61 (2) JUNE CLIN-2 (4)

Invest Clin 61(2): 117 - 123, 2020 https://doi.org/10.22209/IC.v61n2a02


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Diagnostic application of transabdominal ultrasound in pediatric patients with hematochezia.


Chunlin Zhang1,2and Chaoxue Zhang1


1Department of Ultrasound, The First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China.

2Department of Ultrasound, Anhui Province Children’s Hospital, Hefei, Anhui, China.


Key words: transabdominal ultrasound; hematochezia; diagnosis.


Abstract. The objective of the work was to analyze the diagnostic accuracy of transabdominal ultrasound in diseases causing hematochezia. The present retrospective study included 427 pediatric patients with hematochezia or hema- tochezia accompanied by abdominal pain, who came to our hospital from Octo- ber 2014 to September 2018. Transabdominal ultrasound was performed in all patients. Demographic data such as age, gender and clinical variables including symptoms and the hematochezia aspect were recorded. The diagnostic accu- racy was analyzed. Among all patients, the hematochezia types were dark red bloody stools 163 (38.2%), black stools 102 (23.9%), jam-like bloody stools74

(17.3%), scarlet blood 55 (12.9%) and fecal occult blood 33 (7.7%). There were

153 (35.8%) patients with intussusception, 116 (27.2%) patients with Meckel’s

diverticulum, 95 (22.2%) patients with intestinal duplication, and 63 (14.8%) patients with intestinal polyps. Transabdominal ultrasound showed there were 150 patients with intussusception, with an accuracy of 98.0%; 103 patients with Meckel’s diverticulum, with an accuracy of 88.8%; 84 patients with intestinal duplication, with an accuracy of 88.4%; and 54 patients with intestinal polyps, with an accuracy of 85.7%. The diagnostic sensitivity was significantly higher for intussusception than for other diseases. It is concluded that transabdominal ultrasound had a high accuracy in the diagnosis of hematochezia-related dis- eases, including intussusception, Meckel’s diverticulum, intestinal polyps and intestinal duplication.


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Corresponding author: Chaoxue Zhang. Department of Ultrasound, The First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, 230022, China. Tel: 86-055162237114, Email: zz084126@aliyun.com


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Aplicación diagnóstica del ultrasonido transabdominal en pacientes pediátricos con hematoquecia.

Invest Clin 2020; 61 (2): 117-123


Palabras clave: ultrasonido transabdominal; hematoquecia; diagnóstico.


Resumen. El objetivo del presente trabajo fue analizar la precisión diagnós- tica de la ecografía transabdominal en enfermedades relacionadas con hemato- quecia. El presente estudio retrospectivo incluyó un total de 427 pacientes pe- diátricos con hematoquecia o hematoquecia acompañada de dolor abdominal, que acudieron a nuestro hospital entre octubre de 2014 y septiembre de 2018. Se realizó una ecografía transabdominal en todos los pacientes. Se registraron datos demográficos como la edad, el sexo y las variables clínicas, incluidos los síntomas y el aspecto de la hematoquecia. Se analizó la precisión diagnóstica. Entre todos los pacientes, los tipos de hematoquecia presentes fueron: heces con sangre de color rojo oscuro 163 (38.2%), heces negras 102 (23.9%), heces

con sangre como mermelada 74 (17.3%), sangre escarlata 55 (12.9%) y sangre

oculta en heces 33 (7,7%). Hubo 153 (35,8%) pacientes con invaginación intes-

tinal, 116 (27,2%) pacientes con divertículo de Meckel, 95 (22,2%) pacientes con duplicación intestinal y 63 (14,8%) pacientes con pólipos intestinales. La ecografía transabdominal mostró que había 150 pacientes con invaginación in- testinal, con una precisión del 98,0%; 103 pacientes con divertículo de Meckel, con una precisión del 88,8%; 84 pacientes con duplicación intestinal, con una precisión del 88,4%; y 54 pacientes con pólipos intestinales, con una precisión del 85,7%. La sensibilidad diagnóstica fue significativamente mayor para la in- vaginación intestinal que para otras enfermedades. Se concluye que la ecografía transabdominal tuvo una alta precisión en el diagnóstico de enfermedades rela- cionadas con la hematoquecia, incluidos la invaginación intestinal, el divertícu- lo de Meckel, los pólipos intestinales y la duplicación intestinal.


