ORIGINAL ARTICLE
THE DIAGNOSTIC ACCURACY OF SONOGRAPHY IN CHILDREN
SUSPECTING INTUSSUSCEPTION KEEPING SURGICAL FINDINGS
AS A GOLD STANDARD
Pari Gul,1 Muhammad Ayub Mansoor,1 Roomi Mahmud,1 Ameet Jesrani,1
S. Mustansir H. Zaidi2
1
2
De partm e ntofRadiol
ogy, Liaq uatNationalH os pital
, Karach i, Pak is tan.
De partm e ntofStatis tics , Liaq uatNationalH os pital
, K arach i, Pak is tan.
PJR October - December 2016; 26(4): 291-295
ABSTRACT
BACKGROUND: Intus s us ce ption occurs w h e n a s e gm e nt of bow e linvaginate s into an im m e diate l
y adjace nt
s e gm e nt, ofte n l
ik e ne d to a te l
e s cope . Ul
tras ound is th e prim ary im aging m odal
ity for initialdiagnos is w ith h igh
accuracy approach ing 100% w ith s e ns itivity of 9 8% to 100% and s pe cificity of 88% to 100% . It al
so h e l
p to
uate th e
de te rm ine w h e th e r th e invol
ve d bow e ls h oul
d be re duce d or s urgical
l
y re s e cte d. OBJECTIVE: To e val
diagnos tic accuracy of s onograph y in ch il
dre n s us pe cting intus s us ce ption k e e ping s urgicalfindings as a gol
d
s tandard. METHODS: Total19 2 ch il
dre n pre s e nte d w ith cl
inicaltriad of col
ick y abdom inalpain, vom iting and
je l
l
y s tool
s s ince l
as t 5 h ours w e re incl
ude d. Ul
tras ound w as pe rform e d and s e riall
ongitudinaland trans ve rs e
im age s w e re as s e s s e d. Al
lth e patie nts diagnos e d as h aving s igns of irre ducibl
e intus s us ce ption l
ik e fre e fl
uid,
abs e ntbl
ood fl
ow on col
or Doppl
e r w e re fol
l
ow e d afte r s urge ry. Se ns itivity, s pe cificity, and accuracy oful
tras ound
e w e re 109 (56.8% ) and fe m al
e
w e re cal
cul
ate d us ing s urgicalproce dure as gol
d s tandard. RESULTS: Th e m al
w e re 83 (43.2% ). Th e m e an age w as 4.3 ± 2.3 ye ars . O n ul
tras ound e xam ination, intus s us ce ption w as diagnos e d
in 33 patie nts . In s urgicalproce dure it w as diagnos e d in 31 patie nts . Th e ove ral
ls e ns itivity of ul
tras ound w as
tras onograph y is an accurate ,
83.9 % , s pe cificity w as 9 5.7% and diagnos tic accuracy w as 9 3.7% . CONCLUSION: Ul
s afe and val
uabl
e cl
inicaltoolin th e diagnos is of acute intus s us ce ption in ch il
dre n.
Key words: Diagnos tic Accuracy, Ul
tras onograph y, Intus s us ce ptions , Surgicalfindings
Introduction
Intus s us ce ption is th e m os tcom m on abdom inale m e rge ncy s ituations in infants and s m al
lch il
dre n.1 Cl
inical
pre s e ntation incl
ude s irritabil
ity, inte rm itte nt crying,
abdom inalcol
ic, bil
e -s taine d vom iting, re d je l
l
y s tool
s
and pal
pabl
e abdom inalm as s . Th e triad ofinte rm itte nt
abdom inalpain, vom iting and righ t uppe r-q uadrant
abdom inalm as s h as a pos itive pre dictive val
ue of
2
9 3% . Itis one ofth e m os tcom m on caus e s ofbow e l
obs truction in infancy l
e ading to inte s tinalne cros is ,
bow e lre s e ction and e ve n de ath if not re cogniz e d
and tre ate d appropriate l
y. 3 Intus s us ce ption occurs
w h e n a s e gm e ntofbow e linvaginate s into an im m e diate l
y adjace nt s e gm e nt, ofte n l
ik e ne d to a te l
es cope .1 Four type s ofintus s us ce ption are de s cribe d;
Il
e ocol
ic-intus s us ce ption is th e m os t com m on type ,
accounting for ove r 80% ofcas e s in ch il
dre n.1 Intus s e s ce ption s e e m s to be idiopath ic in 9 0% of cas e s
and is as s ociate d w ith Path ol
ogic l
e ad points s uch
as m e ck e l
’s dive rticul
um , s ol
id bow e ll
e s ion and
inte s tinall
ym ph om a. Itcan occur pos tope rative l
y and
3
afte r bl
untabdom inaltraum a.
