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https://www.youtube.com/watch?v=8e2bZOKjAF0
Transcript

- [Laura] Welcome to the Sonosite webinar

called Jelly on the Belly,

using POCUS to improve pediatric intussusception outcomes.

Before we begin, please be advised all attendees are muted.

You may type your questions

into the Q&A box located at the bottom

or side of your screen at any time.

We will conduct a Q&A session

at the end of the presentation.

This webinar will be recorded

and archived for future reference.

It is an honor to introduce our speaker today,

Dr. Marla Levine.

Dr. Levine is an Associate Professor

of Pediatrics at Vanderbilt University.

Dr. Levine is boarded in pediatrics

and pediatric emergency medicine,

and she completed an emergency ultrasound fellowship

following her PEM training.

Dr. Levine has been an educator in POCUS

for the last 10 years, having lectured locally, nationally,

and internationally on POCUS in the care of children.

Her academic interests include POCUS education,

medical education, and gender equity issues.

She recently published an expert panel curriculum tool

for a PEM POCUS Fellowship

and is currently involved in the development

of a PEM POCUS competency checklist

for POCUS within a PEM fellowship.

So without further ado, I will turn it over to you,

Dr. Levine.

- [Marla] Thank you so much Laura for this opportunity

to speak today

and for Sonosite for inviting me to give this lecture.

I feel very passionately about

how important ultrasound is in the care of children

and there aren't that many pediatric specific applications,

but one of the more important ones is ultrasound

for the diagnosis of intussusception

and it is one of those skill sets

that's not super technically challenging to master.

And so I thought it would be a great starting point

for our discussion and hopefully future discussions on how

to use point care ultrasound in the care

of our pediatric patients.

Just a quick disclosure,

the content of this lecture is not proprietary of

or representing the views of Vanderbilt University,

Vanderbilt Medical Center,

or Monroe Carell Children's Hospital at Vanderbilt.

Okay, so to start us off today,

these are the objectives of our talk.

We're going to review pediatric intussusception.

We're going to discuss the literature that supports the use

of POCUS in the diagnosis of intussusception,

and then we're going to describe how

to perform a bedside ultrasound

for the diagnosis of intussusception.

So to better elucidate

and describe ultrasound in the care of our patients,

we're going to do this in a case-based approach.

So this was a child that I had not too long ago.

He was a previously healthy three-year-old male.

His immunizations were up to date

and he was coming into the emergency department

with complaint of intermittent abdominal pain

for the last two days.

Mom had reported that the child had had some non-bilious,

non-blood emesis over the last day,

approximately three episodes

and he didn't have any other symptoms.

So no history of cough, congestion, fever or diarrhea.

He did, however, have some decreased oral intake.

He had history of constipation, no surgical history

and no concerning family history.

And on review of systems, as mentioned,

he had this abdominal pain that was described

as intermittent in nature

and he had had these three episodes of vomiting,

non-bilious, non-bloody,

and otherwise other than somewhat decreased level

of activity today,

he was otherwise at his baseline.

His vital signs were reassuring.

On exam, he looked a little bit tired but not toxic.

He showed no signs of dehydration.

His belly was soft

and the remainder of his physical exam was negative.

So as we considered this child,

our differential diagnosis included viral illness,

a foodborne illness, potentially his constipation.

And then because I am always on guard

for the possibility of intussusception

and appendicitis in my youngest patients,

these were also on my differential diagnosis.

For medical workup,

we gave this little guy some Zofran and Tylenol.

We ordered a KUB as is the protocol

for our hospital when we're entertaining

the possibility for intussusception.

And we ordered a radiology ultrasound.

So what was nice is that this was one

of those cases where the x-ray already pointed me

in the direction of what the nature of this pathology was

because as you can see in this x-ray,

there's a positive (indistinct) just under the liver.

And if you look at this particular area, so right over here,

you can see what looks like a tissue-like mass

just under the liver.

So at this point, once I saw this x-ray, I knew my diagnosis

and I knew how to expedite the care of this child

because I brought my ultrasound to the bedside,

and I started doing my ultrasound

for intussusception protocol.

So I began scanning his belly, starting on the right side

and moving towards the left.

