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Tempel DG, Balk DS, Schafer JM, Hoffmann B. A brief review of diagnostic properties of point-of-care ultrasound for adult bowel intussusception: Making the case for ultrasound. J Ultrason 2023; 23:e90-e96. [PMID: 37520744 PMCID: PMC10379853 DOI: 10.15557/jou.2023.0016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/30/2023] [Indexed: 08/01/2023] Open
Abstract
Undifferentiated abdominal pain in adults is a common chief complaint in acute care clinics and emergency departments worldwide, representing up to 10% of visits to emergency departments. Many patients have a non-specific presentation and an initial workup with labwork, urine analysis or X-ray might not reveal a specific diagnosis. Although bowel intussusception is a primarily pediatric disease, adult intussusception is a recognized but rare cause of bowel obstruction often requiring surgical intervention. However, recent data from advanced multi-detector computed tomography imaging shows that milder or recurring cases in adults have been underrecognized. Multi-detector computed tomography is still the imaging gold standard for detecting intussusception in adults, but new data showed that sonographers with basic training using the point-of-care ultrasound approach have a reasonable accuracy in detecting this pathology. As the point-of-care ultrasound for undifferentiated abdominal pain is an emerging core skill in the acute care setting, knowledge of sonographic signs of intestinal intussusception should be included in the skill set of physicians. Sonographic findings in adults mimic pediatric cases, but different location patterns and higher malignancy rates exist in adults. In this manuscript, we will review the current literature on adult intussusception and summarize key knowledge of intestinal intussusception in adults. We will present four adult patients diagnosed with different types of adult acute bowel intussusception using the point-of-care ultrasound and describe a focused scanning approach with typical sonographic findings.
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Affiliation(s)
- David G. Tempel
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Daniel S. Balk
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Jesse M. Schafer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Beatrice Hoffmann
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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Paul SP, Holbrook F, Plowman L, James J. Abdominal X-rays in children: indications, procedure and interpretation. Nurs Child Young People 2021; 34:e1410. [PMID: 34779158 DOI: 10.7748/ncyp.2021.e1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 11/09/2022]
Abstract
Abdominal X-rays (AXRs) are often used as an imaging modality in children who present with abdominal pain with a suspected serious underlying pathology. Nausea, vomiting and constipation that are unresponsive to treatment may also prompt a request for an AXR in a child. Nurses play an important role in ensuring that requests for AXRs in children are appropriate and that the procedure is performed safely. This is the second of two articles on the use of AXRs for diagnosing abdominal pathologies in childhood. The first article focused on AXRs in neonates. This one focuses on AXRs in children, discussing their indications, procedure and interpretation and describing abdominal conditions in children for which an AXR is likely to support diagnosis.
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Affiliation(s)
| | | | - Lisa Plowman
- children's ward, Yeovil District Hospital, Yeovil, England
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Hsiao HJ, Wang CJ, Lee CC, Hsin YC, Yau SY, Chen SY, Lo WC, Wu PW, Chen CL, Chang YJ. Point-of-Care Ultrasound May Reduce Misdiagnosis of Pediatric Intussusception. Front Pediatr 2021; 9:601492. [PMID: 33614550 PMCID: PMC7889804 DOI: 10.3389/fped.2021.601492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/08/2021] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Hsiang-Ju Hsiao
- Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Department of Pediatrics, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chao-Jan Wang
- Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chien-Chung Lee
- Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Chen Hsin
- Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Sze-Yuen Yau
- Chang Gung Medical Education Research Centre, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shih-Yen Chen
- Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Wan-Chak Lo
- Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Patricia-Wanping Wu
- Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chyi-Liang Chen
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Jung Chang
- Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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4
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Lee JY, Kim JH, Choi SJ, Lee JS, Ryu JM. Point-of-care ultrasound may be useful for detecting pediatric intussusception at an early stage. BMC Pediatr 2020; 20:155. [PMID: 32284038 PMCID: PMC7153228 DOI: 10.1186/s12887-020-02060-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to verify the usefulness of point-of-care ultrasound (POCUS) performed by pediatric emergency physicians for detecting intussusception at an early stage. METHODS This retrospective study included 1-month- to 6-year-old children with clinically suspected intussusception, who underwent POCUS in the pediatric emergency department between December 2016 and February 2018. The criteria for performing POCUS were set to broader standards: presenting any one of intermittent abdominal pain/irritability or bloody stool, or ≥ 2 symptoms among nonspecific abdominal pain/irritability, abdominal mass/distension, vomiting, or lethargy. POCUS results were interpreted and categorized as "negative" or "suspicious," and a radiologist performed confirmatory ultrasound in "suspicious" cases. RESULTS We analyzed 575 POCUS scans from 549 patients (mean age, 25.5 months). Among the 92 "suspicious" cases (16.0%), 70 (12.2%) were confirmed to have intussusception. POCUS showed 100% sensitivity, 95.6% specificity, and 97.8% accuracy. Patients with confirmed intussusception were mainly diagnosed in the early stages, with a mean symptom duration of 11.7 h, and most patients (97.1%) were treated successfully via air enema reduction. Compared to the non-intussusception group, the intussusception group had more intermittent abdominal pain (P < 0.001), but less vomiting (P = 0.001); the other clinical features showed no intergroup differences. CONCLUSION POCUS performed using the criteria set to broader standards by pediatric emergency physicians may be useful for detecting intussusception at an early stage, which may present with obscure clinical symptoms.
