Elsevier

Annals of Emergency Medicine

Volume 60, Issue 3, September 2012, Pages 264-268
Annals of Emergency Medicine

Pediatrics/brief research report
Diagnosis of Intussusception by Physician Novice Sonographers in the Emergency Department

Presented as an abstract at the American Institute of Ultrasound in Medicine annual convention, March 2010, San Diego, CA.
https://doi.org/10.1016/j.annemergmed.2012.02.007Get rights and content

Study objective

We investigate the performance characteristics of bedside emergency department (ED) ultrasonography by nonradiologist physician sonographers in the diagnosis of ileocolic intussusception in children.

Methods

This was a prospective, observational study conducted in a pediatric ED of an urban tertiary care children's hospital. Pediatric emergency physicians with no experience in bowel ultrasonography underwent a focused 1-hour training session conducted by a pediatric radiologist. The session included a didactic component on sonographic appearances of ileocolic intussusception, review of images with positive and negative results for intussusceptions, and a hands-on component with a live child model. On completion of the training, a prospective convenience sample study was performed. Children were enrolled if they were to undergo diagnostic radiology ultrasonography for suspected intussusception. Bedside ultrasonography by trained pediatric emergency physicians was performed and interpreted as either positive or negative for ileocolic intussusception. Ultrasonographic studies were then performed by diagnostic radiologists, and their results were used as the reference standard. Test characteristics (sensitivity, specificity, positive and negative predictive values) and likelihood ratios were calculated.

Results

Six pediatric emergency physicians completed the training and performed the bedside studies. Eighty-two patients were enrolled. The median age was 25 months (range 3 to 127 months). Thirteen patients (16%) received a diagnosis of ileocolic intussusception by diagnostic radiology. Bedside ultrasonography had a sensitivity of 85% (95% confidence interval [CI] 54% to 97%), specificity of 97% (95% CI 89% to 99%), positive predictive value of 85% (95% CI 54% to 97%), and negative predictive value of 97% (95% CI 89% to 99%). A positive bedside ultrasonographic result had a likelihood ratio of 29 (95% CI 7.3 to 117), and a negative bedside ultrasonographic result had a likelihood ratio of 0.16 (95% CI 0.04 to 0.57).

Conclusion

With limited and focused training, pediatric emergency physicians can accurately diagnose ileocolic intussusception in children by using bedside ultrasonography.

Introduction

Intussusception is a common pediatric abdominal emergency, with an estimated incidence of 38 cases per 100,000 live births in the first year of life and 31 cases per 100,000 live births in the second year of life.1 Clinical presentations of intussusception may vary and can include nonspecific symptoms such as crying episodes, abdominal pain, vomiting, and lethargy. The appearance of “currant jelly” stools, a late finding and marker for bowel ischemia, is observed in a minority of cases. Delays in diagnosis are associated with increased morbidity rates. Longer periods of intussusception can decrease enema reduction success rates. A high index of suspicion is imperative to reduce the need for surgical intervention in children with intussusception.

Ultrasonography is an accurate method to diagnose intussusception.2 In the hands of experienced operators, it is considered the criterion standard for the diagnosis of ileocolic intussusception, with both high sensitivity (98% to 100%) and specificity (88% to 100%).2, 3 Compared with contrast enema, which once was the diagnostic tool of choice, ultrasonography is a safer and more cost-effective method of diagnosis. Case reports of emergency physicians diagnosing intussusception with bedside ultrasonography exist.4 To our knowledge, no study to date has compared the accuracy of bedside ultrasonography performed by emergency physicians with that of diagnostic radiology ultrasonography for the diagnosis of ileocolic intussusception.

The goal of this study was to investigate the performance characteristics of bedside ultrasonography by pediatric emergency physicians who received limited and focused training in the diagnosis of ileocolic intussusception in children.

Section snippets

Study Design and Setting

This was a prospective study of pediatric emergency department (ED) patients who underwent ultrasonography for the evaluation of suspected ileocolic intussusception. The study was performed in an urban pediatric ED at a tertiary care children's hospital from July 2008 to September 2011. The pediatric ED has an annual census of approximately 34,000 visits. Pediatric diagnostic radiology ultrasonography is available continuously.

Children with suspected ileocolic intussusception were enrolled if

Results

Eighty-two subjects were enrolled. Patient characteristics are listed in the Table. All patients were able to sufficiently cooperate with bedside ultrasonography. A total of 6 pediatric emergency physicians performed the bedside ultrasonographic studies. Study physician 1 enrolled 43 patients; study physician 2, 16 patients; study physician 3, 9 patients; study physician 4, 7 patients; and study physicians 5 and 6, 5 and 2 patients, respectively. Of the 13 patients who received a diagnosis of

Limitations

Our study has several limitations. Because spontaneous resolution and recurrence of intussusception is possible, there is the potential for misclassification at the bedside and in the diagnostic radiology department. The majority of bedside ultrasonography (52%) was performed by study physician 1, which may skew the results toward the performance of this physician. However, a sensitivity analysis involving study physicians 2 to 6 alone showed findings similar to those of the overall study

Discussion

In this prospective observational study, we demonstrated good performance characteristics of pediatric emergency physician–performed bedside ultrasonography for the diagnosis of intussusception in children after a single, focused training session.

The performance of bedside ultrasonography in our study exhibited high specificity with narrow CIs, which would make it an excellent test to rule in intussusception. The lower sensitivity scores make bedside ultrasonography less useful as a screening

References (10)

  • M. Buettcher et al.

    Three-year surveillance of intussusception in children in Switzerland

    Pediatrics

    (2007)
  • P. Verschelden et al.

    Intussusception in children: reliability of US in diagnosis—a prospective study

    Radiology

    (1992)
  • A.L. Hryhorczuk et al.

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

    Pediatr Radiol

    (2009)
  • N. Kairam et al.

    Diagnosis of pediatric intussusception by an emergency physician–performed bedside ultrasound: a case report

    Pediatr Emerg Care

    (2009)
  • M. Longjohn et al.

    Point-of-care echocardiography by pediatric emergency physicians

    Pediatr Emerg Care

    (2011)
There are more references available in the full text version of this article.

Cited by (92)

  • Diagnostic accuracy of point-of-care ultrasonography for intussusception in children: A systematic review and meta-analysis

    2022, American Journal of Emergency Medicine
    Citation Excerpt :

    Sonographers were adult or pediatric emergency physicians who had various levels of POCUS training, with some having received relatively brief training while others had completed POCUS-specific fellowships. All studies who described their transducer [12,14,16-19,21-23] used a linear transducer with one study also using a curvilinear transducer [22]. The reference standard varied between studies with the majority using radiology-performed ultrasonography [14-20] with some adding clinical course and follow-up [12,21-23].

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Please see page 265 for the Editor's Capsule Summary of this article.

Supervising editor: Kathy N. Shaw, MD, MSCE

Author contributions: TRG and LC conceived and designed the study. AR, ALH, ML, and LC conducted data collection and performed data analysis. LC obtained research funding. AR drafted the article, and all authors contributed substantially to its revision. AR takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Supported in part by Clinical and Translational Science Awards grant KL2 RR024138 from the National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research.

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Publication date: Available online March 15, 2012.

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