Point-of-Care Ultrasound May Reduce Misdiagnosis of Pediatric Intussusception

Abstract

Aim: Intussusception, the most common abdominal emergency in early childhood, is frequently misdiagnosed at initial presentation. The effect of using point-of-care ultrasonography (POCUS) by emergency medicine physicians on pediatric intussusception misdiagnosis rate remains unclear. Here, we summarize outcomes and misdiagnoses before and after training junior and senior physicians on using POCUS for diagnosing intussusception and compared their performance levels.Materials and Methods: This observational cohort analysis included patients with suspected intussusception who visited a pediatric emergency department (ED) between January 2017 and December 2019. All enrolled patients were evaluated by junior (<10-year experience) or senior attending physicians. Misdiagnosis was defined as a finding of negative air reduction or confirmation of diagnosis on ED revisit or admission. The misdiagnosis rates and outcomes before and after POCUS training for intussusception diagnosis were evaluated and performance of the junior and senior physicians was compared.Results: Of the 167 enrolled patients, 130 were confirmed to have intussusception by air reduction. Misdiagnosis rate was significantly lower in the post-training patient group after training than in the pre-training patient group (43.7 vs. 12.7%, P < 0.001). After training, fewer misdiagnoses were made by the junior (59.1 vs. 25.9%, P = 0.003) and senior (31.7 vs. 0%, P < 0.001) physicians. In the post-training patient group, the door-to-reduction time and rate of ultrasonography consultation with an expert also decreased significantly (118.2 ± 124.5 vs. 198 ± 250.2 min, P = 0.006). Abdominal pain (80.9%) was the most common symptom of intussusception, followed by vomiting (58.3%), fever (17.8%), bloody stool (15.4%), and diarrhea (14.2%). Even after training, the presenting symptoms of intussusception often leading junior physicians to misdiagnosis were diarrhea and fever.Conclusions: A brief POCUS training leads to decreased misdiagnosis rates in both the senior and junior physicians. Junior physicians should increase their awareness regarding diarrhea and fever being the presenting symptoms of intussusception, particularly in early childhood. Combining clinical judgment and POCUS results forms the core principle of the evaluation of children with intussusception.

Point of Care Ultrasound in Pediatric Surgery across the European Region—European Pediatric Surgery Association Endorsed Survey

“…To help diagnose appendicitis, intussusception or perform a FAST (focused assessment with sonography in trauma) scan in the setting of pediatric trauma. This is in keeping with the literature, where POCUS has been described in several institutions as a valuable means of providing timely diagnosis of intussusception, in order to avoid delays in treatment and reduce the risk of bowel necrosis [8][9][10] . Several studies have demonstrated 100% sensitivity in detecting intussusception when POCUS is performed by non-radiology clinicians [8][9][10][11] .…”

“…[8][9][10] Several studies have demonstrated 100% sensitivity in detecting intussusception when POCUS is performed by non-radiology clinicians. [8][9][10][11] 44.5% (N ¼ 83/186) of respondents had self-perceived competence (from basic to being confident enough to train others) in diagnosing intussusception with POCUS. About 27.4% (N ¼ 51/186) would like to learn POCUS for this purpose.…”

Single-center experience of managing childhood intussusception

“…Ultrasound has a sensitivity of about 98-100% and specificity of almost 98% to diagnose intussusceptions. [6][7][8] In our study, ultrasound helped in almost every case for the diagnosis; and ultrasound-guided hydrostatic reduction as well in the majority of the patients. Hydrostatic reduction is an urgent emergency intervention and should be performed soon after diagnosis with preparation for possible surgical intervention.…”

“…Ultrasonography is now a more commonly suggestive and preferable diagnostic modality in addition to plain radiography and contrast enema study. [4][5][6][7][8] If not recognized and treated promptly, intussusception may progress to intestinal ischemia needing a bowel resection. [9] Saline, Barium, or gas enemas are mostly used to reduce uncomplicated intussusceptions, although it has been reported that 10% to 30% of cases eventually need sur-…”

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception

“…14 Similarly, it has been estimated that the sensitivity of POCUS for the identification of intussusception is 90% among PEM physicians with focused training in bowel sonography compared with 79% among those without formal training. 8 More recently, Hsiao et al 31 showed that misdiagnosis of intussusception by POCUS decreased from 44% to 13% after the implementation of formal POCUS training; however, misdiagnosis rates improved more among senior compared with junior physicians with less clinical experience. Given the modest sensitivity and specificity among novice reviewers in our study, it is likely that a more focused training curriculum, including image interpretation, is needed for residents and PEM fellows.…”