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Affiliation(s)
- Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Jung Heon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Seung Jun Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jong Seung Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Min Ryu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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5
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Chang HC, Wang CJ, Lai JY. Lead point in a colo-colic intussusception identified by combined air and barium enema. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
BACKGROUND Intussusception is a common abdominal emergency in children with significant morbidity. Prompt diagnosis and management reduces associated risks and the need for surgical intervention. Despite widespread agreement on the use of contrast enema as opposed to surgery for initial management in most cases, debate persists on the appropriate contrast medium, imaging modality, pharmacological adjuvant, and protocol for delayed repeat enema, and on the best approach for surgical management for intussusception in children. OBJECTIVES To assess the safety and effectiveness of non-surgical and surgical approaches in the management of intussusception in children. SEARCH METHODS We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library; Ovid MEDLINE (1950 to September 2016); Ovid Embase (1974 to September 2016); Science Citation Index Expanded (via Web of Science) (1900 to September 2016); and BIOSIS Previews (1969 to September 2016).We examined the reference lists of all eligible trials to identify additional studies. To locate unpublished studies, we contacted content experts, searched the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (September 2016), and explored proceedings from meetings of the British Association of Paedatric Surgeons (BAPS), the American Soceity of Pediatric Surgery, and the World Congress of Pediatric Surgery. SELECTION CRITERIA We included all randomised controlled trials comparing contrast media, imaging modalities, pharmacological adjuvants, protocols for delayed repeat enema, and/or surgical approaches for the management of intussusception in children. We applied no language, publication date, or publication status restrictions. DATA COLLECTION AND ANALYSIS Two review authors independently conducted study selection and data extraction and assessed risk of bias using a standardised form. We resolved disagreements by consensus with a third review author when necessary. We reported dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We analysed data on an intention-to-treat basis and evaluated the overall quality of evidence supporting the outcomes by using GRADE criteria. MAIN RESULTS We included six randomised controlled trials (RCTs) with a total of 822 participants. Two trials compared liquid enema reduction plus glucagon versus liquid enema alone. One trial compared liquid enema plus dexamethasone versus liquid enema alone. Another trial compared air enema plus dexamethasone versus air enema alone, and two trials compared use of liquid enema versus air enema. We identified three ongoing trials.We judged all included trials to be at risk of bias owing to omissions in reported methods. We judged five of six trials as having high risk of bias in at least one domain. Therefore, the quality of the evidence (GRADE) for outcomes was low. Interventions and data presentation varied greatly across trials; therefore meta-analysis was not possible for most review outcomes. Enema plus glucagon versus enema alone It is uncertain whether use of glucagon improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 218 participants; RR 1.09, 95% CI 0.94 to 1.26;low quality of evidence). No trials in this comparison reported on the number of children with bowel perforation(s) nor on the number of children with recurrent intussusception. Enema plus dexamethasone versus enema alone Use of the adjunct, dexamethasone, may be beneficial in reducing intussusception recurrence with liquid or air enema (two trials, 299 participants; RR 0.14, 95% CI 0.03 to 0.60; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 13 (95% CI 8 to 37). It is uncertain whether use of the adjunct, dexamethasone, improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 356 participants; RR 1.01, 95% CI 0.92 to 1.10;low quality of evidence). Air enema versus liquid enema Air enema may be more successful than liquid enema for reducing intussusception (two trials, 199 participants; RR 1.28, 95% CI 1.10 to 1.49; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 6 (95% CI 4 to 19). No trials in this comparison reported on the number of children with bowel perforation(s) or on the number of children with recurrent intussusception nor any intraoperative complications, such as bowel perforation, or other adverse effects. Only one trial reported postoperative complications, but owing to the method of reporting used, a quantitative analysis was not possible. We identified no studies that exclusively evaluated surgical interventions for management of intussusception. AUTHORS' CONCLUSIONS This review identified a small number of trials that assessed a variety of interventions. All included trials provided evidence of low quality and were subject to serious concerns about imprecision, high risk of bias, or both. Air enema may be superior to liquid enema for successfully reducing intussusception in children; however, this finding is based on a few studies including small numbers of participants. Dexamethasone as an adjuvant may be more effective in reducing intussusception recurrence rates following air enema or liquid enema, but these results are also based on a few studies of small numbers of participants. This review highlights several points that need to be addressed in future studies, including reducing the risk of bias and including relevant outcomes. Specifically, surgical trials are lacking, and future research is needed to address this evidence gap.