Th e incide nce of intus s us ce ption in infants range s
Correspondence : S. M us tans ir H . Z aidi
De partm e ntofStatis tics ,
Liaq uatNationalH os pital
,
K arach i, Pak is tan.
Mobil
e : + 9 2-312-9 29 8804
Em ail
: m us tans ir.z aidi@ gm ail
.com
Subm itte d 1 De ce m be r 2015, Acce pte d 8 January 2016
PA K I S TA N J OU R N A L O F RA D IO L O GY
PJR October - December 2016; 26(4)
291
from 0.3 to 4 cas e s pe r 1,000 l
ive birth s in Europe ,
North Am e rica and Aus tral
ia, butin s om e de ve l
oping
countrie s a h igh e r incide nce and a h igh rate ofcom pl
ications h ave be e n de s cribe d.3 Itoccurs pre dom inantl
y
in m al
e s , w ith pe ak incide nce be tw e e n 6 m onth s and
2 ye ars of age afte r w h ich th e incide nce gradual
l
y
de cl
ine s . Itcom m onl
y occurs in th e s pring and w inte r
s e as ons .4-5
Ul
tras ound is th e prim ary im aging m odal
ity for initial
diagnos is in th e de ve l
oping countrie s . Sonograph y
s cre e ning in ch il
dre n h as be e n s ugge s te d to re duce
cos t, radiation e xpos ure and both patie ntand pare ntal
anxie ty/dis com fortw ith e ne m a. Ul
tras ound al
s o pl
ays
a rol
e in ide ntifying al
te rnative diagnos e s as w e l
las
th e e val
uation of re ducibil
ity of an intus s us ce ption,
th e pre s e nce ofa l
e ad pointm as s and intus s us ce ption
l
im ite d to th e s m al
lbow e l
. Publ
is h e d s e rie s s ugge s t
h igh accuracy approach ing to 100% in e xpe rie nce d
h ands , w ith s e ns itivity of 9 8% -100% and s pe cificity
tras ound are
of 88% -100% .6-7 Th e advantage s of ul
th atital
l
ow s non-invas ive , rapid and confide ntdiagnos is w ith l
ack of ioniz ing radiation as com pare d to
CT s can and barium e ne m a. It can be done at be d
s ide e ve n w ith l
e s s e xpe rie nce d re ade rs . Ital
soh el
p
to de te rm ine w h e th e r th e invol
ve d bow e ls h oul
d be
re duce d or s urgical
l
y re s e cte d. Inabil
ity to de te ct
bl
ood fl
ow in th e intus s us ce ption pre dicts th e ne e d
for s urge ry.8
Th e rational
e ofth is s tudy w as to form a noninvas ive
e as il
y avail
abl
e m odal
ity to diagnos e intus s us ce ption
in ch il
dre n s o th attim e l
y inte rve ntion coul
d be done
to re duce m orbidity and m ortal
ity.
2012 to Jul
y 2012. Th e approvalof ins titutional
re s e arch & e th icalcom m itte e and inform e d cons e nt
w as tak e n prior to com m e nce m e ntofth e s tudy. Th e
s am pl
e s iz e w as cal
cul
ate d by us ing s e ns itivity and
s pe cificity oful
tras ound for diagnos is ofintus s us ce ptions . Th e s am pl
e w as col
l
e cte d th rough nonprobabil
ity cons e cutive s am pl
ing te ch niq ue .