Received: 08-08-2019 Accepted: 12-03-2020


INTRODUCTION


Hematochezia, also known as acute overt lower gastrointestinal bleeding, ac- counts for about 20% of all gastrointestinal bleeding (1-3). Since many diseases may lead to hematochezia, patients with hematochezia often need hospital admission and may re- ceive various clinical detections, such as en- doscopic, radiographic detection or nuclear medicine (4-6). Though most hematochezia patients will stop bleeding and recover, some patients without timely treatment will prog-

ress to more serious consequences, especially for children and elderly patients (7, 8).

For pediatric patients, an intestinal malformation is one of the main causes of hematochezia (9, 10). The most common diagnosis method for hematochezia is the colonoscopy (11, 12). Despite the advan- tages of colonoscopy, which can provide ac- curate diagnosis and endotherapy, it is not convenient for the diagnosis in pediatric pa- tients. Trans-abdominal ultrasound, a widely used method in diagnosis of many diseases, is reported to be sufficient in the diagno-


sis of intestinal diseases (13, 14). However, the diagnostic accuracy of trans-abdominal ultrasound for patients with hematochezia symptoms is still to be determined.

In the present retrospective study, we aimed to analyze the diagnostic accuracy of trans-abdominal ultrasound in pediatric pa- tients with hematochezia. This study might give additional evidences for the application of trans-abdominal ultrasound in the diagno- sis of hematochezia-related diseases.


PATIENTS AND METHODS


The present retrospective study includ- ed 916 pediatric patients with hematochezia or hematochezia accompanied with abdomi- nal pain who came to our hospital from Oc- tober 2014 to September 2018.

The inclusion criteria in the study were:

(1) hospitalized children <14 years old; (2) hematochezia was the main clinical mani- festation. Exclusion criteria: (1) false fecal blood of non-gastrointestinal bleeding: a. hematochezia caused by swallowing blood: such as mother’s ruptured nipple bleeding, swallowed by the child when sucking milk;

b. swallowing blood when bleeding occurs in the nasal cavity, mouth or gums; c. feed on animal blood such as chicken blood, pig blood or liver (2) black stools that appeared after taking some drugs, such as iron, Chi- nese medicines, etc. (3) patients that had severe heart, renal, liver diseases, infection or hematological diseases (4) patients that had an incomplete medical history.

Among the children, 427 patients were finally selected. This study was approved by the Ethic Committee of Children’s Hospital of Anhui Medical University Hospital. Demo- graphic data such as age, gender and clinical variables including symptoms and the hema- tochezia aspect were recorded.

For ultrasonic detection, the Siemens ACUSON S2000 (Siemens Healthcare, Erlan- gen, Germany), MINDRAY DC-8 (MINDRAY,

China) and Philips HD15 (Philips Medizin Systeme, Hamburg, Germany) color ultrason-

ic imagers were used, with a frequency 5~12 MHz. Other parameters were default setting and changed according to different patients. Briefly, patients were placed in a supine po- sition; for uncooperative patients, 10% chlo- ral hydrate (0.5 mL/kg) was used before the detection. The probe was used to detect all trans-abdominal places. The detection depth, scanning gain and focusing area were altered to get the best photograph. When too much intestinal gas existed, the patients’ position was changed or the detection place was prop- erly pressed. The patients were asked to drink water or juice 20~30 min before detection to stimulate the intestinal peristalsis if nec- essary. For obese patients or patients with polyps in the sigmoid colon or in the rectum, an enema was administered using the proper amount of warm normal saline. All data and pictures were recorded. All detection results were further confirmed by enteroscopy or colonoscopy and pathological analysis.