And lo and behold, right under the liver, the answer

to what was causing this child's pain came into view.

So we have a beautiful intussusception right under the liver

and you can see the gallbladder is coming

into view as I scan.

And there we go,

right over here is his gallbladder and the liver parenchyma.

And we made the diagnosis.

So without having to send this child to radiology,

I already knew what was going on

and what the next steps had

to be in this child's management.

I love beautiful ultrasounds.

And so I took many, many clips

of this child's intussusception

just because I knew that there would be a time

where I would want to go back

and look over these images again.

And here we have just another clip of this ultrasound,

of this intussusception and what you can see

and what is probably the most important thing

to recognize is that it has a very, very defined appearance.

It looks like a target.

You can see the small bowel inside

with the large bowel outside.

And we'll discuss this further in the coming slides.

Size is important when it comes to intussusception

because the bigger the intussusception,

the less likely it is to self reduce

and it also helps distinguish between ileocolic

and small bowel intussusception.

So we measured the cross-sectional diameter

of this intussusception and it measured at 3.08 centimeters.

So I knew this was a child who would need

to go for reduction in radiology.

So child did in fact go for an air enema by radiology.

Unfortunately the intussusception failed to reduce initially

and he underwent a second air enema a few hours later.

At that time, the intussusception completely resolved

and child went home the following day.

So what is ileocolic intussusception?

Well, it's essentially a telescoping of bowel when

what happens is that the small bowel basically gets sucked

into the large bowel and creates an obstruction.

Just in terms of verbiage,

the small bowel is referred to as the intussusceptum

and large bowel is referred to as the intussuscipiens

when it's in the context of an intussusception.

So what you'll notice once you start scanning

and doing these in your patient population is

that the vast majority of these intussusceptions

will have small bowel as well

as lymph nodes within the intussusception.

And they most frequently arise

on the right side of the abdomen.

So it's not uncommon to see, for example,

in this case liver parenchyma coming into view

in that gallbladder because the right size does tend

to be the more common location for you

to find this entity.

Just another beautiful picture of intussusception.

Again, I'm a really firm believer in the importance

of getting comfortable with the pattern

of both normal anatomy and pathology on ultrasound.

So kind of seeing the picture of the intussusception,

getting comfortable with what it looks like

and kind of storing it in your brain

will help you pick this up at the bedside

because you will see something

that looks like intussusception

and you will make that diagnosis.

So just another example of what intussusception looks like

in real time scanning.

So who gets intussusception

and in which patient demographic do we have

to be concerned about intussusception?

The incidents of intussusception, there's varying reports.

There was a report out of Switzerland that said

that something around 30 cases per 100,000 children

I've seen rates averaging

or estimating in the mid 60s to 100,000 children.

So common, it will not be every other patient that you see,

but definitely worth keeping your radar up

in the age demographic of children who get intussusception.

It is in fact the most common cause

of pediatric gastrointestinal obstruction

and it occurs most commonly in our youngest patients.

So those that are aged six to 36 months of age,

in fact, 80% of cases actually occur

in our youngest patients under the age of two.

And here's the thing is that these cases, the vast majority

of which are idiopathic, there's no good explanation

as to why one child will get it

and one child won't get it.

When an intussusception occurs beyond the typical age range,

so beyond that six to 36 months,

and I would even say, you know,

you'll still see it sometimes in your four year olds,

even potentially your five year olds.

But once you start moving really far away

from that typical age range, it's important

to consider the possibility of a pathological lead point

that there's some other pathological entity

that's causing this intussusception.

When we talk about idiopathic causes,

often in the report you're going to get from parents is

that there was some sort of viral illness

that preceded this intussusception.

Common causes are adenovirus,

those viral illnesses that cause gastroenteritis

or even viral URIs.

And what's so interesting is that as you're scanning

so often you see this really heavy lymph node burden

within the intussusception.

So it starts to make a lot more sense

that these kids have recently had a viral illness,

they have some hypertrophy of their intraabdominal

or mesenteric lymph nodes

and then they end up getting an intussusception.

And those lymph nodes are then present

in their intussusception.

If you remember from histology,

we have Peyer's patches within small bowel.

