Risk stratification of children being evaluated for intussusception

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.

Cohort analysis of pediatric intussusception score to diagnose intussusception

BACKGROUND

Intussusception is a primary cause of intestinal obstruction in young children. Delayed diagnosis is associated with increased morbidity. Ultrasonography (USG) is the gold standard for diagnosis, but it is operator dependent and often unavailable in limited resource areas.

AIM

To study the clinical characteristics of intussusception including management and evaluation of the diagnostic accuracy of abdominal radiography (AR) and the promising parameters found in the pediatric intussusception score (PIS).

METHODS

Children with suspected intussusception in our center from 2006 to 2018 were recruited. Clinical manifestations, investigations, and treatment outcomes were recorded. AR images were interpreted by a pediatric radiologist. Diagnosis of intussusception was composed of compatible USG and response with reduction. The diagnostic value of the proposed PIS was evaluated.

RESULTS

Ninety-seven children were diagnosed with intussusception (2.06 ± 2.67 years, 62.9% male), of whom 74% were < 2 years old and 37.1% were referrals. The common manifestations of intussusception were irritability or abdominal pain (86.7%) and vomiting (59.2%). Children aged 6 mo to 2 years, pallor, palpable abdominal mass, and positive AR were the parameters that could discriminate intussusception from other mimics (P < 0.05). Referral case was the only significant parameter for failure to reduce intussusception (P < 0.05). AR to diagnose intussusception had a sensitivity of 59.2%. The proposed PIS, a combination of clinical irritability or abdominal pain, children aged 6 mo to 2 years, and compatible AR, had a sensitivity of 85.7%.

CONCLUSION

AR alone provides poor screening for intussusception. The proposed PIS in combination with common manifestations and AR data was shown to increase the diagnostic sensitivity, leading to timely clinical management.

Diagnostic validation and development of an algorithm for identification of intussusception in children using electronic health records of Ningbo city in China

BACKGROUND

Monitoring the risk of intussusception after the introduction of rotavirus vaccines is recommended by the World Health Organization (WHO). Although the validity of intussusception monitoring using electronic health records (EHRs) has been confirmed previously, no similar studies have been conducted in China. We aimed to verify the diagnosis and determine an algorithm with the best performance for identification of intussusception using Chinese EHR databases.

RESEARCH DESIGN AND METHODS

Using the Regional Health Information Platform in Ningbo, patients aged 0-72 months from 2015 to 2021 with any related visits for intussusception were included. The algorithms were based on diagnostic codes or keywords in different clinical scenarios, and their performance was evaluated with positive predictive value (PPV) and sensitivity in line with the Brighton guidelines.

RESULTS

Brighton level 1 intussusception was confirmed in 2958 patients with 3246 episodes. Fine-tuned algorithms combining the appearance of the relevant ICD-10 codes or the Chinese keyword 'Chang Tao' in any diagnostic reports with the results of enema treatments or related surgeries showed the highest sensitivity, while the highest PPV was obtained by further criteria based on typical radiographic appearances.

CONCLUSION

Intussusception could be identified and validated internally using EHRs in Ningbo.

Double Intussusceptions in a 20-Year-Old Lady Harboring a Tubulovillous Adenoma with High-Grade Dysplasia: A Case Report and Literature Review

Underlying malignancy is a concern when intussusception is diagnosed in adults and the elderly. Management includes oncological resection of the intussusception. We report a case of a 20-year-old female patient who presented with signs of bowel obstruction. Computed tomography demonstrated double intussusceptions (ileo-cecal and transverse colo-colonic). During laparotomy, the mid-transverse intussusception reduced spontaneously while the other did not. Both intussusceptions were managed with oncological resection. The final pathology showed a tubulovillous adenoma with high-grade dysplasia. As a result, intussusception in adults should be investigated thoroughly to exclude malignant potential.

Artificial Intelligence in Emergency Radiology: Where Are We Going?

Emergency Radiology is a unique branch of imaging, as rapidity in the diagnosis and management of different pathologies is essential to saving patients' lives. Artificial Intelligence (AI) has many potential applications in emergency radiology: firstly, image acquisition can be facilitated by reducing acquisition times through automatic positioning and minimizing artifacts with AI-based reconstruction systems to optimize image quality, even in critical patients; secondly, it enables an efficient workflow (AI algorithms integrated with RIS-PACS workflow), by analyzing the characteristics and images of patients, detecting high-priority examinations and patients with emergent critical findings. Different machine and deep learning algorithms have been trained for the automated detection of different types of emergency disorders (e.g., intracranial hemorrhage, bone fractures, pneumonia), to help radiologists to detect relevant findings. AI-based smart reporting, summarizing patients' clinical data, and analyzing the grading of the imaging abnormalities, can provide an objective indicator of the disease's severity, resulting in quick and optimized treatment planning. In this review, we provide an overview of the different AI tools available in emergency radiology, to keep radiologists up to date on the current technological evolution in this field.