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Affiliation(s)
- Steven Gluckman
- Sydney Adventist HospitalUniversity of SydneyWahroonga NSW 2076SydneyAustralia
| | | | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
| | - Richard G McGee
- The Children's Hospital at WestmeadInstitute of Endocrinology and DiabetesLocked Bag 4001WestmeadNSWAustralia2145
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7
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Carroll AG, Kavanagh RG, Ni Leidhin C, Cullinan NM, Lavelle LP, Malone DE. Comparative Effectiveness of Imaging Modalities for the Diagnosis and Treatment of Intussusception: A Critically Appraised Topic. Acad Radiol 2017; 24:521-529. [PMID: 28268146 DOI: 10.1016/j.acra.2017.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/15/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of intussusception and methods used in the treatment of ileocolic intussusception. METHODS A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome (PICO) method comparing radiography, ultrasound, and computed tomography in the detection of intussusception. The same methods were used to compare pneumatic (gas) reduction and hydrostatic (liquid) reduction using saline, water-soluble contrast, and barium. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies. RESULTS The retrieved sensitivity for the diagnosis of intussusception using plain radiography is 48% (95% confidence interval [CI], 44%-52%), with a specificity of 21% (95% CI, 18%-24%). The retrieved sensitivity for the diagnosis of intussusception using ultrasound is 97.9% (95% CI, 95%-100%), with a specificity of 97.8% (95% CI, 97%-99%). Based on a good quality meta-analysis, the combined success rate of gas enema reduction was shown to be 82.7% (95% CI, 79.9%-85.6%) compared to a combined success rate of 69.6% (95% CI, 65.0%-74.1%) for liquid enema reduction. CONCLUSIONS The best available evidence recommends ultrasound as the diagnostic modality of choice for the diagnosis of ileocolic intussusception in children. In stable children without signs of peritonism, nonoperative reduction is the treatment of choice. Pneumatic (gas) reduction enema has been shown to be superior to hydrostatic (liquid) enema reduction.
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Affiliation(s)
- Anne G Carroll
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Richard G Kavanagh
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | | | - Noelle M Cullinan
- Department of Pediatrics, Our Lady's Children's Hospital, Dublin, Ireland
| | - Lisa P Lavelle
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Dermot E Malone
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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8
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Abstract
BACKGROUND Children with intussusception require rapid and accurate diagnosis to enable timely intervention for satisfactory outcome. Ultrasonography is the recommended standard diagnostic modality; however, abdominal radiography (AR) is still used as an initial investigation. The aim of this study was to investigate the benefit of AR in intussusception by determining diagnostic accuracy and analysing correlation of AR findings with outcome. METHODS Index cases of intussusception presenting over 15 years (1998-2013) were analysed. Those who had AR performed were allocated into groups with positive or normal findings. Outcome of pneumatic reduction of intussusception (PRI) between these groups was compared. RESULTS Six hundred and forty-four cases of intussusception treated with PRI were identified, 412 (64 %) had AR performed and 232 (36 %) did not. 303 (74 %) radiographs had positive findings and 109 (26 %) were normal. The success rate of PRI did not differ between AR positive (82 %) and AR normal (84 %). Occult pneumoperitoneum was not detected in any patient by AR in our cohort. CONCLUSION AR is not recommended for the diagnosis of intussusception in children, for the prediction of the outcome of PRI or for the detection of occult pneumoperitoneum. AR should always be performed when clinical peritonism is present but is not otherwise necessary in children with suspected or confirmed intussusception.