These are a little lymph,

or sorry, lymphoid islands within the small bowel.

And again, when there's a preceding viral illness,

those can hypertrophy

and again become part of the reason

why a child may develop intussusception.

A little bit of pediatric history.

We in 2021 don't see very much rotavirus anymore.

Rotavirus was a really important viral illness in children,

but with the advent of RotaTeq

we don't see very much rotavirus thankfully.

So the first iteration

of the rotavirus vaccine was actually called RotaShield

and that came on the market

and I think it was around 2007 if I'm not mistaken.

And it provided a lot of hope for us

to decrease the incidence of rotavirus in our community.

Unfortunately, there was a very high incidence

of intussusception amongst those children

who were vaccinated towards rotavirus using RotaShield

and it was then quickly taken off the market.

So this next iteration of the Rotavirus vaccine, RotaTeq

which is currently what we give to children,

has not showed that kind of tendency.

So it's still a very active

and effective vaccine on the market.

But it was interesting to be going through my training

as there was RotaTeq came to market

and then was taken off market.

When we talk about pathological lead points as discussed,

this is when you have an intussusception

beyond the typical age range.

It's important to consider possible causes

and those can be a Meckel's diverticulum, a polyp,

a duplication cyst, a tumor, a hematoma,

a vascular malformation.

You may see intussusception in the context

of Henoch-Schonlein purpura,

or even within hemolytic uremic syndrome.

So again, another example of a clip showing intussusception.

And here you can see this very, very high burden

of mesenteric nodes within the intussusception.

So what does intussusception look like sonographically?

As I mentioned earlier in cross-section,

your intussusception is going to look very targetoid.

You're going to get concentric loops of bowel, the inside

of the bowel, sorry, the inside

of the intussusception representing small bowel

and the outside

of the intussusception representing large bowel.

In long axis, the intussusception may take on a more

of a kidney shape, so we actually refer to it

as a pseudokidney appearance.

So let's go into our next case.

We have a previously healthy nine month old female.

She's previously vaccinated.

She is coming to the emergency today

with altered mental status for the last day or so.

Mother notes that the infant appears kind of dazed

and poorly responsive.

The infant has had no fever, no vomiting,

no seizure-like movements, no cough or congestion,

no vomiting or diarrhea.

She hasn't been on any new medications.

There are no sick contacts in the home.

She does attend daycare

and did have a viral illness a few weeks ago.

Her medical history is negative.

She has a little bit of eczema,

but otherwise she's a healthy baby.

And on review of systems,

the only pertinent positive is this altered mental status

and she has somewhat decreased oral intake today.

So on exam,

you know, her vital signs are completely reassuring,

but you appreciate this lethargy in this child

and it's a concerning lethargy.

The rest of her exam looks good.

Her neck is soft, she doesn't have any meninges,

her lungs are clear, her heart rate is normal and regular.

Her belly is soft and non-distended.

She's got normal strength and normal perfusion and pulses

and so on the differential diagnosis of this child,

I remember like it was yesterday,

we were thinking more meningitis, sepsis,

maybe traumatic brain injury

or non-accidental trauma, possibly drug exposure,

or even electrolyte abnormality.

So with her we got to working pretty fast.

We placed our IVs, we gave her normal saline bolus,

we sent off a whole rainbow of tubes

and obtained a venous blood gas.

We catheterized her and obtained urine for urinalysis

and urine drug screen and we ordered a head CT.

And then one of us kind of decided

that it would probably be a good idea

to do a FAST exam because part

of our concern was non-accidental trauma.

And lo and behold, we found our answer.

So this child did not have sepsis or meningitis,

she did not have intraabdominal trauma,

she did not have a drug exposure.

This little peanut had an intussusception

and it was a pretty dramatic reminder

to always include intussusception in our management

and workup of these patients who present

with altered mental status.

Another example over here, just again scanning through

and seeing that beautiful intussusception.

So we have our typical presentation

and our atypical presentation for intussusception.

The typical presentation is what we

as providers commonly think about

when we think of intussusception.

It's that intermittent severe crampy abdominal pain,

maybe inconsolable crying, vomiting, legs being drawn up.

