Role of plain abdominal radiograph in the diagnosis of intussusception

Date First Published:

January 25, 2002

Last Updated:

March 23, 2009

Report by:

Dylan Broomfield, Consultant in Emergency Medicine (St Mary's London)

Search checked by:

Ian Maconochie, St Mary's London

Three-Part Question:

In [a child with abdominal pain] does [plain abdominal radiography] assist in [the diagnosis of intussusception]?

Clinical Scenario:

A 10-month-old child is brought to the emergency department in the middle of the night, with a short history of episodic inconsolable crying, pulling his legs up and non-bilious vomiting. You suspect intussusception is the diagnosis, and you wonder whether a plain abdominal X-ray will assist in the diagnosis.

Search Strategy:

Medline 1966–04/07 using the OVID interface.

Search Details:

[Intussusception OR exp intussusception] AND [abdominal x-ray/ x-ray OR Radiology or Radio*] LIMIT to human & English.
Cochrane Library: Intussusception

Outcome:

A total of 395 papers were found, of which 388 were irrelevant or of insufficient quality. Details of the remaining seven papers are shown in the table

Relevant Paper(s):

Study Title	Patient Group	Study type (level of evidence)	Study Weaknesses
Reliability of the Abdominal Plain Film Diagnosis in Pediatric Patients with Suspected Intussusception. Eklof O, Hartelius H. 1980 Sweden	100 X-rays of patients with intussusception 100 X-rays of patients in whom intussusception was excluded	Case control study	Poor quality study Randomisation/blinding process unclear
The plain abdominal film in intussusception: the accuracy and incidence of radiographic signs. Ratcliffe J F, Fong S, Cheong I, O'Connell P. 1992 Australia	180 X-rays from 100 children with intussusception 100 Films from 80 children without intussusception	Retrospective Randomised Study	Data are cumulative, in only 26/180 (14%) did all 4 radiologists agree there was a soft tissue mass In only 141/180 (78%) did any of the radiologists diagnose soft tissue mass, therefore 39/180 (22%) could be classified as false negatives Data are cumulative, in only 26/180 (14%) did all 4 radiologists agree there was a soft tissue mass. In only 141/180 (78%) did any of the radiologists diagnose a soft tissue mass, therefore 39/180 (22%) could be classified as false negatives
The role of abdominal x-rays in the diagnosis and management of intussusception. Smith D S, Bonadio W A, Losek J D, Walsh-Kelly C M, Hennes H M, Glaeser P W, Melzer-Lange M, Rimm A A. 1992 USA	126 x-rays 42 intussusception 42 suspected but ruled out 42 normals	Retrospective Randomised study	Small sample size
Plain film diagnosis in intussusception. British Journal of Radiology 1994; 67: 147-149. Meradji M, Hussain M, Robben SGF, Hop WCJ. 1994 Netherlands	163 X-xrays of patients with intussusception 163 X-rays of patients in whom intussusception was excluded	Retrospective randomised study	Weighting and scoring system devised retrospectively System too convoluted to be of practical use
Plain abdominal radiography in suspected intussusception: a reassessment. Sargeant M A, Babyn P, Alton D J. 1994 Canada	182 Patients X-rays with suspected intussusception	Retrospective Randomised Study	Sensitivity not calculated All statistics calculated on majority agreement
Intussusception: characteristic radiolucencies on the abdominal radiograph. Lee J M, Kim H, Byun J Y, Lee H G, Kim C Y, Shinn K S, Bahk Y W. 1994 Korea	288 Patients with 315 episodes of intussusception 310 Patients with gastrointestinal symptoms without Intussusception	Retrospective Randomised Study	Poor quality study 4 Paediatric radiologists assessed films, unclear if results were consensus view No results on presence of soft tissue mass in the control group Unclear how they excluded intussusception in the control group
Validity of plain films in intussusception. Hernandez JA, Swischuk LE, Angel CA. 2004 USA	80 Cases of intussusception	Retrospective study	4 Paediatric radiologists assessed films, unclear if results were consensus view No results on presence of soft tissue mass in the control group Unclear how they excluded intussusception in the control group Small study No blinding No control group

Author Commentary:

The study by Smith et al most accurately reflects the clinical scenario using paediatric emergency physicians rather than paediatric radiologists to assess the films, and by using the clinically relevant endpoint of requesting a barium enema. Despite a sensitivity of 80% and a specificity of 58%, however, a false negative rate of 20% would be clinically unacceptable. The most commonly used argument for performing a plain abdominal X-ray in a case of possible intussusception is to pick up small bowel obstruction (58% in the study by Hernandez et al) and to exclude perforation. None of the papers comment on the incidence of perforation picked up on plain abdominal radiography although Hernandez et al comment that perforation with intussusception is generally uncommon before reduction attempts. Abdominal ultrasound in comparison has 98–100% sensitivity and 88% specificity with a negative predictive value of 100% (Verschelden et al).

Bottom Line:

Plain abdominal radiography adds little to the management of patients with suspected intussusception.

References:

Eklof O, Hartelius H.. Reliability of the Abdominal Plain Film Diagnosis in Pediatric Patients with Suspected Intussusception.
Ratcliffe J F, Fong S, Cheong I, O'Connell P.. The plain abdominal film in intussusception: the accuracy and incidence of radiographic signs.
Smith D S, Bonadio W A, Losek J D, Walsh-Kelly C M, Hennes H M, Glaeser P W, Melzer-Lange M, Rimm A A.. The role of abdominal x-rays in the diagnosis and management of intussusception.
Meradji M, Hussain M, Robben SGF, Hop WCJ.. Plain film diagnosis in intussusception. British Journal of Radiology 1994; 67: 147-149.
Sargeant M A, Babyn P, Alton D J.. Plain abdominal radiography in suspected intussusception: a reassessment.
Lee J M, Kim H, Byun J Y, Lee H G, Kim C Y, Shinn K S, Bahk Y W.. Intussusception: characteristic radiolucencies on the abdominal radiograph.
Hernandez JA, Swischuk LE, Angel CA.. Validity of plain films in intussusception.
Verschelden P, Filiatrault D, Garel L, et al.. Intussusception in children: reliability of US diagnosis—a prospective study.