Statistical analysis

The measurement data was expressed by mean ± SD. The Chi square test was used for comparison of counting materials. It was considered to be statistically significant when P-value was less than 0.05. All calcula- tions were made using SPSS 18.0.


RESULTS


Basic characteristics for all patients

The present study included a total of 427 children patients with hematochezia, with a mean age 4.7±2.3 years (3~13), male:female 231:196. As shown in Table I, among all pa- tients, the hematochezia types were dark red bloody stools in 163 (38.2%), black stools in

102 (23.9%), jam like bloody stools in 74

(17.3%), scarlet blood in 55 (12.9%) and fe-

cal occult blood in 33 (7.7%). Besides, 215 (50.4%) patients showed intestinal colic ac- companied with hematochezia, 128 (29.9%) patients showed abdominal distention accom- panied with hematochezia, and 84 (19.7%) pa- tients only showed simple hematochezia.


TABLE I

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BASIC CHARACTERISTICS OF ALL PATIENTS.


Variables Value

Age, years 4.7±2.3

Gender, male: female 231: 196

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Symptom n (%)

Intestinal colic accompanied with hematochezia 215 (50.4)

Abdominal distention accompanied with hematochezia 128 (29.9)

Simple hematochezia 84 (19.7)

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Hematochezia type n (%)

Dark red bloody stool 163 (38.2)

Black stool 102 (23.9)

Jam like bloody stool 74 (17.3)

Scarlet blood 55 (12.9)

Fecal occult blood 33 (7.7)

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Pathological results for all patients

The pathogeny of hematochezia was confirmed by pathological analysis for all pa- tients. Among all patients, there were 153 (35.8%) with intussusception, 116 (27.2%)

with Meckel’s diverticulum, 95 (22.2%) with

intestinal duplication and 63 (14.8%) with intestinal polyps (Table II).


The diagnostic accuracy of trans- abdominal ultrasound for all patients

At last, we analyzed the diagnostic ac- curacy of trans-abdominal ultrasound for all patients. Among all patients, trans-ab- dominal ultrasound showed there were 150 patients with intussusception, with an ac- curacy of 98.0%; 103 patients with Meckel’s diverticulum, with an accuracy of 88.8%; 84 patients with intestinal duplication, with an accuracy of 88.4%; and 54 patients with in- testinal polyps, with an accuracy of 85.7%. The diagnostic sensitivity was significantly higher in different diseases (Table III).

The typical ultrasound pictures for the above patients are shown in Fig. 1. For intus- susception, the sonogram showed that there was a low echo mass with clear boundaries, regular margin and different sizes in the ab- dominal cavity. The diameter of small intes-

tine type was about 2 cm, and the diameter of colon type was ≥ 3cm. Its cross section showed “target ring” sign, “false kidney” sign or “sleeve” sign. For Meckel’s diver- ticulum, all imaging showed that there was an abnormal shape of an intestinal loop in the abdominal cavity, and the wall thickness was about 0.4-1.0 cm, and there was no ob- vious peristalsis. For intestinal duplication, we can always observe a spherical, tubular, or diverticulate cavity mass attached to the mesenteric side of the intestine and commu- nicating with the intestine. The ultrasonic features of the cyst are that the wall of the cyst is thick, like the echo of the normal intestinal wall; it has the characteristics of mucosa layer, muscular layer and serosa lay- er, showing “strong weak strong” stratifica- tion. CDFI can show the blood flow signal of the cyst wall. For intestinal polyps, the sono- grams showed round or oval solid mass with low or medium echo, clear boundary, hetero- geneous internal echo, scattered round like liquid dark area, polyp connected with intes- tinal wall through different pedicle. These results indicated that the trans-abdominal ultrasound had high accuracy for the diag- nosis of hematochezia related diseases.


TABLE II

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PATHOLOGICAL RESULTS FOR ALL PATIENTS.


