Ultrasound Best for Diagnosing Intussusception

Ultrasound Best for Diagnosing Intussusception

Ultrasound is superior to 2-view abdominal radiography to rule out or confirm a diagnosis of ileo-intussusception in children, according to new research presented at the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition.

"Ileo-colic intussusception is a common surgical emergency in young children who come into the emergency department with abdominal pain, and we often have to image these patients," senior author Rakesh Mistry, MD, from the Children's Hospital of Philadelphia in Pennsylvania, said.

Some recent studies suggest that intussusception can be easily ruled out using 3-view abdominal radiography, Dr. Mistry said. "However, when you look at what's commonly done across the country, it's usually 2-view films, not 3-view films, that are the standard practice for the evaluation of abdominal pain when people order radiographs."

Dr. Mistry and his team did a retrospective chart review of 286 children aged 3 months to 3 years who had both 2-view radiography and an ultrasound performed in their emergency department for suspected intussusception between 2007 and 2009.

The patients' mean age was 16 months; 62% of patients were male, and 44% were African American. Of these patients, 61 (21.3%) had confirmed intussusception. Physical examination findings showed a significant positive association with abdominal tenderness (38.6% vs 20.0%; P = .003), grossly bloody stool (36.8% vs 8.2%; P = .001), and guaiac-positive stool (64.7% vs 30.4%; P = .009).

The researchers found that 2-view abdominal radiography had a greater false-positive rate, 10.5%, compared with 2.8% for ultrasound, and a greater false-negative rate, 8.0%, compared with 0.3% for ultrasound.

Ultrasound also exhibited superior positive and negative predictive values and likelihood ratios compared with 2-view radiography.

"Our conclusion is essentially that ultrasound should be used primarily when there is a suspicion for intussusception or if you wish to exclude intussusception in your patient, and that plain film itself is not reliable enough to rule out these possibilities," Dr. Mistry said. "If you use 2-view, there is a possibility that you could be making some clinical decisions that may not be prudent if you base them solely on the x-ray."

He added, "There is a possibility that 3-view would be better, but it's not routine practice in most places. Also the 3-views are not always agreed upon."

Lei Chen, MD, from Yale University School of Medicine in New Haven, Connecticut, was asked to comment on this study. According to Dr. Chen, ultrasound's superior sensitivity and specificity are well established.

"The use of plain films to rule out intussusception would be useful but the sensitivity of the test is too low, as reported by the research presented here in Dr. Mistry's study, to be used in this way," Dr. Chen said.

"As ultrasound becomes more widely available, the next research should look at how good pediatric emergency medicine physician-performed ultrasound is," he added.

View the article online.

Article written by staff at medscape.com and adapted for the purposes of this newsletter.

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Imaging Technology Might Help Doctors Determine Best Treatment for Crohn's Disease Patients

It’s difficult for doctors to tell whether a patient with Crohn’s disease has intestinal fibrosis, which requires surgery, or inflammation, which can be treated with medicine. A new imaging method might make that task easier, according to a U-M-led study.
Ultrasound elasticity imaging, or UEI, could allow doctors to noninvasively make the distinction between inflammation and fibrosis, allowing patients to receive more appropriate and timely care. Crohn’s disease patients suffer from chronic inflammation of the intestines, which over time can cause scar tissue to form, resulting in intestinal fibrosis.

Patients with intestinal inflammation usually are treated with medicines that suppress their immune system, while patients with fibrosis are treated surgically. Because current diagnostic tests, including CT scans and MRIs, cannot detect the difference between the two conditions, many patients with fibrosis are often initially treated with immune system-suppressing drugs, which are expensive and are unlikely to help.

“These therapies are potent, costly and carry risk,” said Ryan Stidham, M.D., clinical lecturer in the Department of Internal Medicine. “And for patients with fibrosis, such treatment might be for naught.”

Inflamed intestinal tissue is softer than fibrotic tissue, which is hard and thick. The new method uses ultrasound to measure the relative hardness and thickness of tissue inside the body, potentially allowing doctors to differentiate between the two conditions without performing surgery. In animal models, UEI was able to accurately tell the difference between inflamed tissue and scar tissue.