An Extra Set of Intelligent Eyes: Application of Artificial Intelligence in Imaging of Abdominopelvic Pathologies in Emergency Radiology

Imaging in the emergent setting carries high stakes. With increased demand for dedicated on-site service, emergency radiologists face increasingly large image volumes that require rapid turnaround times. However, novel artificial intelligence (AI) algorithms may assist trauma and emergency radiologists with efficient and accurate medical image analysis, providing an opportunity to augment human decision making, including outcome prediction and treatment planning. While traditional radiology practice involves visual assessment of medical images for detection and characterization of pathologies, AI algorithms can automatically identify subtle disease states and provide quantitative characterization of disease severity based on morphologic image details, such as geometry and fluid flow. Taken together, the benefits provided by implementing AI in radiology have the potential to improve workflow efficiency, engender faster turnaround results for complex cases, and reduce heavy workloads. Although analysis of AI applications within abdominopelvic imaging has primarily focused on oncologic detection, localization, and treatment response, several promising algorithms have been developed for use in the emergency setting. This article aims to establish a general understanding of the AI algorithms used in emergent image-based tasks and to discuss the challenges associated with the implementation of AI into the clinical workflow.

Evidence-Based Diagnostic Test Accuracy of History, Physical Examination, and Imaging for Intussusception: A Systematic Review and Meta-analysis

INTRODUCTION

Intussusception is the most common cause of pediatric small bowel obstruction. Timely and accurate diagnosis may reduce the risk of bowel ischemia. We quantified the diagnostic test accuracy of history, physical examination, abdominal radiographs, and point-of-care ultrasound.

METHOD

We conducted a systematic review for diagnostic test accuracy of history, physical examination, and imaging concerning for intussusception. Our literature search was completed in June 2019. Databases included Medline via Ovid, Embase, Scopus, and Wiley Cochrane Library. We conducted a second review of the literature up to June 2019 for any additional studies. Inclusion criteria were younger than 18 years and presenting to the emergency department for abdominal complaints, consistent with intussusception. We performed data analysis using mada, version 0.5.8. We conducted univariate and bivariate analysis (random effects model) with DerSimonian-Laird and Reitsma model, respectively. QUADAS-2 was used for bias assessment.

RESULTS

The literature search identified 2639 articles, of which 13 primary studies met our inclusion criteria. Abdominal pain, vomiting, and bloody stools had positive likelihood ratios LR(+) between 1 and 2, whereas the negative likelihood ratio, LR(-), ranged between 0.4 and 0.8. Abnormal abdominal radiograph had LR(+) of 2.5 and LR(-) of 0.20, whereas its diagnostic odds ratio was 13. Lastly, point-of-care ultrasound had LR(+) of 19.7 and LR(-) of 0.10. The diagnostic odds ratio was 213.

CONCLUSIONS

History and physical examination had low diagnostic test accuracy. Abdominal radiographs had low diagnostic test accuracy, despite moderate discriminatory characteristics. Point-of-care ultrasound had the highest diagnostic test accuracy to rule in or rule out intussusception.

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.

Clinical management and recommendations for children with more than four episodes of recurrent intussusception following successful reduction of each: an institutional review

AIM

To describe patterns and risk factors of multiple recurrences to optimise management for pediatric patients with more than four episodes of intussusception.

MATERIALS AND METHODS

Following IRB approval, all sonographic evaluations for intussusception in patients <18 years over a 6-year period were reviewed. Data extracted included age at onset of first intussusception, gender, presenting symptoms, symptoms upon recurrence, presence of pathological lead points, and surgical findings.

RESULTS

During a 6-year period, five cases had four or more instances of recurrence after enema reduction attempts. All patients were male with an average age of 16 months. Two of the five cases resolved after the fourth enema reduction and no lead points were identified. Two other cases involved surgical reduction with intraoperative findings of Meckel's diverticulum and juvenile polyp. The final case had five recurrence episodes and six separate enema reductions. Ultimately, lymphoid hyperplasia was discovered on colonoscopy and the patient never recurred after being treated with steroids.

