The Vomiting Neonate: A Review of the ACR Appropriateness Criteria and Ultrasound’s Role in the Workup of Such Patients

Vomiting, Pyloric Mass, and Point-of-Care Ultrasound: Diagnostic Test Accuracy for Hypertrophic Pyloric Stenosis-A Meta-Analysis

BACKGROUND

Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy.

OBJECTIVE

The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS.

METHODS

We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis.

RESULTS

From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1-99.3%) and a specificity of 94.1% (95% CI 88.7-97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6-82.1%) and a specificity of 97.5% (95% CI 93.8-99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1-96.0) and a specificity of 60.8% (95% CI 8.5-96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0.

CONCLUSIONS

Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures.

Upper GI series in infants and children with vomiting: insights into ACR appropriateness criteria

Background

Although upper gastrointestinal series (UGI) series are frequently requested in pediatric radiology department, there are few articles investigating its value in children with vomiting. The purpose of this study was to review imaging findings perceived during UGI series in infants and children presented with vomiting in correlation to their symptoms based on the ACR appropriateness criteria. This was to identify clinical scenarios with higher diagnostic yield.

Results

A cross-sectional study including UGI series of 76 patients presented with vomiting (1 month–17 years) was performed. Patients were grouped according to their age into 5 groups and stratified according to the type of vomiting into 3 groups (bilious vomiting, new-onset nonbilious vomiting, intermittent nonbilious vomiting since birth). Associated symptoms were described with calculation of a novel clinical score. Radiological abnormalities in different age groups were described in relation to the type of vomiting. All patients with bilious vomiting or nonbilious vomiting associated with melena or dysphagia had abnormal findings. Gastroesophageal reflux was detected in 25% of cases. Patients with normal and abnormal study were compared according to their clinical score. The clinical score was significantly higher in the group of patients with abnormal findings (p < .001). Patients with recurrent chest symptoms and loss of weight had significantly higher rate of abnormal findings.

Conclusion

UGI series had a higher diagnostic yield in patients with bilious vomiting, children with nonbilious vomiting with higher clinical scores when associated with recurrent chest symptoms, loss of weight, dysphagia, or GIT bleeding especially melena.

Early pyloric stenosis: a case control study

OBJECTIVE

Pyloric stenosis (PS) is rare in the first 2 weeks of life, often leading to delays in diagnosis and treatment. We conducted a case control study to delineate the characteristics of patients with early PS (EPS). In addition, we tested the hypothesis that patients with EPS present with a smaller pylorus than older patients.

METHODS

A database of all patients presenting with PS to a children's hospital over a 5-year period (2002-2006) was obtained. Each patient admitted during the first 2 weeks of life (subject) was matched to a patient admitted after 4 weeks of age (control), with the same gender, electrolyte status, and treating surgeon. A single pediatric radiologist, blinded to patient age, reviewed all available ultrasounds retrospectively. Demographic, clinical, diagnostic, therapeutic, and outcome data were compared.

RESULTS

During the study period, 278 pyloromyotomies were performed for PS. Sixteen patients (5.8%) presented with EPS between 2 and 14 days of life. EPS patients had a higher prevalence of positive family history (31 vs. 0%, P = 0.043), and breast milk feeding (75 vs. 31%, P = 0.045). Sonographic measurements showed a pylorus that was of significantly less length (17.1 +/- 0.6 vs. 20.5 +/- 0.9 mm, P = 0.006) and muscle thickness (3.5 +/- 0.2 vs. 4.9 +/- 0.2 mm, P < 0.001) in patients with EPS. Hospital stay was significantly longer for EPS patients (4.3 +/- 0.9 vs. 2.0 +/- 0.1 days, P = 0.19).

CONCLUSIONS

Babies presenting with EPS are more likely to be breast fed and to have a positive family history. EPS is associated with a longer hospital stay. Use of sonographic diagnostic measurements specific to this age group may prevent delays in diagnosis and treatment, and improve outcomes.

Gastrointestinal symptoms in infancy: a population-based prospective study

BACKGROUND

During the first months of life, infants can suffer from many 'minor' gastroenterological disturbances. However, little is known about the frequency of these problems and the factors which predispose or facilitate their onset.

AIMS

(a) To ascertain the frequency of the most common gastrointestinal symptoms in infants during the first 6 months after birth; (b) to evaluate the influence of some variables on the onset of the symptoms.

STUDY DESIGN AND PATIENTS

Each of the 150 paediatricians distributed throughout Italy followed 20 consecutive infants from birth to 6 months. 2879 infants (1422 f, 1457 m) concluded the study. The presence of the following symptoms was evaluated: constipation, diarrhoea, vomiting, regurgitation, failure to thrive and prolonged crying fits (colic). Symptoms were recorded whenever the parents requested a clinical check-up or during a set monthly examination.

RESULTS

1582/2879 (54.9%) infants suffered from one of the gastrointestinal symptoms. Regurgitation was the most common disturbance (present in 23.1% of infants), followed by colic (20.5%), constipation (17.6%), failure to thrive (15.2%), vomiting (6%) and diarrhoea (4.1%). Low birth weight was the factor most frequently associated with the onset of gastrointestinal symptoms, followed by low gestational age. Feeding habits did not influence the onset of symptoms, with the exception of constipation, which was linked to a low frequency of breast-feeding. Ninety-three infants (3.2%) were hospitalised for one or more of the gastrointestinal symptoms which were considered. During the whole study period the type of formula-milk was changed in 60% of the infants with one or more gastrointestinal symptoms, and in 15.5% of the infants who did not suffer from any gastrointestinal troubles.

CONCLUSIONS

Gastrointestinal symptoms are very common in infants during the first 6 months after birth. These symptoms required hospitalisation only in a small percentage of cases, but led to the prescription of a 'dietary' milk formula in approximately 60% of the cases. Low birth weight and low gestational age were the main factors influencing the onset of the symptoms.