Ultrasound In The Dx of Intussception and In The Dx of Inflammatory Bowel Disease But Not For Volvulus

I found the article, Diagnostics in Inflammatory Bowel Disease: Ultrasound [links in Resources], in Google search.

I was reviewing some of the cases in Case Studies In Pediatric and Emergency and Critical Care Ultrasound 2013 (an excellent book for learning clinically relevant pediatric office ultrasound). In Case 26, Paroxysmal abdominal pain and vomiting in a 7-month-old male, the authors stated that “Ultrasound screening [in addition to decreasing radiation exposure by obviating the need for fluoroscopy] similarly decreases enema-induced perforations in the setting of acute colitis,a common mimicker of intussception.” (p 123)

Of course, the most important time sensitive cause of bilious vomitting and/or abdominal pain is malrotation of the gut.

The clinical and ultrasound exam can be normal in the case of recurrent – resolving intussception.

And the clinical exam can be normal in the case of intermitent volvulus in malrotation.

While ultrasound is excellent for the diagnosis of intussception (if present at the time of diagnosis), ultrasound is not accurate enough to rule out midgut malrotation.

All that follows is from Midgut Volvulus Imaging in Resources:

An upper GI series is the preferred diagnostic test for malrotation with midgut volvulus and must be performed, unless a delay in surgical treatment will compromise outcome (as in the case of a moribund child).[2, 4, 5, 21, 22] Upper GI series’ sensitivity is 85-95%, with a higher specificity (false positives are rare). [emphasis added]

[The upper GI series should be performed at a tertiary care pediatric center.]

Intestinal malrotation occurs in between 1 in 200 and 1 in 500 live births.[6, 7] However, most patients with malrotation are asymptomatic, with symptomatic malrotation occurring in only 1 in 6000 live births.[8] Symptoms and diagnosis may occur at any age, with some reports of prenatal diagnosis of intestinal malrotation.[9]

Traditional teaching suggests that as many as 40% of patients with malrotation present within the first week of life, 50% in the first month, and 75% in the first year. However, more recent series have shown that malrotation is increasingly identified in adults. A series of 170 patients with intestinal malrotation diagnosed at a single institution between 1992-2009 found that 31% were infants, 21% were aged 1-18 years, and the remaining 48% were adults.[18] A second series found that 42% of patients with malrotation were adults.[19]

Malrotation may occur as an isolated anomaly or in association with other congenital anomalies; 30-62% of children with malrotation have an associated congenital anomaly. All children with diaphragmatic hernia, gastroschisis, and omphalocele have intestinal malrotation by definition. Additionally, malrotation is seen in approximately 17% of patients with duodenal atresia and 33% of patients with jejunoileal atresia.[10, 11]

The moderate-to-low degree of confidence associated with ultrasonography and CT necessitates an upper GI series to confirm the diagnosis.[27, 28, 29] Ultrasonography and CT have false-negative rates of approximately 30% and false-positive rates as high as 20%.

Resources:

Diagnostics in inflammatory bowel disease: ultrasound [PubMed Abstract] [Full Text HTML] [Full Text PDF]. World J Gastroenterol. 2011 Jul 21;17(27):3192-7. doi: 10.3748/wjg.v17.i27.3192.

Ulcerative Colitis Imaging, Updated: Nov 22, 2015, from emedicine.medscape.com.

Imaging In Crohn’s Disease, Updated: Nov 02, 2015, from emedicine.medscape.com.

Intestinal Malrotation, Updated: Oct 08, 2015, from emedicine.medscape.com.

Midgut Volvulus Imaging, Updated: Mar 30, 2016,

Intussusception Diagnosis and Treatment, YouTube Video Published on Jan 5, 2015, by Dr. Larry Mellick. “A five year presented with abdominal pain and was diagnosed with intussusception by an ER ultrasound. Air contrast enema was performed and the intussusception was reduced.”

Life Threatening Intussusception Emergency, YouTube Video Published on Jan 25, 2015, by Dr. Larry Mellick. “In this video a young patient with a life threatening intussusception emergency is treated with an air contrast enema. The actual reduction of the intussuscepted bowel is nicely demonstrated. Additionally, we capture one of the painful cramping episodes caused by the intussusception. Thanks to the patient’s mother we were able to capture important and rarely seen clinical elements of this disease.

Bedside Ultrasound Diagnosis of Pediatric Intussception, YouTube Video Published on Aug 7, 2012, ACMC EM residency.

 

 

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