Variables, n (%) Intussusception Meckel’s

diverticulum

Intestinal duplication

Intestinal polyps


Total

Dark red bloody stool 112 8 40 3 163 (38.2)

Black stool 4 63 33 2 102 (23.9)

Jam like bloody stool 31 29 12 2 74 (17.3)

Scarlet blood 3 10 5 37 55 (12.9)

Fecal occult blood 3 6 5 19 33 (7.7)

Total 153 (35.8) 116 (27.2) 95 (22.2) 63 (14.8)

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TABLE III

THA DIAGNOSTIC ACCURACY OF TRANS-ABDOMINAL ULTRASOUND FOR ALL PATIENTS.


Variables, n (%)

Intussusception,

Meckel’s

Intestinal

Intestinal polyps,

n=153

diverticulum,

duplication,

n=63

n=116

n=95

Diagnosed

150 (98.0)

103 (88.8)

84 (88.4)

54 (85.7)

Missed diagnosis

3 (2.0)

10 (8.6)

8 (8.4)

7 (11.1)

Misdiagnosis

0 (0)

3 (2.6)

3 (3.2)

2 (3.2)

Diagnostic rate

98.0%

88.8%

88.4%

85.7


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Intussusception Meckel,s diverticulum

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Intestinal duplication Intestinal polyps


Fig. 1. Typical ultrasound pictures for intussusception, Meckel’s diverticulum, intestinal duplication and intestinal polyps.


DISCUSSION


The diagnostic application of trans-ab- dominal ultrasound has been widely adopted in many diseases. However, the diagnostic accuracy of trans-abdominal ultrasound for patients with hematochezia is seldom ana- lyzed. In the present retrospective study, we confirmed for the first time that trans- abdominal ultrasound had a high accuracy in the diagnosis of hematochezia-related dis- eases, including intussusception, Meckel’s diverticulum, intestinal polyps and intesti- nal duplication.

The diagnosis of hematochezia has been reported in many researches. Nava- neethan et al showed that colonoscopy was sufficient in the diagnosis of hematochezia and early diagnosis might reduce the length of the hospital stay and hospitalization costs in patients with lower gastrointestinal bleeding (12). Epifanio et al demonstrated color Doppler ultrasound was accurate in the diagnosis of allergy induced hematoche- zia (15). Recently, it was also found that a multi-detector row helical CT was useful in the diagnosis of acute massive gastrointes- tinal bleeding (16). However, despite these researches, more clinical evidences are still needed for trans-abdominal ultrasound in the diagnosis of hematochezia.

The diagnostic value of ultrasound was also reported in lower gastrointestinal bleed- ing and other gastrointestinal diseases. Ya- maguchi et al showed trans-abdominal ultra- sound was useful in the diagnosis of lower gastrointestinal bleeding; however most of the cases that the study included were colitis and cancer (17). In a recent study, a sono- graphic method was also found to be effec- tive in the diagnosis of an ileal adenomyoma in a neonate (18). Multiparametric ultra- sound could be used in the diagnosis and monitoring of ischemic colitis (19). Ultra- sound was also reported to be useful in the diagnosis of intussusception (20), intestinal duplication (21), Meckel’s diverticulum (22) and intestinal polyps (23). However, despite

the researches, studies focusing on the di- agnosis and differentiation of hematochezia- related diseases by trans-abdominal ultra- sound are still few. In the present research, we found trans-abdominal ultrasound was also valuable and accurate in the diagnosis of diseases, which induced hematochezia. The present study also has some limitations, such as the limited size of the study samples.

In conclusion, we conducted a retro- spective study to analyze the diagnostic ac- curacy of trans-abdominal ultrasound in the detection of hematochezia-related diseases in pediatric patients. The results show that the trans-abdominal ultrasound had a high accuracy in the diagnosis of hematochezia related diseases, including intussusception, Meckel’s diverticulum, intestinal polyps and intestinal duplication. This study might give additional clinical evidences for the applica- tion of trans-abdominal ultrasound in the di- agnosis of hematochezia.


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