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Adult intussusception caused by myoepithelial hamartoma in the small bowel: A case report. Int J Surg Case Rep 2015; 8C:92-5. [PMID: 25644557 PMCID: PMC4353930 DOI: 10.1016/j.ijscr.2015.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Intussusception is rare in adults and can have acute, intermittent or chronic presentations. We present an unusual case of intussusception in an adult. PRESENTATION OF CASE A 25 year old male presented with sudden severe abdominal pain and vomiting. He had no relevant medical history. Mechanical small bowel obstruction was confirmed on imaging and laparotomy revealed a nodular lead point in the submucosa of the ileum. He had resection of a segment of small bowel with a primary anastamosis. Histopathology of the lesion demonstrated myoepithelial hamartoma (MEH), a rare cause of intussusception. DISCUSSION Although intussusception is not uncommon in children, it is rare in adults. Management delays are a major cause of morbidity. This report details our management of a case of intussusception caused by MEH in an otherwise healthy adult. CONCLUSION Intussusception caused by MEH is a rare but serious cause of mechanical bowel obstruction. We propose that surgeons should consider this diagnosis in atypical cases of bowel obstruction and expedite laparotomy when it is suspected.
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10
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Patel S, Eagles N, Thomas P. Jejunal intussusception: a rare cause of an acute abdomen in adults. BMJ Case Rep 2014; 2014:bcr-2013-202593. [PMID: 24872480 DOI: 10.1136/bcr-2013-202593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abdominal pain secondary to intussusception is a common presentation in the paediatric population but rare in adults. Diagnosis is often difficult due to non-specific signs and symptoms. Adult intussusception presents more insidiously with intermittent abdominal pain and signs and symptoms of an acute abdomen are rare. In children, the aetiological factor is usually idiopathic, whereas intussusception in adults is more commonly due to an underlying pathology giving rise to a lead point. Consequently the treatment of choice is different-while it is supportive in children, surgical management is typically indicated in adults. In addition, the causes of a lead point precipitating adult intussusception are different depending on whether they arise from the small or large bowel. This report presents a case of jejunal intussusception in a 30-year-old man with a characteristic CT scan who required exploratory laparotomy and small bowel resection.
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Affiliation(s)
- Sonali Patel
- Department of Accident and Emergency, Milton Keynes General Hospital, Milton Keynes, UK
| | - Natasha Eagles
- Department of Accident and Emergency, Milton Keynes General Hospital, Milton Keynes, UK
| | - Peter Thomas
- Department of Accident and Emergency, Milton Keynes General Hospital, Milton Keynes, UK
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11
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Saliakellis E, Borrelli O, Thapar N. Paediatric GI emergencies. Best Pract Res Clin Gastroenterol 2013; 27:799-817. [PMID: 24160935 DOI: 10.1016/j.bpg.2013.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/21/2013] [Indexed: 01/31/2023]
Abstract
Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.
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Affiliation(s)
- Efstratios Saliakellis
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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Chang YJ, Chao HC, Wang CJ, Lo WC, Yan DC. Evaluating pediatric intussusception using 24-hour ultrasound. Pediatr Neonatol 2013; 54:235-8. [PMID: 23597532 DOI: 10.1016/j.pedneo.2013.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 08/21/2012] [Accepted: 01/11/2013] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Yi-Jung Chang
- Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Tauyuan, Taiwan
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13
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Comparison of clinicians to radiologists in assessment of abdominal radiographs for suspected intussusception. Pediatr Emerg Care 2013; 29:584-7. [PMID: 23603646 DOI: 10.1097/pec.0b013e31828e62d6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this study were to determine agreement of abdominal radiography (AXR) interpretation and to compare test characteristics, between pediatric emergency medicine (PEM) physicians and pediatric radiologists for evaluation of intussusception. METHODS This was a retrospective cohort study of children aged 3 months to 3 years presenting to a pediatric emergency department (ED) between 2007 and 2009. For inclusion, subjects required an ED presentation for suspected intussusception, performance of a 2-view AXR (supine and upright/lateral decubitus views) and abdominal ultrasound performed during the ED visit, and a subsequent criterion-standard measure for intussusception available (contrast enema, operative report, or clinical follow-up). All AXRs were reviewed by 2 blinded PEM physicians and 2 pediatric radiologists. Interrater agreement (κ) for AXR interpretation and diagnostic test characteristics were calculated for comparison. RESULTS A total of 286 children were included; intussusception was present in 61 patients (21.3%). Moderate agreement was present between the PEM physicians and radiologists for AXR assessment, with κ = 0.57 (95% confidence interval [CI], 0.47-0.66). Radiologist AXR interpretation had specificity of 86.7% (95% CI, 81.6-90.5), sensitivity of 62.3% (95% CI, 49.8-73.4), positive predictive value of 55.9% (95% CI, 43.3-67.9), and negative predictive value of 89.4% (95% CI, 84.6-93.2). Pediatric emergency medicine physician AXR interpretation had specificity of 68.9% (95% CI, 62.6-74.6), sensitivity of 78.7% (95% CI, 66.9-87.1), positive predictive value of 40.7% (95% CI, 32.2-49.7), and negative predictive value of 92.3% (95% CI, 87.1-95.5). CONCLUSIONS Agreement between PEM physicians and pediatric radiologists for evaluation of AXR in suspected intussusception is moderate. Sensitivity and negative predictive value of AXR alone are not sufficiently high overall to exclude intussusception; however, PEM physician interpretation of AXR may possess utility in determining need for abdominal ultrasound in low-risk patients given the high negative predictive value.