CONCLUSION

Given the favorable reduction rate in re-recurrent cases and complete lack of perforation observed, up to four attempts at enema reduction is recommended before considering an alternative strategy. If recurrence continues past the fourth reduction attempt, computed tomography (CT) is recommended to identify a lead point. If CT remains inconclusive, then consider exploratory laparotomy.

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.

Diagnosis and treatment of childhood intussusception from 1997 to 2016: A population-based study

OBJECTIVES

Describe changes in the diagnostic approach and treatment for pediatric intussusception over two decades.

STUDY DESIGN

Administrative universal healthcare data were used to conduct a population-based cohort study of intussusception between January 1997 and December 2016 in Ontario, Canada. A validated case definition was used to identify all patients (<18 years) treated for intussusception in the province at community or tertiary care centers. Treatment modality was determined using physician billing data and databases linked at ICES; it was categorized as nonoperative alone, surgical alone, or failed nonoperative. Descriptive statistics, Cochrane-Armitage for trend analyses, and graphical and multinomial logistic regression were performed.

RESULTS

Over 20 years, 1895 pediatric patients were treated for intussusception. Pretreatment imaging use rose from 57.5% to 99.3%. Nonoperative management increased from 23.4% to 75.2%. However, 43% of children who presented to a community hospital underwent immediate surgical management, compared with just 11% of children at tertiary centers (RR 0.39, 95% CI: 0.25-0.62). Among children who underwent surgery, there was an increase in bowel resection over time (41.7% to 57.6%).

CONCLUSIONS

Over the 20 year period of study, pretreatment imaging became universal, and management shifted from predominantly surgical to nonoperative reduction in Ontario. The rate of surgical intervention remains higher in community versus tertiary centers.

LEVEL OF EVIDENCE

Treatment study, III.

Point-of-care ultrasound may be useful for detecting pediatric intussusception at an early stage

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.

Comparison Between Small and Large Bowel Intussusception in Children: The Experience of a Large Tertiary Care Pediatric Hospital

BACKGROUND

Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to serious sequelae. The objective of this study was to determine the prevalence of ileoileal intussusception and to document and compare clinical outcomes with ileocolic intussusception.

METHODS

A retrospective cohort study of children with an abdominal ultrasound that diagnosed intussusception. Clinical data and diagnostic studies were retrieved, to compare ileoileal with ileocolic intussusception.

RESULTS

A total of 488 patients were evaluated with an abdominal ultrasound on suspicion of intussusception; 54 (11%) had ileoileal intussusception and 30 (6%) ileocolic intussusception. The significant features distinguishing the 2 conditions were fever, more common in patients with ileoileal intussusception, and an abdominal mass, which was papable more commonly in ileocolic intussusception. None of the ileoileal intussusception patients required surgical intervention, and all were discharged without complication.

CONCLUSIONS

With recent advances in abdominal ultrasound, the diagnosis of ileoileal intussusception has become easier than before. Patients presenting with small bowel intussusception may not need any immediate intervention. The presence of fever supports the diagnosis of ileoileal intussusception.

Performance of deep learning-based algorithm for detection of ileocolic intussusception on abdominal radiographs of young children

The purpose of this study was to develop and test the performance of a deep learning-based algorithm to detect ileocolic intussusception using abdominal radiographs of young children. For the training set, children (≤5 years old) who underwent abdominal radiograph and ultrasonography (US) for suspicion of intussusception from March 2005 to December 2017 were retrospectively included and divided into control and intussusception groups according to the US results. A YOLOv3-based algorithm was developed to recognize the rectangular area of the right abdomen and to diagnose intussusception. For the validation set, children (≤5 years old) who underwent both radiograph and US from January to August 2018 with the suspicion of intussusception were included. Diagnostic performances of an algorithm and radiologists were compared. Total 681 children including 242 children in intussusception group were included in the training set and 75 children including 25 children in intussusception group were included in the validation set. The sensitivity of the algorithm was higher compared with that of the radiologists (0.76 vs. 0.46, p = 0.013), while specificity was not different between the algorithm and the radiologists (0.96 vs. 0.92, p = 0.32). Deep learning-based algorithm can aid screening of intussusception using abdominal radiography in young children.

Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in Pediatric Practice

Diagnostic point-of-care ultrasound (POCUS) is a growing field across all disciplines of pediatric practice. Machine accessibility and portability will only continue to grow, thus increasing exposure to this technology for both providers and patients. Individuals seeking training in POCUS should first identify their scope of practice to determine appropriate applications within their clinical setting, a few of which are discussed within this article. Efforts to build standardized POCUS infrastructure within specialties and institutions are ongoing with the goal of improving patient care and outcomes.

Fever as a Presenting Symptom in Children Evaluated for Ileocolic Intussusception: The Experience of a Large Tertiary Care Pediatric Hospital

BACKGROUND

Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation. The objective of this study was to determine the prevalence of fever in patients with ileocolic intussusception and to determine its utility as a predictive symptom.

METHODS

This was a 3-year retrospective study, at a tertiary care center, of children aged 1 month to 6 years, presenting with possible intussusception. Charts were reviewed for clinical signs and symptoms at presentation, and all diagnostic studies were retrieved. A pediatric radiologist reviewed all ultrasounds.

RESULTS

A total of 488 ultrasounds were performed on suspicion of intussusception. In 30 patients with confirmed ileocolic intussusception, mean age was 27 months and all were successfully reduced by air enema. Of 118 patients with fever, 2 had confirmed intussusception, 1 with pneumonia and 1 with acute otitis media, compared with 116 febrile patients with negative ultrasounds (P < 0.05).

CONCLUSIONS

Traditional teaching is that intussusception presents as intermittent colicky abdominal pain, red currant jelly stool, vomiting, and a palpable abdominal mass, but it is important to remember that this classic triad is a very late finding and this condition should be recognized before the development of these findings. The concurrence of fever can help to rule out the possibility of intussusception and prompt the health care professional to search diligently for alternative infectious etiologies but cannot eliminate the possibility, especially when other findings suggestive of intussusception are present.

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.

Intestinal Intussusception: Etiology, Diagnosis, and Treatment

Intussusception is defined as the invagination of one segment of the bowel into an immediately adjacent segment of the bowel. Idiopathic ileocolic intussusception is the most common form in children and is typically managed with nonoperative reduction via pneumatic and/or hydrostatic enemas. In the adult population, intussusception is uncommon and occurs more often in the small intestine than in the colon. It is associated with lead point pathology in most symptomatic cases presenting as bowel obstruction. When lead point pathology is present in adult small bowel intussusception, it is usually benign, though when malignant it is most frequently due to diffuse metastatic disease, for example, melanoma. In contrast, adult ileocolic and colonic intussusception lead point pathology is most frequently primary adenocarcinoma when malignant. The diagnosis is typically made intraoperatively or by cross-sectional imaging. With increasingly frequent CT/MRI of the adult abdomen in the current era, transient and/or asymptomatic intussusceptions are increasingly found and may often be appropriately observed without intervention. When intervention in the adult population is warranted, usually oncologic bowel resection is performed due to the association with lead point pathology.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Clinical prediction rules for failed nonoperative reduction of intussusception

PURPOSE

The nonoperative reduction of intussusception in children can be performed safely if there are no contraindications. Many risk factors associated with failed reduction were defined. The aim of this study was to develop a scoring system for predicting the failure of nonoperative reduction using various determinants.

PATIENTS AND METHODS

The data were collected from Chiang Mai University Hospital and Siriraj Hospital from January 2006 to December 2012. Inclusion criteria consisted of patients with intussusception aged 0-15 years with no contraindications for nonoperative reduction. The clinical prediction rules were developed using significant risk factors from the multivariable analysis.

RESULTS

A total of 170 patients with intussusception were included in the study. In the final analysis model, 154 patients were used for identifying the significant risk factors of failure of reduction. Ten factors clustering by the age of 3 years were identified and used for developing the clinical prediction rules, and the factors were as follows: body weight <12 kg (relative risk [RR] =1.48, P=0.004), duration of symptoms >48 hours (RR =1.26, P<0.001), vomiting (RR =1.63, P<0.001), rectal bleeding (RR =1.50, P<0.001), abdominal distension (RR =1.60, P=0.003), temperature >37.8°C (RR =1.51, P<0.001), palpable mass (RR =1.26, P<0.001), location of mass (left over right side RR =1.48, P<0.001), ultrasound showed poor prognostic signs (RR =1.35, P<0.001), and the method of reduction (hydrostatic over pneumatic, RR =1.34, P=0.023). Prediction scores ranged from 0 to 16. A high-risk group (scores 12-16) predicted a greater chance of reduction failure (likelihood ratio of positive [LR+] =18.22, P<0.001). A low-risk group (score 0-11) predicted a lower chance of reduction failure (LR+ =0.79, P<0.001). The performance of the scoring model was 80.68% (area under the receiver operating characteristic curve).