Sometimes there's a report

of a sausage like mass in the right lower quadrant.

Sometimes the child will present with bloody mucusy stool.

If you remember from the literature, there's a triad

that includes pain, mass, and currant jolly stool.

But this only represents 15% of children,

15% of cases of children who have intussusception.

Now the atypical presentation is much harder

to kind of wrap your head around sometimes

because isolated lethargy or altered mental status

can also be a presentation of intussusception.

And that's because the intussusception,

the actual obstruction causes the release,

or the secondary release of endogenous opioids in the child.

And so the reason the child looks

like they're under the influence of drugs is

because there's an endogenous release of opioids,

naturally occurring opioids.

So these children really just look altered

and that's an important other manifestation

and presenting clinical presentation of these children

who have intussusception.

And it's often confused with meningitis and sepsis.

So x-rays often are part of our workup

for intussusception.

I know many institutions will require one view x-ray

before the child goes for reduction.

Some shops even require x-rays to be obtained

as part of the workup.

A single view x-ray has not very much diagnostic accuracy,

almost equivalent to flipping a coin.

Only 45% of cases will be picked up on x-ray.

The three view abdominal x-ray will increase your accuracy

for the diagnosis of intussusception,

but nothing's as good as ultrasound

for the diagnosis of intussusception.

The test characteristics really are almost perfect

and those are the test characteristics

of intussusception ultrasound performed by radiology.

But what has been really interesting

over the last several years is we

as PEDS emergency medicine point

of care ultrasound specialists have recognized

that this particular skillset is not too sophisticated,

that we can't do this as well.

So there's been a big push within PEDS emergency medicine

to study how good we are

as PEDS emergency medicine providers

at diagnosing intussusception at the bedside in order

to help care for our patients and expedite management.

And several studies have recently been published

that really support the role of the PEM provider

doing this application in the emergency department.

So back in 2019 there was a meta-analysis

that looked at about 30 papers

that met inclusion in their study

that was basically aimed at looking

at the test characteristics of PEM point-of-care ultrasound

for diagnosis of intussusception as compared

to radiology ultrasound for diagnosis of intussusception.

And what we can see here in table three

is if you look at POCUS versus RADUS in terms

of the sensitivity, the specificity,

the positive likelihood ratio, the negative likelihood ratio

and the area under the curve,

our test characteristics are almost exactly

like those of radiology performed ultrasound

in this other recently published meta-analysis.

The authors of this paper were actually looking more to see

what those signs and symptoms,

what would really help us make the diagnosis

for intussusception.

They looked at 13 studies that met inclusion

and they were looking at obtaining the history

from the family versus physical exam findings

versus x-ray versus ultrasound.

And what they found was that actually the test accuracy

for history, physical exam and x-ray was not great.

The only thing that helped make the diagnosis

for intussusception actually doing the ultrasound.

This was a study that didn't look specifically

at point-of-care ultrasound

but still kind of pushes on the point

of the importance of ultrasound,

in the diagnosis of intussusception.

The group led by Trigylidas and colleagues,

they were looking not only at the test characteristics

of point-of-care ultrasound for the diagnosis

of intussusception, but they were also looking

at those findings that could predict

a more challenging reduction

or even a failure of reduction of the intussusception.

This was a study that was performed over a 15 year timeframe

looking at 102 patients and was published in 2019.

So again, the test characteristics were excellent,

a sensitivity of 96%, specificity of 92%,

positive predictive value of 97%

and a negative predictive value of 89%.

So again, comparable test characteristics

to the previous studies, but they also were able

to kind of help us know which patients we just had

to be a little bit more mindful of as they were going

for reduction.

And what they found is that children less than six months

of age or amongst children

who had intussusception located distal

to the splenic flexure,

which is essentially the left side of the belly,

were more likely to undergo failure of their reduction.

So that was an interesting additional,

these were additional interesting additional findings

of this group identified on their study.

Dr. Park and colleagues did a study

that was also recently published

in 2019 looking at point-of-care ultrasound

to help distinguish small bowel-small bowel intussusception

versus ileocolic intussusception.

