What follows are excerpts from the above:
Your nurse is about to fill three rooms with vomiting children – must be another AGE virus going around! Two of the kids have classic vomiting with diarrhea and had a sick contact, and look very well. They’ll be easy Zo-Po-Go (ie Zofran, PO challenge, Go Home)!
The third one, however, is a 2-year-old now on his second day of vomiting (non-bilious, non-bloody), has no diarrhea, no fever, and the parent tells you they’ve been very “irritable.” It’s hard to examine his belly as he starts crying the minute you get close (even with all your great pediatric flair). His vitals are “OK” – somewhat tachycardic but probably was crying, normal BP, RR, SpO2, and temperature.
So you’re thinking differential: Could still be AGE? However, you’re also worried about other pathologies, such as appendicitis, intussusception, or testicular torsion (though normal GU exam).
And also don’t forget to consider other causes of just vomiting without accompanying diarrhea such as diabetic ketoacidosis, increased intracranial pressure, or other causes of bowel obstruction.
You want some more information…
So see the rest of the post for details and for how to perform the exam.
(1) The POCUS Atlas:
A Collaborative Ultrasound Education Platform
All of our content is freely available to be shared and used for global point-of-care ultrasound education.
What is the utility of bedside US for SBO?
Gold standard for diagnosing SBO is surgical pathology, however this is not useful as a diagnostic tool in the ED. Historically, KUB’s are performed as an initial diagnostic test, followed by CT if they are indeterminate. However, abdominal X-ray has a sensitivity of 66-77% and specificity of 50-57%.
A recent meta-analysis by Taylor and Lalani aimed to provide ED physicians with evidence-based data for the utility of ultrasound as an initial and accurate imaging modality to detect SBO. While the study points out that more data is needed (only 6 US studies met inclusion criteria), early results suggested that x-ray has limited utility with a positive likelihood ratio (+LR) of only 1.64, CT and MRI had +LRs of 3.6 and 6.77 respectively, whereas ultrasound had a +LR of 14.1 when performed by radiologists and 9.55 when performed as bedside US scans. Further commentary based on this study brings into question whether we should stop considering plain film (acute abdominal series) as an initial diagnostic tool for evaluating SBO.
One of the two bedside ED-performed studies reviewed in this meta-analysis was performed by Unluer et. al., who performed a prospective study of 174 patients presenting to the ED with suspected SBO. The team trained EM residents to perform POCUS for SBO during a 3-hour session and with 5 practice scans. Studies were considered positive if 2 or more of these findings were present:
● Dilated loops of bowel in 3 segments
● Increased peristalsis
● Collapsed colonic lumen
They found a sensitivity of 97.7% and a specificity of 92.7%. These seem like good numbers!