Brie f h is tory re garding duration and s ym ptom s of
intus s us ce ption w e re s ough t. Ul
tras ound w as pe rform e d us ing probe s of3.5 M H z and 8.0 M H z on Apl
io
Tos h iba m ach ine .
Se riall
ongitudinaland trans ve rs e im age s w e re tak e n
and as s e s s e d by a cons ul
tantradiol
ogis t. Pre s e nce
offol
l
ow ing ul
tras ound fe ature s w as cons ide re d intus s us ce ption pre s e nt
Targe ts ign (dough nuts ign): Th e appe arance w as
ge ne rate d by conce ntric al
te rnating e ch oge nic and
h ypoe ch oge nic bands . Th e e ch oge nic bands w e re
form e d by m ucos a and m us cul
aris w h e re as th e
s ubm ucos a is re s pons ibl
e for th e h ypoe ch oic
Ps e udo k idne y s ign: Th e ps e do k idne y s ign of
Intus s e s ce ption re fe rre d to th e l
ongitudinalul
tras ound
appe arance ofth e intus s us ce pte d s e gm e ntofbow e l
.
Cre s ce nt in a dough nut s ign: Th is re fe rre d to th e
trans ve rs e ul
tras ou nd appe arance of inte s tinal
intus s e s ce ption and w as a variation ofth e targe ts ign.
Fre e fl
uid: Th e trappe d fre e fl
uid indicate d poor
re producibil
ity and indication for s urge ry
Abs e nt bl
ood fl
ow : Th is indicate d is ch e m ia and
ne cros is ofbow e l
.
Materials & Methods
Total19 2 ch il
dre n of both ge nde rs , age be l
ow 12
ye ars pre s e nte d w ith cl
inicaltriad ofcol
ick y abdom inal
pain, vom iting and je l
l
y s tool
s s ince l
as t5 h ours w e re
incl
ude d in th is cros s s e ctionals tudy to de te rm ine
th e diagnos tic accuracy of s onograph y in ch il
dre n
s us pe cting intus s us ce ption k e e ping s urgicalfindings
as a gol
d s tandard. Th e s am pl
e s ubje cts w e re s e l
e cte d
th rough Radiol
ogy de partm e nt, Liaq uat National
Pos tgraduate M e dicalCe ntre , K arach i, from January
PAK I S TA N J O U R N A L OF R A D I O LO GY
Figure 1: Abdom inalul
tras onograph y re ve al
s th e cl
as s ic targe t
s ign ofan intus s us ce ptum ins ide an intus s us cipie ns
PJR October - December 2016; 26(4)
292
Al
lth e patie nts diagnos e d as h aving s igns of irre ducibl
e intus s us ce ptions on col
or Doppl
e r w e re
fol
l
ow e d afte r s urge ry.
Data com pil
ation and anal
ys is w as done on SPSS
ve rs ion 21. De s criptive s tatis tics w e re cal
cul
ate d.
Quantitative variabl
e i.e . age w as e xpre s s e d as m e an
± SD and q ual
itative variabl
e s i.e . ge nde r, cl
inical
fe ature s , ul
tras ound findings , and s urgicalfindings
w e re pre s e nte d in te rm s of fre q ue ncy and pe rce ntage s . Se ns itivity, s pe cificity, pos itive pre dictive val
ue ,
and ne gative pre dictive val
ue s of ul
tras ound for
de te cting intus s us ce ption w e re cal
cul
ate d us ing 2 by
2 tabl
e s by tak ing s urgicalfindings as a gol
d s tandard.
Stratification w as done w ith re gards to age and ge nde r
to th e s e e th e e ffe ctofth e s e on outcom e .
