Literature Summaries - Emergency Bedside Ultrasound For The Diagnosis Of Pediatric Intussusception: A Retrospective Review
Editor: Betül Gülalp, Prof.
Date: 14 November 2017
Lam SHF, Wise A, Yanter C. Emergency bedside ultrasound for the diagnosis of pediatric intussusception: a retrospective review. World J Emerg Med, 2014; 5(4):255-258
Intussusception is the second only to appendicitis as the most common cause of an acute abdominal emergency in pediatrics, frequently encountered in the emergency department. Its incidence has been reported to be 2.4 per 1,000 live births. The classic triad of intussusception; Colicky abdominal pain, vomiting, and currant jelly-like stool is seen in only 30%-40% of patients. If unnoticed, it may potentially lead to intestinal wall necrosis, perforation and, death.
As barium enema is invasive, exposes to radiation, leads to be a possible complication, requires the on-site presence of an experienced radiologist can not be used practical.
Emergency ultrasound has become the first-line diagnostic test for suspected intussusception.
However, ultrasonographic image finding is termed in various names such as the "classic doughnut", "pseudokidney" and "crescent-in-doughnut" can help to make the diagnosis.
Figure 1: Classic Doughnut Sign
The aim of the study was to test the accuracy of bedside ultrasonography (BUS) performed by emergency physicians in the diagnosis of pediatric intussusception. The study was conducted in the Advocate Christ Medical Center Pediatric Emergency Department, which is a tertiary level medical center receiving approximately 30,000 visits per year. A retrospective comparison was made between the BUS image recordings performed by emergency physicians and the formal diagnostic workouts carried out by radiologists (such as computed tomography, ultrasonography, and barium enema) in patients who presented to the emergency department with suspected intussusception between January 1, 2009, and October 3, 2012. The sensitivity, specificity, negative and positive predictive values were calculated.
The inclusion criteria were as follows: (1) Age<18 years, (2) Clinical findings indicative of intussusception, (3) BUS was performed and the images were recorded in the electronic medical record database, (4) A formal radiological evaluation was made. The exclusion criteria were: (1) No formal radiological evaluation was made for intussusception, (2) No BUS images were recorded, (3) The interpretation of BUS was not documented. BUS was conducted by emergency physicians who received at least 1 hour of didactic training. Collected images were re-assessed by a third person in order to prevent potentially missed cases.
Among 1631 cases, 49 met the inclusion criteria. Five of them were then excluded due to lack of documentation. Of the remaining 44 cases, the BUS images were interpreted as ‘positive’ for intussusception in 12 patients, and ‘negative’ in 32 patients. The authors stated that these BUS investigations were conducted by seven different physicians. The prevalence of intussusception was calculated as 23%. Thirty (68%) of the cases were male, and the mean age was 31 months.
The test characteristics revealed a sensitivity of 100%, a specificity of 97%, a negative predictive value of 100%, a positive predictive value of 91%, a negative LR (likelihood ratio) of zero, and a positive LR of 32, respectively.
The authors stated that BUS may be a useful tool as a clinical decision maker in patients with suspected intussusception, with a negative LR of zero and a high positive LR. In other words, BUS results, whether positive or negative, may help guide the treatment approach in patients with clinically suspected intussusception.
In my opinion, the rather small sample size, the lack of blinding between BUS performers and the third author who reassessed the BUS images, and the monocentric design of the study, are serious limitations which may lead to bias and excessive false positive test rates. In addition, the retrospective design is another limitation, since this study could easily be designed as prospective. The lack of inter- and intra-rater reliability is also another factor diminishing the power of the study.
Pediatric patients with abdominal pain form a vast majority of the patient population in the emergency department. We would like to know whether if BUS, which is a non-invasive and radiation-free imaging modality, can be used a reliable tool to help with the timely diagnosis of serious conditions such as intussusception. Replicating this study prospectively in pediatric emergency departments may yield more reliable outcomes.
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Emre Özlüer, Asst. Prof.
Betül Gülalp, Prof.
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