All infants with postnatal intussusception had a smooth recovery.

CONCLUSIONS

Infants aged 3 months or younger may suffer from intussusception and most of them present with typical symptoms. Early diagnosis and treatment are needed for a good prognosis. Intrauterine intussusception may be an etiological factor for ileal atresia.

Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception

BACKGROUND

From the early 1980s onward, US has been considered a possible primary modality to assess patients for ileocolic intussusception. Since 2001, our institution has routinely used US to assess patients for ileocolic intussusception.

OBJECTIVE

We analyzed 7 years of institutional experience to assess the value of US as a primary diagnostic test for intussusception.

MATERIALS AND METHODS

This study was IRB-approved. From 1 January 2001 through 16 December 2007 814 US examinations for intussusception were performed in children aged 10 years and younger. Clinical records and radiological reports were reviewed for each patient, and cases were classified as true-positive, true-negative, false-positive, or false-negative.

RESULTS

Of the 814 US examinations, 112 (13.8%) were interpreted as positive for intussusception, and of these, 96 were confirmed by enema, 1 was confirmed by surgery, and 15 (13.4%) were false-positive. Of the 814 examinations, 700 (85.9%) were interpreted as negative for intussusception, and of these, 698 (99.7%) were true-negative, and 2 were false-negative. Less than 1% of studies were nondiagnostic. The overall sensitivity of US for detecting intussusception was 97.9% and specificity was 97.8%. The positive predictive value of the test was 86.6% and the negative predictive value was 99.7%.

CONCLUSION

US is a sensitive and specific test for detecting ileocolic intussusception and should be utilized as a first-line examination for assessment of possible pediatric intussusception.