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Comparative Effectiveness of Imaging Modalities for the Diagnosis of Intestinal Obstruction in Neonates and Infants

Posted Apr 30, 2016 Updated Apr 10, 2023
By A.G. Carroll MB BCh BAO LRCPI FFRRCSI , R.G. Kavanagh MB BSc MCh MRCSI , C. Ni Leidhin MB BCh BAO MRCSI , N.M. Cullinan MB BCh BAO LRCSI MRCPI , L.P. Lavelle MB BCh MRCPI FFRRCSI , D.E. Malone MD FRCPI FFRRCSI FRCR FRCPC
13 min read

Rationale and Objectives

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of upper and lower gastrointestinal (GI) tract obstruction in neonates and infants.

Methods

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome method comparing radiography, upper GI contrast study, and ultrasound in the detection of upper GI tract obstruction such as duodenal atresia and stenosis, jejunal and ileal atresia, and malrotation and volvulus. The same methods were used to compare radiography and contrast enema in the detection of lower GI tract obstruction such as meconium plug syndrome, meconium ileus, Hirschsprung disease, and imperforate anus. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

Results

There were no sensitivities/specificities available for the imaging diagnosis of duodenal atresia or stenosis, jejunal or ileal atresias, meconium plug, and meconium ileus or for the use of cross-table lateral radiography for the diagnosis of rectal pouch distance from skin in imperforate anus. The retrieved sensitivity for the detection of malrotation on upper GI contrast study is 96%, and the sensitivity for the diagnosis of midgut volvulus on upper GI contrast study is 79%. The retrieved sensitivity and specificity for the detection of malrotation with volvulus on ultrasound were 89% and 92%, respectively. The retrieved sensitivity and specificity for the detection of Hirschsprung disease on contrast enema were 70% and 83%, respectively. The retrieved sensitivity of invertogram for the diagnosis of rectal pouch distance from skin in imperforate anus is 27%. The retrieved sensitivities of perineal ultrasound and colostography for the diagnosis of rectal pouch distance from skin in imperforate anus were 86% and 100%, respectively.

Conclusions

There is limited evidence for the imaging diagnosis of duodenal atresia and stenosis, jejunal and ileal atresias, meconium plug, meconium ileus, and imperforate anus, with recommended practice based mainly on low-quality evidence or expert opinion. The available evidence supports the use of upper GI contrast study for the diagnosis of malrotation and volvulus, with ultrasound as an adjunct to diagnosis. Contrast enema is useful in the investigation of suspected Hirschsprung disease, but a negative study does not outrule the condition. Colostography is the investigation of choice for the work-up of infants with complex anorectal malformations before definitive surgical repair.

Introduction

Duodenal atresia occurs in 1 in 5000–10,000 live births. In one-third of cases, it is an isolated anomaly. In one-third of cases, it is associated with Down syndrome. It can also be associated with other congenital abnormalities, especially cardiac and esophageal anomalies. It results from failure of the duodenum to recanalize during weeks 8–10 of gestation . Neonates typically present with bilious or nonbilious vomiting in the first 24 hours after birth.

Infants with less severe duodenal stenosis may have delayed presentation with frequent vomiting and failure to thrive. Duodenal stenosis is often due to the presence of a duodenal web or may be secondary to extrinsic compression from an annular pancreas, malrotation, or a preduodenal portal vein .

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Figure 1, Search strategy using patient, investigation, comparison, outcome (PICO)-focused keywords.

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Appraise

Upper GI Tract

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Duodenal Atresia and Stenosis, Jejunal, and Ileal Atresia

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Radiography

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Upper GI contrast study

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Contrast enema

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Malrotation and Volvulus

Radiography

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Upper GI contrast study

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Contrast enema

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Ultrasound

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TABLE 1

Test Performances for the Diagnosis of Upper and Lower GI Tract Obstruction in Neonates and Infants

Selected Study Upper Gastrointestinal (GI) Tract Lower GI Tract US Volvulus US with Fixed Midline Bowel US with Whirlpool Sign US with SMV Dilatation Contrast Enema for Hirschsprung Disease Sensitivity, % 89 89 89 56 70 Specificity, % 92 92 92 73 83 Accuracy 0.81 0.81 0.81 0.60 0.70

SMV, superior mesenteric vein; US, ultrasound.