And what was really nice with this study is that we

who are doing point-of-care ultrasound at the bedside

had already kind of identified that the size

of the intussusception is important

because small intussusceptions,

especially those less than two centimeters are very,

very likely to self reduce.

And so it's most likely

that those smaller intussusceptions are

actually not ileocolic intussusceptions

but actually small bowel-small bowel intussusceptions

which aren't pathologic.

So what they found is that exactly to that point,

size is important and if you find an intussusception

and it's less than two centimeters,

you probably will not have to send this child

to radiology for reduction.

This is going to probably resolve on its own

because it's not likely

to be pathologic versus your intussusceptions

that are greater than two centimeters are more likely

to be ileocolic intussusceptions

and will require radiology reduction.

And finally this study out of,

performed by Heon and colleagues.

You know, we live in a time where metrics matter

and hospital administrators want to make sure

that we are moving the board appropriately

in the pediatric emergency department.

So this group actually looked at the initiation

of a workflow protocol where those children

where there was concern for intussusception

actually underwent point-of-care ultrasound

for intussusception at the bedside.

And what they did is they looked at the timing,

their ED length of stay, the door to reduction time,

door to ultrasound time, ultrasound to reduction time

and observation time, pre and post the initiation

of a intussusception protocol

whereby PEM providers were doing these ultrasounds.

And not surprisingly,

when PEM providers are doing these ultrasounds

and not waiting to send their patients over to radiology,

we are more able to expedite care.

So what they were able to find is that they were able

to shave off greater than 220 minutes in the ED length

of stay when they compared pre the initiation

of their point-of-care ultrasound intussusception

for intussusception protocol versus post.

So they did a really great job demonstrating

how this is not only good for patients, it's also good

for systems because it actually can increase

our turnover of beds and improve our throughput.

Also, they also demonstrated

that total observation time needed

for these patients was also shortened by about 170 minutes.

So how do we perform a point-of-care ultrasound

for intussusception?

Well the good news is you need an ultrasound

and a linear probe and gel and that's it.

It is really not

a technically challenging application to do.

And I'm going to demonstrate now by bringing you into my shop

to show you how to do ultrasound on your patient

using one of my fantastic pediatric models.

When we do pediatric abdominal scanning,

we're going to always be pulling our linear probe.

Any linear probe will be sufficient.

Keeping in mind that with a smaller footprint you may need

to scan a second round of the belly

because you may not see everything that you need

to see during your first pass.

I'm going to use the 154 megahertz probe for my study

and I always use probe marker towards the patient's right.

So for pediatric abdomen scanning, you want to make sure

that your patient's as comfortable as possible.

So making sure to drape as needed.

And also if the child is in significant amount of pain,

it's always a good idea to give them a little bit

of pain meds before you start pushing on their belly.

Doing your intussusception ultrasound,

you're going to be scanning from the right lower quadrant up

to the right upper quadrant over to the left upper quadrant

and finishing in your left lower quadrant.

So what I generally do is I put a liberal amount of gel

on the child's belly in the distribution of the area

of the belly that I'm going to be scanning.

So with my probe marker on the patient's,

pointing towards the patient's right,

I'm going to start way down low in the right lower quadrant

and what we're going to see is our psoas muscle

which comes into view,

our iliac vessels and they're there,

pulsating in our field right now.

And what you're going to encounter

throughout your study is bowel gas.

And so your main intention

as you're scanning the abdomen is trying

to displace that bowel gas.

So you can be looking at the large bowel

in its trajectory on the abdomen.

So I'm going to place some gentle compression of the belly

of the bowel gas

and really just scan her large bowel.

So there you can see if you relax a little bit

of the pressure, you're going to see first all seeing bowel

and then when you put pressure you remove a little bit

of that gas and you see more of that compression

of the bowel.

So as you go northbound you're going to hit

liver up in the right upper quadrant,

again encountering bowel, you are going to see her gallbladder

that comes into be right over there.

And now we're going to go

across to the left upper her quadrant,

again compressing bowel as we move.

Bowel, bowel, bowel.

With gas you're going to try to press a little bit,

get the gas out of the way so that you can see your bowel

as you're moving over the left upper quadrant.