CONCLUSION

This scoring guideline was used to predict the results of nonoperative reduction and forecast the prognosis of the failed reduction. The usefulness of these prediction scores is for informing the parents before the reduction. This scoring system can be used as a guide to promote the possible referral of the cases to tertiary centers with facilities for nonoperative reduction if possible.

Abdominal radiography is not necessary in children with intussusception

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.

Clinical signs and symptoms associated with intussusception in young children undergoing ultrasound in the emergency room

OBJECTIVE

The purpose of this study was to evaluate all patients suspected of having intussusception and identify which signs and symptoms were associated with the disease.

METHODS

We performed a retrospective review of 553 charts from 2006 to 2010 of patients' age 2 months to 5 years who had an abdominal ultrasound obtained to evaluate for intussusception. Charts were reviewed for signs and symptoms previously shown to be associated with intussusception.

RESULTS

There were 452 patients (mean age, 21.5 months, 43% female) evaluated and 101 (22.3%) were found to have intussusception. Of the 18 signs and symptoms, crying (adjusted odds ratio [OR], 3.3; 95% confidence interval [95% CI], 1.3-8.1), abdominal mass (adjusted OR, 15.7; 95% CI, 4.4-55.3), pallor (adjusted OR, 6.5; 95% CI, 1.8-23.5), and vomiting (adjusted OR, 3.1; 95% CI, 1.4-6.5) were associated with disease confirmation in logistic regression analysis. The presence of all 4 clinical signs/symptoms together resulted in a 95% probability of intussusception. Intussusception was unlikely if all 4 clinical indicators were absent (probability = 1.6%).

CONCLUSIONS

The presence of crying, abdominal mass, pallor, and vomiting were clinical indicators of intussusception. Individually, none of these variables were helpful in confirming the diagnosis but in the presence of all 4, there is a 95% probability of having the disease. The absence of all 4 of these made the likelihood of having the disease very low.

Fluoroscopy screen time during contrast enema for the evaluation and treatment of intussusception

OBJECTIVE

The objective of this study was to describe fluoroscopy screen time (FST) for children undergoing contrast enema (CE) for suspected intussusception.

METHODS

This is a single-center, retrospective cohort study of children younger than 7 years examined for intussusception by CE. We reviewed medical records for demographics, radiographic results, and FST. We used nonparametric descriptive statistical tests and calculated odds ratios (OR).

RESULTS

The median FST for 457 included CEs was 116 seconds. The median FST for positive CEs (n = 194) was 138 seconds (95% confidence interval [CI], 126-152); for negative CEs (n = 250), 86 seconds (95% CI, 78-102); and for uncertain studies (n = 13), 138 seconds (95% CI, 89-208) (P < 0.01). There was no difference in median FST if symptoms were present 24 hours or less versus longer than 24 hours. There was no difference between contrast types. Median FST for successful reductions was 122 seconds (95% CI, 114-138). In cases of failed reductions, median FST for those undergoing surgery was 277 seconds (95% CI, 195-370) and 175 seconds (95% CI, 128-271) (P < 0.01) for those undergoing delayed repeat CE. The OR for receiving a repeat CE was 1.3 (95% CI, 1.1-1.4; P < 0.01) for every minute of FST. The OR for undergoing surgical reduction was 1.3 (95% CI, 1.2-1.5; P < 0.01) for every minute of FST and 3.7 (95% CI, 2.0-6.9; P < 0.01) for FST longer than 3 minutes.

CONCLUSIONS

Fluoroscopy screen time for the evaluation and diagnosis of intussusception is shorter than that previously described. When an initial screening ultrasound is not available or nondiagnostic and the suspicion is high, further evaluation with a CE may be warranted because the radiation exposure is likely lower than that previously reported.

Intussusception in children presenting to the emergency department

A retrospective chart review of children diagnosed with intussusceptions from March 2005 to March 2007 was conducted at a tertiary care pediatric hospital. There were 152 children with 170 episodes of intussusceptions during the study period. Around one third (30%) of children diagnosed with intussusceptions had a concurrent infection. There were 114 large bowel intussusceptions, with a mean age of 27 months (SD = 25) and a success rate of 91% for air enema reductions. Bowel resection was performed in 8.8% of children with large bowel intussusceptions. Small bowel intussusceptions (n = 38) were associated with gastrostomy tubes in 42% (n = 16) of patients, and 81% needed tube shortening. The varying age range of many children diagnosed with intussusceptions and the high incidence of intercurrent illnesses and fever in our study alert health professionals to suspect intussusceptions in children presenting with abdominal pain or crying.

