Diagnosis of Intussusception by Physician Novice Sonographers in the Emergency Department

Abstract

Objective To investigate the performance characteristics of bedside emergency department ultrasound by non-radiologist, physician sonographers in the diagnosis of ileo-colic intussusception in children. Methods This was a prospective, observational study conducted in a pediatric emergency department of an urban tertiary care children’s hospital. Pediatric emergency medicine (PEM) physicians with no previous experience in bowel ultrasound underwent a focused one-hour training session conducted by a pediatric radiologist. The session included a didactic component on sonographic appearances of ileo-colic intussusception, review of positive and negative images for intussusceptions, and a hands-on component using a live child model. Upon completion of the training a prospective convenience sample study was performed. Children were enrolled if they were to undergo a diagnostic radiology (DR) ultrasound for suspected intussusception. Bedside ultrasound (BUS) by trained PEM physicians were performed and interpreted as either positive or negative for ileo-colic intussusception. Ultrasound studies were then performed by DR 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 PEM physicians completed the training and performed the bedside studies. Eighty two patients were enrolled. The median age was 25 months (range 3 months – 127 months). Thirteen patients (16%) were diagnosed with ileo-colic intussusception by DR. BUS 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 BUS had a likelihood ratio of 29 (95% CI 7.3 to 114) and a negative BUS had a likelihood ratio of 0.16 (95% CI 0.04 to 0.57). Conclusions With limited and focused training, PEM physicians can accurately diagnose ileo-colic intussusception in children using BUS.

Diagnosing Pediatric Intussusception Through Bedside Ultrasound by Novice Emergency Department Sonographers: A Case Report

“…In another study (Riera et al 2012), a prospective observational study was conducted in the emergency department of a paediatrics tertiary centre. A total of 82 patients aged between 3 months and 10.5 yrs with suspected intussusception were enrolled.…”

“…They did not go on to explain what the didactic training comprise of. Riera (Riera et al 2012) subjected the 6 emergency physicians to 1 hr of training under paediatric radiologists. 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.…”

Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians

“…20,26,[46][47][48] Point-of-care US in pediatric patients by PEM providers has recently been adopted into practice, and the literature is still evolving. Nonetheless, there are numerous studies demonstrating the accuracy of point-of-care US by PEM physicians [49][50][51][52][53][54][55][56][57][58] and the ability of PEM physicians to become proficient in point-of-care US after adequate training. 55,56,59 Although the point-ofcare US examinations performed should be specific to the needs of the department, the most common indications for which point-of-care US is being used in PEM are for focused assessment with sonography in trauma, soft tissue evaluation, and vascular access.…”

Ultrasonographic Diagnosis of Intussusception in the Emergency Department

“…Classically in the United States, ultrasound is performed by an ultrasound technician or radiologist. 5 It has not yet been widely adopted that a bedside point of care ultrasound (POCUS) by an emergency provider can replace a formal ultrasound by radiology if determined negative. However, studies indicate specificity of POCUS by emergency providers is approaching 100%.…”

“…However, studies indicate specificity of POCUS by emergency providers is approaching 100%. 5 Identification of an intussusception on POCUS could greatly impact the speed of disposition, particularly in departments without ultrasound and radiology available overnight. The diagnosis is made noting a "bulls eye" or "target" appearance 6 in transverse view, created by invagination of the intussusceptum (proximal bowel) into the intussuscepiens (distal segment).…”