Article, Emergency Medicine

Diagnosis of intussusception using point-of-care ultrasound in the pediatric ED

Case Report

Diagnosis of intussusception using point-of-care ultrasound in the pediatric ED

A case report

Over the past decades, Ultrasonography expanded from radiology to many different specialties including emergency medicine. In 1999, the American Academy of Emergency Medicine published its position statement defining point-of-care (POC) US as a sonographic imaging procedure by an emergency physician on a patient in the emergency department (ED) in an effort to detect Acute medical problems. In 2001, the American College of Emergency Physicians issued a policy statement on the use of emergency US, endorsing its use in EDs nationwide. Since then, POC US use has dramatically increased, particularly in adult patients. Pediatric emergency medicine attendings have been slower to understand the importance of this application in the diagnosis of some specific pediatric conditions. This report illustrates the use of POC US in a case of a 10-month-old male infant that presented to the ED with fussiness as the only symptom. A diagnosis of intussusception was made using real-time POC US by a pediatric emergency medicine attending that was subsequently confirmed with radiology department US. The use of POC US and knowledge of the sonographic characteristics of intussusception can help the physician in the early diagnosis of intussusception and thereby reduce the likelihood for surgical reduction or even intestinal resection. The diagnosis of intussusception is best performed by an experienced sonographer, such as the radiologist. However, if a delay for this study is anticipated, POC US by a physician trained in POC US can be crucial in reducing time to diagnosis and definitive treatment.

POC US is increasingly performed in adult emergency medicine for a variety of indications. It is not a complete US but a focused, limited, goal-directed examination with the purpose of answering a specific question. POC US in pediatric emergency medicine is in its infancy, and only a few pediatric emergency medicine fellowship programs have integrated POC US training into their curriculum [1].

To our knowledge, there are no previous reported cases of pediatric intussusception diagnosed by a pediatric emergen- cy medicine attending (PEMA) using POC US. A case is

reported here from one of the authors (BMH) who was trained as part of her curriculum and obtained knowledge in pediatric US through a foreign pediatric residency.

A 10-month-old previously healthy male infant was brought to the pediatric (ED) with the chief complaint of fussiness for 3 days. One day before this visit, he was seen in a different ED for the same symptoms. He was given a fleet enema after which he had 2 green watery stools. The mother stated that he had crying episodes that lasted for

2 to 3 minutes every 30 minutes followed by normal behavior. His oral intake was slightly decreased, and he last drank liquids just before coming to the ED. He continued to have normal urine output. There was no history of vomiting, fever, or Cold symptoms. On examination, he was alert and active with a few episodes of fussiness. His vital signs were normal. His abdomen was soft and nondistended with normoactive bowel sounds. There appeared to be a lot of gas evident in the upper quadrants. There was no guarding or rebound tenderness, and there were no masses palpable. The remainder of the physical examination was unremarkable.

Intravenous fluids were started, and the patient was given morphine for pain control. abdominal x-rays showed an absence of gas in the right side of the abdomen but no signs suggestive of intussusception (Fig. 1). A radiology US was ordered, but the sonographer was not in-house. In the meantime, the PEMA performed a POC US for possible intussusception.

Using a TITAN Handcarried Ultrasound scanner (Sono- Site, Inc, Bothell, WA) with a 10-5-MHz 38-mm broadband linear array transducer, the right lower quadrant and right mid-abdomen were evaluated. The study revealed a soft tissue mass in the right mid-abdomen with the classic “target” sign on a cross section through the transverse axis of the involved segment (Fig. 2) and the “pseudokidney” sign on longitudinal view suggesting intussusception (Fig. 3). A pediatric surgeon and the radiologist on call were notified of the findings. A radiology US confirmed the diagnosis, and the patient underwent a barium enema that successfully reduced the intussusception.

For PEMAs, rapid diagnosis and treatment of life- threatening conditions are of utmost importance. The classic presentation of acute intussusception in children involves vomiting, intermittent abdominal pain, and bloody stools. However, up to 50% children may have a nonspecific

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354.e2 Case Report

Fig. 3 Ultrasound in long-axis plane showing the “pseudokid- ney” sign or “sandwich” sign.

Fig. 1 abdominal radiograph, upright view showing no signs of intussusception.

presentation like our patient who presented with fussiness only [2]. In addition, signs of intussusception are not always apparent on Abdominal radiographs [3-7]. The goal is to diagnose and treat intussusception early because a Delay in diagnosis may result in the need for surgical reduction or even intestinal resection.

Fig. 2 Ultrasound with cross-sectional image showing the

“target” sign or “multiple concentric ring” sign.

The gold standard for the diagnosis of intussusception has been a contrast enema. Over the last few years, US has gained favor over enema studies as the initial study for suspected intussusception. US is a risk-free, low-cost, noninvasive, fast, and painless procedure that does not involve contrast and can be done at the bedside. In addition, it does not use ionizing radiation that is particularly important in the pediatric population [8].

Traditionally, the radiology department makes the diagnosis of intussusception with US. The sensitivity and specificity of a US examination range from 98% to 100% depending on the experience of the ultrasonographer [5,6,9-11]. Several studies suggested that emergency physi- cians can be quickly trained in POC US [12-16]. However, so far, there are no studies that specifically looked at intussusception. A literature search showed only one previous report by Kairam et al [17] where pediatric intussusception was diagnosed by a pediatric emergency medicine fellow under the supervision of an emergency medicine attending. This patient had classic signs of intussusception including intermittent abdominal pain, blood per rectum, and an abdominal radiograph suggestive of intussusception.

In some pediatric hospitals, radiology department US may not be readily available [18]. Therefore, POC US is valuable in this scenario if the physician had training in POC US. False-positive US examinations are usually due to inexpe- rience of the operator. One study reported fecal matter as the most common imitator of intussusception [10]. False- negative US examinations can result from intermittent intussusception and from overlying bowel gas obscuring the view [19].

Brunhild M. Halm MD, PhD

Emergency Department Kapiolani Medical Center for Women and Children

Honolulu, HI 96826, USA

Case Report 354.e3

University of Hawaii John A Burns School of Medicine Honolulu, HI 96822, USA

Cancer Research Center of Hawaii University of Hawaii, Honolulu

HI 96813, USA

E-mail address: [email protected]

Rodney B. Boychuk MD

Emergency Department Kapiolani Medical Center for Women and Children

Honolulu, HI 96826, USA University of Hawaii

John A Burns School of Medicine Honolulu, HI 96822, USA

Adrian A. Franke PhD

Cancer Research Center of Hawaii

University of Hawaii Honolulu, HI 96813, USA

doi:10.1016/j.ajem.2010.03.016

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