You can make gain and depth adjustments as you need to go.

And now we're on the left side of her belly,

again seeing her large bowel

and bits of small bowel.

As we move down, and now we are in the area again

of her psoas muscle

and her iliac vessels coming into view.

Now as we've seen in our videos,

if you encounter intussusception,

you're going to see a targetoid structure

that's going to come into view,

that's going to pop up generally in a depth location

of somewhere between four

and six centimeters from the surface of the abdomen.

So I pre-set my scan to five centimeters of depth

but I could have made those adjustments to my depth setting

as I needed it if I wasn't seeing enough anatomy.

So just one more time to review, I'm going to start.

In my patient's right lower quadrant,

there's my psoas muscle and my iliac vessels.

There's bowel, with bowel gas coming into view,

I'm going to compress it a little bit to get it out of the way

and move north on her belly,

again just encountering a bunch

of bowel gas which is completely normal

until I get into the region of the liver.

That tells me I'm right high up in the belly,

I see my gallbladder and now I move over to the left side.

I see bowel, now I have a kidney that just popped into view

and I'm going to start scanning down

into her left lower quadrant.

And there again I see her psoas muscle coming into view,

her iliac vessels medially

and I end it down in the left lower quadrant

and that is your intussusception ultrasound.

So with that I think it's a great time

to go back into our cases and do one final case.

So this was an 18 month old female

whose immunizations were up to date and she was presenting

to the emergency department with intermittent abdominal pain

for the last two days,

and mom has noted that the last three diapers

containing stool also had some increase

in blood consistency.

She's had some poor oral intake over the last 24 hours

and mother reports the child had a single episode

of vomiting as well.

Mother also describes the child has been more fussy

and clinging over the last day

and she has actually had some intermittent spells

of crying and screaming.

She has a history of a urinary tract infection times one

in the past, but otherwise is a healthy little girl.

So on review of systems, she had one episode of vomiting

as well as these three episodes of bloody stools.

She's also had decreased oral intake, no diarrhea, no cough

or congestion, but she does seem

like she has decreased level of activity per mom.

So on exam she's crying so she's a little tachycardic

but otherwise her vital signs look normal.

She does look fussy, non-toxic,

but she does look a little bit dehydrated.

Her mucus membranes are a little bit tacky

but otherwise her exam is normal.

No abdominal, her abdomen is soft.

There's some mild abdominal tenderness

but it's not distended

and she does have a slightly delayed cap refill.

So in our differential diagnosis

we were considering viral gastro, intussusception

and abdominal trauma.

So again, IVs were placed, CBC, CMP,

respiratory pathogen panel was ordered

and this was a case where we didn't have access

to pediatric radiology.

So the only option would be to get a CT scan.

And a point-of-care ultrasound was performed.

And so this is again, we kind of had a sense

before we got any imaging

that this is probably going to be an intussusception just based

on the history, but this is just another example

of what intussusception looks like at the bedside.

And I really want to push on the point that this is not

a technically challenging ultrasound application.

And so if you decide to start doing this

and really looking for it,

you'll make this diagnosis no question.

Additionally what I tell my learners all the time is

as you're learning how to do

any particular application in ultrasound medicine,

if you make sure to scan those patients

that you know have the pathology.

So once you kind of know

that the child either has a intussusception

or has appendicitis, I really encourage you to go back

and do the ultrasound yourself

because all it takes is that confidence to know

that you can pick it up to see

what it looks like on the screen with your hand on the probe

to really make you feel empowered

to use ultrasound in your practice.

And this was one of those cases where we were able

to make the diagnosis and completely change

this child's whole approach to her management.

CT scan was canceled and child was transferred to a hospital

for management of this intussusception

and diagnosis was made.

Treatment for intussusception is air

or barium enema usually performed

by radiology under fluoroscopic guidance.

And the whole reason why we want to make sure

that we diagnose intussusception and we don't miss it is

because there will be progressive injury

to the bowel the longer it stays intussuscepted.

So it starts with bowel ischemia.

This is when you start to see this bloody stool

that's noted in the diaper

and this usually progresses to bowel necrosis

and ultimately bowel perforation if left untreated.

There are some mimics to intussusception.