Results
In th is s tudy out of totals tudy ch il
dre n, m al
e w e re
109 (56.8% ) and fe m al
e w e re 83 (43.2% ). Th e m al
e
to fe m al
e ratio w as 1.3:1. Th e m e an age w as 4.3 ±
2.3 ye ars . Age of136 (70.8% ) ch il
dre n w as 4 ye ars
and re s t of th e 56 (29 .2% ) ch il
dre n w e re age d >4
ye ar. As far as cl
inicalfe ature s at pre s e ntation are
conce rne d, th e re s ul
ts s h ow e d th atcol
ick y abdom inal
pain w as obs e rve d in 85 (44.3% ) patie nts , vom iting
w as obs e rve d in 30 (15.6% ) patie nts , abdom inal
m as s w as obs e rve d in 16 (18.2% ) patie nts , and Curre ntje l
l
y s toolw as obs e rve d in 16 (8.3% ) patie nts .
O n ul
tras ound e xam ination, intus s us ce ption w as
diagnos e d in 33 patie nts (Graph -1) and in s urgical
proce dure itw as found in 31 patie nts (Graph -2) and
(Tab. 1).
Graph 2: Pe rce ntage ofintus s us ce ption findings in Surgical
Exam ination
Frequency
(n=192)
%
Ultrasound
Present
33
17.2%
Findings
Absent
159
82.8%
Surgical
Present
31
16.1%
Findings
Absent
161
83.9%
Table 1: Fre q ue ncy dis tribution for diagnos is ofintus s us ce ption
In both ul
tras ound and s urgicalproce dure s , intus s us ce ption w as diagnos e d am ong 26 patie nts (true
pos itive , corre ctl
y diagnos e d) and itw as notdiagnos e d
in 154 patie nts (true ne gative , corre ctl
y diagnos e d).
Th e ove ral
ls e ns itivity oful
tras ound w as found to be
83.9 % , s pe cificity w as 9 5.7% and diagnos tic accuracy
w as 9 3.7% (Tab. 2).
Frequency
(n=192)
Present
Absent
Total
Ultrasound
Present
26 (83.9%)*
7
33
Findings
Absent
5
154 (95.7%)**
159
31
161
192
Total
*Sensitivity
**Specificity
PPV= 78.8%
NPP=96.9%
Diagnostic accuracy=93.7%
Table 2: Diagnos tic accuracy oful
tras ound for diagnos is of
intus s us ce ption.
Graph 1: Pe rce ntage ofintus s us ce ption findings in Ul
tras ound
e xam ination
PAK I S TA N J O U R N A L OF R A D I O LO GY
Pos ts tratification anal
ys is bas e d on age s h ow e d th at
th os e patie nts w h os e age w as 4 ye ars or l
e s s h ad
81.0% s e ns itivity, 9 5.7% s pe cificity, and 9 3.4%
diagnos tic accuracy and th os e patie nts w h os e age
w as m ore th an 4 ye ars h ad 9 0.0% s e ns itivity, 9 5.7%
s pe cificity, and 9 4.6% accuracy of ul
tras ound in
diagnos is of intus s us ce ptions . Stratifie d anal
ys is
PJR October - December 2016; 26(4)
293
according to ge nde r s h ow e d th atm al
e patie nts h ad
80.0% s e ns itivity, 9 5.7% s pe cificity, and 9 3.6% diagnos tic accuracy and am ong fe m al
e patie nts s e ns itivity
w as 87.5% , s pe cificity w as 9 5.35% , and diagnos tic
accuracy w as 9 4.0% of ul
tras ound in diagnos is of
intus s us ce ption (Tabl
e -3).
AGE
(n=192)
 4 years > 4 years
GENDER
Male
Female
Sensitivity
81.0%
90.0%
80.0%
87.5%
Specificity
95.7%
95.7%
95.7%
95.5%
Positive Predictive Value
77.3%
81.8%
75.0%
82.4%
Negative Predictive Value
96.5%
97.8%
96.8%
97.0%
Diagnostic Accuracy
93.4%
94.6%
93.6%
94.0%
Table 3: Diagnos tic accuracy oful
tras ound for diagnos is of
intus s us ce ption according to age and ge nde r
Discussion
Th e traditionalinve s tigations w ith s m al
lbow e le nte rocl
ys is and s m al
lbow e lfol
l
ow -th rough re ve alinform ation s paringl
y, and unfortunate l
y invol
ve radiation
e xpos ure of th e patie nt. Al
th ough itis an organ th at
is s pare d from fre q ue nt dis e as e , m ore pre cis e and
patie nt-frie ndl
y m e th ods are ne e de d.9 Ne w im aging
te ch niq ue s h ave be e n de ve l
ope d th at h ave prove n
us e ful
. Com pute riz e d tom ograph y (CT), m agne tic
re s onance im aging (MRI), w ire l
e s s caps ul
e e ndos copy
and doubl
e -bal
l
oon e ndos copy are al
lre l
ative l
y ne w
additions to th e diagnos tic arm am e ntarium .
