How to identify basic pediatric surgery conditions using an abdominal X-ray (Radiograph)?

From the Guidelines

To identify basic pediatric surgery conditions using an abdominal X-ray, focus on specific radiographic patterns and abnormalities that suggest common pediatric surgical issues, but consider ultrasound as the first-line imaging modality for suspected appendicitis, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. When examining the X-ray, look for air patterns, bowel gas distribution, organ shadows, calcifications, and foreign bodies. For suspected intestinal obstruction, look for dilated bowel loops with air-fluid levels, which may indicate conditions like intussusception (a target sign may be visible) or malrotation with volvulus (a double bubble sign). In necrotizing enterocolitis, pneumatosis intestinalis (air in the bowel wall) or portal venous gas may be present. Pneumoperitoneum (free air under the diaphragm) suggests bowel perforation. For appendicitis, look for a fecalith, localized ileus, or loss of the psoas shadow, but note that ultrasound has been shown to have high diagnostic accuracy for appendicitis as an initial imaging investigation and can reduce the need for further imaging without increased complications or unacceptable increases in length of stay 1. Some key points to consider when using ultrasound for appendicitis diagnosis include:

• High sensitivity and specificity for the diagnosis of acute appendicitis 1
• Operator-dependent and may be dependent on patient-specific factors, including BMI 1
• Can identify complications such as appendicoliths and perforation 1 Always correlate radiographic findings with clinical presentation, as many conditions have overlapping features. Remember that some conditions may require additional imaging like ultrasound or contrast studies for definitive diagnosis, particularly when the initial X-ray findings are subtle or nonspecific. The use of CT in the pediatric population can be reduced by using appropriate clinical and/or staged algorithm based on US/MRI implementation, with a sensitivity up to 98% and a specificity up to 97% 1. MRI plays a role as an imaging investigation to avoid CT radiation dose in children with inconclusive US findings, with a sensitivity of 96.5%, specificity of 96.1%, positive predictive value of 92.0%, and negative predictive value of 98.3% 1. In pediatric patients with suspected appendicitis, the use of US as first-line imaging is suggested, and in pediatric patients with inconclusive US, the choice of second-line imaging technique should be based on local availability and expertise 1.

From the Research

Identifying Basic Paediatric Surgery Conditions using Abdominal X-Ray

To identify basic paediatric surgery conditions using an abdominal X-Ray, the following points should be considered:

• Abdominal X-Ray is typically reserved for cases where perforation, bowel obstruction, or foreign body ingestion is suspected 2.
• The presence of air-fluid levels at different heights in the same loop of bowel can be an indication of mechanical bowel obstruction, with a sensitivity of 0.52 and a specificity of 0.71 3.
• A differential air-fluid level of 20 mm or greater is moderately suggestive of a mechanical bowel obstruction 3.
• Ultrasonography is usually the first-line imaging technique for abdominal symptoms in children, and can be useful in diagnosing conditions such as appendicitis 2, 4, 5.
• The combination of clinical assessment and imaging tests, such as ultrasonography and abdominal X-Ray, can improve the diagnostic accuracy of paediatric surgery conditions 4, 5.

Common Paediatric Surgery Conditions

Some common paediatric surgery conditions that can be identified using abdominal X-Ray and other imaging tests include:

• Appendicitis: can be diagnosed using ultrasonography and abdominal X-Ray, with a sensitivity of 91.1% and specificity of 71.1% for ultrasonography 4.
• Bowel obstruction: can be diagnosed using abdominal X-Ray and ultrasonography, with the presence of air-fluid levels and free fluid between intestinal loops being indicative of mechanical bowel obstruction 3, 6.
• Foreign body ingestion: can be diagnosed using abdominal X-Ray, with the presence of a foreign body being visible on the X-Ray image 2.

Diagnostic Criteria

The diagnostic criteria for paediatric surgery conditions using abdominal X-Ray and other imaging tests include:

• Clinical assessment: a thorough history taking and physical examination can often reach the correct diagnosis 2.
• Imaging tests: ultrasonography and abdominal X-Ray can be used to diagnose conditions such as appendicitis and bowel obstruction 2, 4, 5, 3, 6.
• Laboratory tests: C-reactive protein (CRP) value >34 mg/L can be indicative of appendicitis 5.