Remarkably the kidney, the vertebral body

and the psoas muscle can all look

very similar to intussusception.

So I'm going to demonstrate that now.

So this was an example that a colleague shared with me

of an intussusception

and what you can see in looking at this long axis

of the intussusception, it looks very similar to a kidney.

In fact this would be described as a pseudokidney

because not only is the shape very kidney bean-esque,

it actually just looks overall like it could be kidney,

but it is in fact an intussusception.

So this is a pseudokidney intussusception.

So to compare intussusception,

so a pseudokidney presentation

of intussusception to a kidney,

you can look side by side.

On the left side you have the pseudokidney

and on the right side you actually have a true kidney

and you can kind of see

how challenging it can sometimes be

to differentiate the two.

Here's an example

of intussusception versus a vertebral body.

On the left side you have a beautiful intussusception.

On the right side you have this vertebral body.

So you can see

that the vertebral body is just over here.

This is actually the spinal canal

and here's the spinal cord inside.

When you have a very small child who's very lean,

it's very common to see the spinal,

the vertebral body when you're scanning the abdomen.

And lastly, intussusception versus psoas muscle.

The more you see the psoas muscle,

the less it's going to look like an intussusception.

But I promise you it is easy to confuse the two

as you're starting out.

So here on the left side is the intussusception

and on the right side is your psoas muscle.

The psoas muscle has a very, very definite look to it,

but if you're ever concerned or confused

or you're not sure, both in the context

where you're seeing something

that might look like the kidney

or the psoas muscle, you have the benefit on the child

to use their contralateral side as the control.

So if you're not sure as you're scanning,

just look at the the other side

and see if it's present on the other side,

it's just their anatomy versus an intussusception

obviously would be only on one side.

So in summary, I really encourage you

to think about intussusception in any young child

with intermittent abdominal pain

because the presentation really can vary

and as we saw it can even, children can even present

with altered mental status

as a manifestation of intussusception.

In order to perform point-of-care ultrasound

for the diagnosis of intussusception,

you'll need a linear probe

and it doesn't really matter what that footprint looks like

or what the frequency is, any linear probe will do.

You're going to scan the large bowel

from the right lower quadrant to the left lower quadrant.

And remember intussusception will look targetoid

in cross-section

and will have a pseudokidney appearance in its long axis.

And I really do believe for those of us that use ultrasound,

this is our superpower.

This allows us to make really important diagnoses

at the bedside.

So all it takes is practice, pattern recognition

and taking the machine to the bedside and looking.

I want to thank my team

of wonderful colleagues who helped me by providing me

with some of their ultrasound imaging as well as Dr. Tran

who did the videographer,

videographer function for that

clip we had during this presentation as well

as his children, Lily and Henry Tran.

And with that, I want to thank you for joining me today

as we discussed intussusception.

- [Laura] Oh thank you, Dr. Levine.

That was fantastic as I knew it would be.

What you guys are seeing on your screen right now is

where you can find the recording of this webinar

and future webinars.

We will likely take a break for the summer months right now,

but there will be a schedule popping up here soon.

Dr. Levine, we had two questions.

So the first one is

how do you measure the intussusception.

Specifically, it was referencing

a three centimeter intussusception

on I think that was case two.

Is it from the outer colon

or diameter of the internal small bowel?

- [Marla] Yeah, I do a cross-sectional diameter.

So the whole thing, so the whole structure

and it's sometimes hard while you're scanning,

sometimes it can kind of scan in and out.

But I would try to measure

the greatest cross-sectional diameter

of this targetoid structure

because that's probably the most accurate representation

of what it is.

So not just the middle but the whole intussusception,

outer rings, through the inner rings

and back down to the outer rings.

- [Laura] Right, okay, thank you so much.

And then if you wouldn't mind going back to kind of one

of your earlier slides, it was the second images

of the intussusception that you showed.

There's a question about whether

or not the colonic wall was thickened in that one.

- Hold on. - Might be hard to go back on.

- [Marla] I'm going to try to remember,

what you will have is there will be,

so I unfortunately can't scroll back in my presentation

in this format, but the wall does get,

your colonic wall will get swollen from the compression

of the small bowel that stuck within.