Ul
tras ound is accurate and ch e ape r com pare d to
oth e r diagnos tic m odal
itie s in diagnos is ofintus s us ce ption. Th e re l
iabil
ity oful
tras onograph y as a diagnos tic toolfor de te ction ofintus s us ce ptions (IS) h as
be e n w ide l
y de bate d.10 In curre nt s tudy th e ove ral
l
s e ns itivity of ul
tras onograph y in de te ction ofIS w as
83.9 % , s pe cificity of9 5.7% and accuracy of9 3.7% .
A l
arge - s cal
e pros pe ctive s tudy re porte d th at
ul
tras onograph y is 9 7.5% s e ns itive and 9 9 .0% s pe cific
for th e diagnos is ofacute IS in ch il
dre n in de ve l
oping
country de s pite th e us e of e q uipm e nt w h ich w e re
ol
de r th an are ge ne ral
l
y avail
abl
e in de ve l
ope d
11
countrie s .
Abs e nce of radiation, non-invas ive ne s s and rapid
nature of ul
tras onograph y h ave m ajor cl
inicaland
te ch nicaladvantage s . Ul
tras onograph y al
s o e nabl
es
PAK I S TA N J O U R N A L OF R A D I O LO GY
fol
l
ow -up s cre e ning to confirm re duction or inve s tigate
pe rs is ting s ym ptom s . 87 O f th e patie nts w h o w e re
ne gative for IS on ul
tras onograph y in th is s tudy, 9 4%
did not proce e d to air e ne m a, avoiding e xpos ure to
radiation and th e dis com fortofunde rgoing an e ne m a.
Trans ie ntIS or s pontane ous re duction can be obs e rve d us ing ul
tras onograph y, obviating th e ne e d for
l
y, col
our Doppl
er
e ne m a re duction.11- 12 Additional
US h as be e n re porte d to aid pre diction ofre ducibil
ity
of IS by e ne m a.13 Pracros e t al
.14 h ave al
s o s h ow n
th at ul
tras onograph y as s is ts th e diagnos is of oth e r
conditions incl
uding urinary tract path ol
ogy, ovarian
dis orde rs , ne crotiz ing e nte rocol
itis , cys tofth e com m on
bil
e ductand s m al
lbow e lvol
vul
us .
Due to th e rare as s ociation be tw e e n a rotavirus
vaccine (Rotas h ie l
d® ) and IS, th e W orl
d H e al
th
O rganiz ation h as re com m e nde d th at countrie s
pl
anning to introduce a rotavirus vaccine s h oul
d de ve l
op pos t-m ark e ting s urve il
l
ance s ys te m s to prom ptl
y
oping
ide ntify and m anage cas e s ofIS.15 M any de ve l
countrie s re l
y on ul
tras onograph y for th e diagnos is
ofIS. Th is s tudy confirm s th e accuracy and re l
iabil
ity
oful
tras onograph y for th e diagnos is ofacute IS.
Conclusion
Ul
tras onograph y is an accurate , s afe and val
uabl
e
cl
inicaltoolin th e diagnos is ofacute intus s us ce ption
in ch il
dre n. Th e us e oful
tras onograph y as a prim ary
inve s tigation for patie nts w ith s us pe cte d intus s us ce ption pre ve nte d unne ce s s ary radiol
ogicalor s urgical
proce dure s be ing pe rform e d. Ul
tras onograph y h as
be e n val
idate d as a val
uabl
e toolfor th e diagnos is
ofintus s us ce ption.
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