Comparison of clinicians to radiologists in assessment of abdominal radiographs for suspected intussusception

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.

Angiolipoma: rare cause of adult ileoileal intussusception

Intussusception in adults is rare and more common in the paediatric population. Clinically, most adult patients have chronic non-specific symptoms due to partial obstruction. In contrast, most paediatric patients present with the classic triad of abdominal pain, vomiting and blood in stool. Adult intussusception is commonly associated with an organic aetiology, most likely a benign or malignant neoplasm as a lead point of intussusception. We describe a case of a 29-year-old woman with subacute presentation due to ileoileal intussusception secondary to a polypoid submucosal angiolipoma. Angiolipoma is a benign lesion composed of mature adipose tissue and thin-walled capillaries. The presence of thin-walled vessels differentiates it from a lipoma. Angiolipomas of the small intestine are extremely rare with very few reported cases. This case not only demonstrates an unusual benign lesion as a cause of intussusception, but also illustrates an atypical clinical presentation in adults with intussusception.

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.

Variation in practice patterns and resource utilization surrounding management of intussusception at freestanding Children's Hospitals

PURPOSE

To characterize variation in practice patterns and resource utilization associated with the management of intussusception at Children's Hospitals.

METHODS

A retrospective cohort study (1/1/09-6/30/11) of 27 Children's Hospitals participating in the Pediatric Health Information System database was performed. Hospitals were compared with regard to their rates of operative management following attempted enema reduction, prophylactic antibiotic utilization, same-day discharge for those successfully managed non-operatively, 48-h readmission rates, and case-related cost and charges.

RESULTS

2544 patients were identified (median: 93 cases/center) with a median age of 17 months. The rate of operation following attempted enema reduction varied significantly across hospitals (overall rate: 21.1%: range: 11%-62.8%; p<0.0001). For patients managed non-operatively, significant variability was found for prophylactic antibiotic utilization (overall rate: 23.3%; range: 1.4%-93.2%; p<0.0001), same-day discharge (overall rate: 15.2%; range: 0%-83.8%; p<0.0001), readmission rates (overall rate: 17.5%; range: 5.3%-32.1%; p<0.0001), treatment-related costs (overall median: $2490; range: $829-$5905; p<0.0001), and charges (overall median: $6350; range: $2497-$10,306; p<0.0001). Variability in costs and charges was even greater when analyzing all patients (operative and non-operative) with intussusception (overall cost median: $2865; range: $1574-$6763; p<0.0001; overall charge median: $7110; range: $3544-$22,097; p<0.0001).

CONCLUSION

Significant variation in practice patterns and resource utilization exists between Children's Hospitals in the management of intussusception. Prospective analysis of practice variation and appropriately risk-adjusted outcomes through a collaborative quality-improvement platform could accelerate the dissemination of best-practice guidelines for optimizing cost-effective care.

External manual reduction of paediatric idiopathic ileocolic intussusception with US assistance: a new, standardised, effective and safe manoeuvre

BACKGROUND

The ultimate goal in the management of paediatric ileocolic intussusception is to achieve non-operative reduction and therefore patient cure. The standard non-surgical treatment consists of enema (air or liquid media).

OBJECTIVE

The purpose of this study is to present external manual reduction for paediatric ileocolic intussusception. We present a new manoeuvre that is standardised, simple, safe and effective for the radiologist in the non-surgical management of this pathology.

MATERIALS AND METHODS

External manual reduction is performed under sedation. Execution of the manoeuvre is detailed and illustrated. The procedure was carried out 15 times in 13 paediatric patients with idiopathic ileocolic intussusception.

RESULTS

Complete reduction exclusively by external manual reduction was accomplished on 12 occasions (80%). In the remaining three procedures, partial reduction to the cecum was obtained. Subsequent enema achieved complete reduction in two. Overall non-surgical reduction rate was 93%.

CONCLUSION

External manual reduction is a radiation-free, safe and effective procedure. In case of incomplete reduction, it facilitates enema performance. External manual reduction incorporates and additional initial step in the non-surgical reduction of intussusception and should be considered a first-line procedure.

Beyond appendicitis: evaluation and surgical treatment of pediatric acute abdominal pain

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.