So you know,

I generally don't put color flow doppler

on my intussusceptions but there is some degree of swelling

that will happen to that outer wall just

because the fact that it's basically being forced out

or swollen out by the presence of bowel within.

- [Laura] Okay, okay, so that probably was true

for that image then, perfect.

Those are all the questions.

Does anyone else have any questions?

We have a couple of minutes.

I did hear of a case of surgery for intussusception.

Is that kind of, if all else fails,

is that the last resort I'm assuming?

- [Marla] Yeah, so in general I think by

and large radiologists will do kind of two attempts

at fluoroscopic reduction of an intussusception.

And usually if it has failed to reduce

after those two attempts, it's usually a surgical reduction.

What you may have encountered is often

once there is a a positive intussusception,

once the child is going for reduction,

often radiology will ask for an x-ray

before doing any kind

of attempted fluoroscopic reduction

because the potential for perforation.

So obviously intussusception reduction is one

of the indications,

or rather the failure of the intussusception to reduce

under radiological fluoroscopic guidance

would be one indication to go to surgery.

And unfortunately there's always the potential

for perforation just by doing air or barium enema.

And so surgery is usually involved, usually surgery is aware

of the child and then depending on

what the clinical status is

and whether it's failure to reduce or perforation,

is usually when they become involved.

- [Laura] Okay, great, thank you.

And one question just popped up,

I'm not sure if this will be easily answered or not,

but how does volvulus

and fecal impaction look on ultrasound?

- [Marla] So those are great questions.

Volvulus is its own separate entity

and there's usually a preceding malrotation

and so you actually have anatomical differences in terms

of the orientation of your SMA, SMV

as opposed to normal.

So that's its own kind of,

that's its own separate discussion.

Versus fecal impaction,

you know, you'll often see large stool bowel

while you're scanning, like you'll see a lot

of peristalsing bowel with stool within, you know,

the only studies that have looked truly at fecal impaction

to my knowledge is usually looking

at the cross-sectional diameter of the rectal vault.

And that's,

and I'm sorry I don't remember the number cutoff,

but usually there's large stool burden distally

as a way of kind of identifying

or diagnosing constipation or fecal impaction.

- [Laura] Okay, that makes sense.

Yeah, that's a hard question without having

a person right there to scan, right?

Okay, great, well I don't see any other questions,

but I am so delighted to work with you on this webinar.

I hope to work with you on more in the future

and this was fantastic.

So thank you so much for your time

and putting together some great cases for us to look at.

- [Marla] Thank you so much, thank you so much for having me

and I look forward to joining you again in the future.

- [Laura] That sounds great.

Thank you, bye-bye, everyone.

Intussusception is a common cause of pediatric abdominal pain in the infant and toddler population. Using point-of-care ultrasound at the bedside can help providers expedite definitive management with greater safety, ease and accuracy than plain radiographs; that’s why POCUS has become a standard tool for evaluating patients with suspected ileocolic intussusception.

Pediatric imaging requires smaller transducer footprints and adjustable frequencies to adapt to various depths and patient sizes. This live webinar will share expert techniques for performing a bedside pediatric intussusception ultrasound through a presentation of actual cases. After reviewing relevant literature, you’ll have the opportunity to discuss intussusception as it pertains to POCUS with Dr. Levine.

What You'll Learn

  • Indications for POCUS evaluations of intussusception
  • Relevant anatomy to be identified in POCUS examinations for intussusception
  • Specific pitfalls to avoid in POCUS examinations for intussusception
Marla Levine, MD
Presenter: Marla Levine, MD
Position: Associate Professor of Pediatrics, Emergency Medicine Director of Point of Care Ultrasound (POCUS) Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, Tennessee

Dr. Marla Levine is an Associate Professor of Pediatrics in the division of Emergency Medicine at Monroe Carell Jr. Children’s Hospital at Vanderbilt and the director of Point of Care Ultrasound (POCUS) within their Pediatric Emergency Department. She completed her pediatric emergency medicine (PEM) fellowship at Children’s National Medical Center and Emergency Ultrasound fellowship at Maimonides Medical Center.

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