What is the imaging modality of choice for pediatric patients with chronic intermittent vomiting?

From the Guidelines

The imaging modality of choice for evaluating pediatric chronic intermittent vomiting is an upper gastrointestinal (UGI) series with small bowel follow-through, as it can effectively identify anatomical abnormalities such as malrotation with or without volvulus, which is a critical diagnosis not to miss in children with chronic vomiting. This recommendation is based on the most recent and highest quality study available, which suggests that a UGI series is usually appropriate for the initial imaging of an infant older than 2 days with bilious vomiting, suspected malrotation 1.

Key Considerations

• The choice of imaging should be guided by the child's age, associated symptoms, and clinical presentation, as certain symptoms such as bilious vomiting require urgent evaluation for malrotation, while projectile vomiting in young infants suggests pyloric stenosis.
• Additional imaging options may include abdominal ultrasound, which can be useful to evaluate for pyloric stenosis in infants or to assess for gallbladder disease in older children, as suggested by the study 1.
• For suspected gastroesophageal reflux disease, a pH probe study or nuclear medicine gastric emptying scan might be more appropriate than anatomical imaging, as noted in the study 1.
• The radiation exposure from a UGI series is relatively low, and the diagnostic yield for identifying anatomical causes of chronic vomiting makes it an appropriate first-line imaging study in most cases.

Clinical Presentation

• Bilious vomiting requires urgent evaluation for malrotation, while projectile vomiting in young infants suggests pyloric stenosis.
• The study by Alazraki et al 1 provides guidance on the appropriate imaging modalities for different clinical scenarios, including variant 5, which recommends a UGI series for the initial imaging of an infant older than 2 days with bilious vomiting.
• The study also notes that imaging is usually not necessary for children with gastroesophageal reflux disease who are otherwise healthy 1.

Imaging Modalities

• UGI series with small bowel follow-through is the recommended initial imaging study for most children presenting with chronic intermittent vomiting.
• Abdominal ultrasound may be useful in certain cases, such as evaluating for pyloric stenosis in infants or assessing for gallbladder disease in older children.
• Head CT or MRI may be warranted if there is concern for increased intracranial pressure causing vomiting.

From the Research

Imaging Modalities for Pediatric Chronic Intermittent Vomiting

• The role of abdominal ultrasound in evaluating children with suspected upper gastrointestinal disease has been established 2.
• Ultrasound is considered an accurate, reliable, and rapid screening method to evaluate the causes of upper gastrointestinal disease in children 2.
• It is recommended as the initial imaging modality, instead of fluoroscopy, to avoid or limit the use of ionising radiation 2.

Common Causes of Pediatric Chronic Intermittent Vomiting

• Intussusception, gastroesophageal reflux, pyloric stenosis, appendicitis, and jejunal/ileal atresia are common causes of upper gastrointestinal disease in children 2.
• The clinical presentation of these conditions can vary, with palpable abdominal mass and bloodstained stool being common in intussusception, and recurrent pneumonia and failure to thrive in gastroesophageal reflux 2.

Diagnostic Approaches

• Ultrasound plays a central role in the diagnostic imaging workup for infantile vomiting 3.
• The American College of Radiology (ACR) Appropriateness Criteria for Vomiting in Infants up to 3 Months of Age provides guidance on the use of ultrasound and other modalities in the workup of vomiting in infants 3.
• Point-of-care ultrasound has been shown to have excellent diagnostic accuracy for a variety of gastrointestinal and biliary pathologies, including hypertrophic pyloric stenosis, intussusception, and appendicitis 4.

Special Considerations

• Certain conditions, such as Schaaf-Yang syndrome, can present with gastrointestinal symptoms, including chronic constipation, gastroesophageal reflux, and feeding difficulties 5.
• Food protein hypersensitivity can be a cause of gastrointestinal symptoms in children, and diagnosis may require a combination of clinical evaluation, laboratory tests, and imaging studies 5.