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Abstract
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.
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15
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Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum. Surg Clin North Am 2012; 92:505-26, vii. [PMID: 22595706 DOI: 10.1016/j.suc.2012.03.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.
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Affiliation(s)
- Victoria K Pepper
- Section of Pediatric Surgery, Department of Surgery, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, IL, USA
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16
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Abstract
PURPOSE OF REVIEW Evaluation of the child with acute abdominal pain is challenging because of the wide range of potential diagnoses. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. RECENT FINDINGS Intussusception and intestinal malrotation are potentially serious causes of intestinal obstruction, which are best evaluated by ultrasound and upper gastrointestinal series, respectively. Ultrasound has diagnostic importance in the evaluation of multiple diseases, including appendicitis, by potentially decreasing the need for inpatient observation, cholecystitis and complications of gall stones such as pancreatitis, and ovarian diseases. Pelvic inflammatory disease should be considered in evaluation of a teenage girl with lower abdominal pain. Less common causes of acute abdominal pain include ingested foreign bodies, infected congenital anomalies, and perforated peptic ulcer disease. SUMMARY Presenting symptoms and physical examination findings can narrow the number of potential diagnoses in pediatric acute abdominal pain and thereby guide diagnostic imaging selection. Abdominal/pelvic ultrasound, rather than computed tomography scan, is the preferred modality for initial evaluation of many potential causes of pediatric abdominal pain.
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17
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Sassower KC, Allister LM, Westra SJ. Case records of the Massachusetts General Hospital. Case 12-2012. A 10-month-old girl with vomiting and episodes of unresponsiveness. N Engl J Med 2012; 366:1527-36. [PMID: 22512486 DOI: 10.1056/nejmcpc1103563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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18
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Dan JM, Agarwal S, Burke P, Mahoney EJ. Adult intussusception secondary to colorectal cancer in a young man: a case report. J Emerg Med 2011; 43:983-6. [PMID: 21262558 DOI: 10.1016/j.jemermed.2010.11.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 07/02/2010] [Accepted: 11/21/2010] [Indexed: 01/30/2023]
Abstract
BACKGROUND The occurrence of adult intussusception from colorectal cancer in a 27-year-old man is quite uncommon. OBJECTIVES To raise awareness of the incidence of intussusception in adults, to educate others about the protean manifestations and high association with malignancy of the disease, and to provide treatment recommendations. CASE REPORT We present a case of a 27-year-old man with a non-contributory family history who presented to the Emergency Department multiple times over a 10-month period with vague abdominal complaints. Clinical symptoms ultimately included a 75-lb weight loss, fatigue, mild right-sided abdominal pain, and anemia. Computed tomography scan of the abdomen revealed right-sided colocolic intussusception with a lead point. The patient underwent a right hemicolectomy with ileocolic anastomosis. Pathologic evaluation and staging revealed a stage IIIB poorly differentiated adenocarcinoma. Molecular analysis was negative for genetic causes. CONCLUSION This case demonstrates how intussusception and possible colorectal cancer must be included in the differential diagnosis even in young adults who have persistent abdominal complaints.
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Affiliation(s)
- Jennifer M Dan
- MD-PHD Program, Boston University School of Medicine, Boston, Massachusetts, USA
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