“The goal of this study is to have technology that can make the distinction between fibrosis and inflammation,” said Stidham, the lead author of the study. “We want to know if it’s worth it to push medical therapy, or if a person is destined for surgery.”

The researchers also found that UEI was capable of differentiating between fibrotic and unaffected intestine in a pilot human study. Patients already scheduled for surgical treatment underwent UEI assessment prior to surgery, and fibrotic strictures were identified in each case.

Stidham said the next step in the group’s research is a long-term human clinical trial, beginning this winter. If UEI is able to accurately assess a patient’s condition, doctors will be able to more efficiently treat Crohn’s disease patients suffering from inflammation or fibrosis.

“UEI has great potential to provide a clear measurement that helps clinicians judge whether medical or surgical management is best for the individual patient earlier in their disease course,” Stidham said.

View the article online.

Article written by staff at uofmhealth.org and adapted for the purposes of this newsletter.

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Echocardiographic Evaluation of Cancer Patients- European and Americans to Jointly Issue Guidelines

According to an announcement made by The European Association of Echocardiography (EAE), the EAE will be collaborating with the American Society of Echocardiography (ASE) in order to issue guidelines on the benefits of serial echocardiographic evaluations and the potential impact of more advanced ultrasound technologies, in particular Speckle Tracking Echocardiography, in patients undergoing cancer therapy.

Professor Juan Carlos Plana, Co-Director of the Cardio-oncology Center at the Cleveland Clinic, from the ASE commented:

"Considering that the early detection of cardio toxicity is a critical issue for patients undergoing chemotherapy, the ASE and the EAE have come together to write guidelines which will highlight the technical advantages of echocardiography in identifying cardio toxicity early. This would help select patients who would benefit from cardio protective regimens, so that heart failure does not become an obstacle to the oncologist during therapy, and to the patient during his/her survival."

Cancer therapies have dramatically progressed over the last decade resulting in significant morbidity and mortality reductions in several types of cancer. Cancer patients receive therapeutic care in form of radiation therapy, a combination of drugs and surgery, some of which, mainly anthracyclines, produce potential adverse cardiac reactions that can have a negative impact on the patient's quality of life and on the prognosis of the oncologic patient. A new generation of targeted treatments, such as trastuzumab in breast cancer, has been linked to unforeseen negative side effects on patients' myocardial function. At present 17% of patients have to cease their cancer treatment due to heart problems.

Chairperson of the EAE task force, Dr Maurizio Galderisi from the Federico II University in Naples, Italy explained:

"Detecting cardio toxicity is a critical issue in the clinical setting, in order to appropriately modulate and, hopefully, not interrupt cancer therapy. The traditional screening of patients with cancer includes a cardiac examination, and both an electrocardiogram (EKG) and a 2D echocardiogram with Doppler at baseline. The monitoring of cardiovascular toxicity might be more accurate using endomyocardial biopsy. However, the test is highly invasive and not free from complications."

An alternative choice for noninvasive examinations of cardiac disease in cancer patients could be Echocardiography, an essential tool for the evaluation of left ventricular systolic and diastolic dysfunction, pericardial and valvular heart disease.

At present, echocardiograms are only routinely performed at the start of cancer treatment to document a normal left ventricular systolic function. A follow up echocardiography is usually only performed during cancer therapy if patients' show an onset of cardiac symptoms and/or signs, particularly after having been administered with recognized cardiotoxic drugs or radiation therapy.

Chairperson of the EAE Scientific Committee Dr Rosa Sicari, FESC, from the CNR Institute of Clinical Physiology in Pisa, Italy commented that:

"The assessment of cardiac toxicity remains a critical issue in oncology. Ejection fraction, the time honored parameter of function is not useful for the detection of early and subtle forms of cardiac dysfunction. New tools are needed and the evidence should be built in the near future with appropriately designed studies and with the common efforts of oncologists, cardiologists and pharmacologists. This document is not meant to fill the gap of knowledge but to provide the state of the art of ultrasound in this field and indicate new research pathways."

Based on these findings, the soon to be issued joint guidelines of the ASE and EAE will address the necessity and clinical practicality of serial echocardiographic evaluations together with potential impacts of more advanced ultrasound technologies in patients undergoing cancer therapy.