Figure 2, Graph of conditional probabilities for ultrasound diagnosis of upper gastrointestinal (GI) obstruction in neonates and infants. Graph of conditional probability and area under the curve (AUC). The x-axis represents the pretest probability of the disease in question, and the y-axis represents the posttest probability. The pretest probability is chosen, and a vertical line is drawn from the corresponding point on the x-axis to the “test-negative” or “test-positive” curve. From this point of intersection, a horizontal line is drawn to the y-axis. The posttest probability is the value at the point where the horizontal line intersects the y-axis. (a) Graph of conditional probabilities for ultrasound diagnosis of volvulus in upper GI obstruction in neonates and infants. Sensitivity = 0.89; specificity = 0.92; and AUC = 0.81. (b) Graph of conditional probabilities for ultrasound detection of fixed midline bowel in upper GI obstruction in neonates and infants. Sensitivity = 0.89; specificity = 0.92; and AUC = 0.81. (c) Graph of conditional probabilities for ultrasound detection of the whirlpool sign in upper GI obstruction in neonates and infants. Sensitivity = 0.89; specificity = 0.92; and AUC = 0.81. As we can see from the above three graphs ( a – c ), the high sensitivity and specificity means that ultrasound is reliable in ruling in and ruling out volvulus and can reliably detect the presence or absence of a fixed midline bowel and the “whirlpool” sign. (d) Graph of conditional probabilities for ultrasound detection of superior mesenteric vein dilatation in upper GI obstruction in neonates and infants. Sensitivity = 0.56; specificity = 0.73; and AUC = 0.60. As we can see from this graph, the available evidence suggests that ultrasound cannot be reliably used to assess the presence or absence of superior mesenteric vein (SMV) dilatation in the setting of upper GI obstruction in neonates and infants.

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Lower GI Tract

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Meconium Plug Syndrome and MI

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Radiography

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Contrast enema

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Hirschsprung Disease

Contrast enema

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Figure 3, Graph of conditional probabilities for contrast enema for the diagnosis of Hirschsprung disease in lower gastrointestinal (GI) obstruction in neonates and infants. Sensitivity = 0.70; specificity = 0.83; area under the curve (AUC) = 0.70. Graph of conditional probability and AUC. The x-axis represents the pretest probability of the disease in question, and the y-axis represents the posttest probability. The pretest probability is chosen, and a vertical line is drawn from the corresponding point on the x-axis to the “test-negative” or “test-positive” curve. From this point of intersection, a horizontal line is drawn to the y-axis. The posttest probability is the value at the point where the horizontal line intersects the y-axis. As we can see from this graph, contrast enema is reliable in patients with a high pretest probability and a positive test. It is not so reliable in patients with a high pretest probability and a negative test. These patients will require further investigation.

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Imperforate Anus

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Radiography

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Ultrasound

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Colostography

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Magnetic Resonance Imaging (MRI)

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Apply

Upper GI Tract

Duodenal Atresia and Stenosis, Jejunal, and Ileal Atresia

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Malrotation and Volvulus

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Lower GI Tract

Meconium Plug Syndrome and MI

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Hirschsprung Disease

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Imperforate Anus

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Evaluate

Upper GI Tract

Duodenal Atresia and Stenosis, Jejunal, and Ileal Atresia

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Malrotation and Volvulus

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Lower GI Tract

Meconium Plug Syndrome and MI

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Hirschsprung Disease

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Imperforate Anus

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Academic Radiology, Volume 23, Issue 5
Journals General Radiology
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