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Purpose: To assess the predictive value of radiomics for surgical decision-making in neonatal necrotizing enterocolitis (NEC) when abdominal radiographs (ARs) do not suggest an absolute surgical indication for free pneumoperitoneum. Methods: In this retrospective study, we finally included 171 newborns with NEC and obtained their ARs and clinical data. The dataset was randomly divided into a training set (70%) and a test set (30%). We developed machine learning models for predicting surgical treatment using clinical features and radiomic features, respectively, and combined these features to build joint models. We assessed predictive performance of the different models by receiver operating characteristic curve (ROC) analysis and compared area under curve (AUC) using the Delong test. Decision curve analysis (DCA) was used to assess the potential clinical benefit of the models to patients. Results: There was no significant difference in AUC between the clinical model and the four radiomic models (P > 0.05). The XGBoost joint model had better predictive efficacy and stability (AUC, training set: 0.988, test set: 0.959). Its AUC in the test set was significantly higher than that of the clinical model (P < 0.05). DCA showed that the XGBoost joint model achieved higher net clinical benefit compared to the clinical model in the threshold probability range (0.2–0.6). Conclusion: Radiomic features based on AR are objective and reproducible. The joint model combining radiomic features and clinical signs has good surgical predictive efficacy and may be an important method to help primary neonatal surgeons assess the surgical risk of NEC neonates. [ABSTRACT FROM AUTHOR]

Ultrasound is the criterion standard imaging modality for the diagnosis of intussusception. However, to our knowledge the utility of abdominal radiographs to concurrently screen for pneumoperitoneum or other abdominal pathology that could have a similar presentation has not been studied. Our institutional protocol requires the performance of AP supine and left lateral decubitus views of the abdomen prior to ultrasound evaluation for intussusception, providing an opportunity to examine the yield of abdominal radiographs in this setting. Our primary objective was to determine the rate of pneumoperitoneum on screening abdominal radiographs in children undergoing evaluation for intussusception. Our secondary objective was to determine the rate that other clinically significant pathology is found on these screening abdominal radiographs. We performed a retrospective chart review of all patients under 6 years of age who had any imaging ordered in our large urban pediatric emergency department to evaluate for suspected intussusception during the calendar years 2018–2020. 1115 patient encounters met our inclusion criteria. Among 1090 who had screening abdominal radiographs, 82 (8%) had findings concerning for intussusception. Of those not concerning for intussusception, 635 (58%) were read as normal, 263 (24%) showed moderate to large stool burden, 107 (10%) showed generalized bowel distention, and 22 (2%) showed abnormal gastric distention. Individually the remainder of all other findings compromised <1% of encounters and included radiopaque foreign body (8), intraabdominal calcification (4), pneumonia/effusion (3), pneumatosis intestinalis, abdominal mass (2), diaphragmatic hernia (1), rib fracture (1), appendicolith (1), feeding tube malposition (1), and bowel wall thickening (1). In one encounter the patient had a bowel perforation with pneumoperitoneum present secondary to ingestion of multiple magnets. Our study indicates that radiograph-detected pneumoperitoneum is rare in children with suspected intussusception. Constipation is the most common abnormal finding on screening radiographs. Other findings occur in approximately 15% of total cases, some of which require further workup. [ABSTRACT FROM AUTHOR]

Objective: Abdominal ultrasonography (AUS) assessment of the neonatal abdomen is emerging as a potential useful addition to traditional abdominal radiographs (AXR) to confirm the diagnosis of necrotizing enterocolitis (NEC). The goal of this study was to assess the abdominal sonographic findings of premature infants with NEC, in order to determine whether AUS is more effective than AXR in the diagnosis of NEC. Methods: This cross-sectional study was performed on consecutive neonates with clinical suspicion of NEC admitted in our hospital’s NICU (Ali-Asghar Children’s Hospital, Tehran, Iran). We prospectively evaluated the hospitalized subjects using AXR and AUS from May 2018 to May 2020. Results: A total of 53 neonates were included in the study. These patients were divided into two groups: suspected NEC patients (stage I) including 31 subjects and definite NEC patients (stage II and III) including 22 neonates. We found a substantial agreement between the two modalities regarding the detection of pneumoperitoneum and pneumatosis intestinalis (κ: 0·658 for both). The concordance concerning portal venous gas detection was considered slight (κ: 0·315). Thirty-eight patients did not show any signs of portal venous gas in either of AUS or AXR. On the contrary, four patients demonstrated evidences of portal venous gas in both AUS and AXR. AUS detected ten more portal venous gas than AXR. AXR found no cases with positive portal venous gas that were undetected by AUS. The most predictive indicator for surgical intervention in neonates was the presence of free echogenic ascites and loculated fluid. Conclusion: Our findings demonstrated that AUS is superior to AXR in demonstrating portal venous gas and pneumatosis intestinalis. Hence, it seems that AUS is a useful adjunct to AXR in the management of NEC.

Introduction: Abdominal surgery in children is known to contribute to Adhesive Small Bowel Obstruction (ASBO). No X-ray findings have been validated for predicting management in ASBO. Various imaging modalities often cannot predict complications or if a conservative line of management would be successful. Aim: To determine if a persistent prominently dilated small bowel loop in the Left Upper Quadrant (LUQ) on plain X-rays (Omega loop) would suggest early operative intervention. Materials and Methods: A retrospective cohort study was conducted in the Department of Paediatric Surgery, IMCH, Government Medical College, Kozhikode, Kerala, India from January 2016 to December 2018. Diagnosis was based on history, clinical features, and radiologic findings. Demographic, clinical, radiologic, and operative data were collected. After exclusions, the study population was divided into two groups: Group A - ASBO patients with the characteristic Omega loop, and Group B - patients without the Omega loop. Appropriate statistical methods were used to compare the groups, with significance defined as p

Introduction: Abdominal surgery in children is known to contribute to Adhesive Small Bowel Obstruction (ASBO). No X-ray findings have been validated for predicting management in ASBO. Various imaging modalities often cannot predict complications or if a conservative line of management would be successful. Aim: To determine if a persistent prominently dilated small bowel loop in the Left Upper Quadrant (LUQ) on plain X-rays (Omega loop) would suggest early operative intervention. Materials and Methods: A retrospective cohort study was conducted in the Department of Paediatric Surgery, IMCH, Government Medical College, Kozhikode, Kerala, India from January 2016 to December 2018. Diagnosis was based on history, clinical features, and radiologic findings. Demographic, clinical, radiologic, and operative data were collected. After exclusions, the study population was divided into two groups: Group A - ASBO patients with the characteristic Omega loop, and Group B - patients without the Omega loop. Appropriate statistical methods were used to compare the groups, with significance defined as p<0.05. Results: Among the 72 cases of ASBO that met the inclusion criteria, 40 (55%) were successfully managed conservatively, and 32 (45%) required non urgent relaparotomy. The median age was 6.9 years (range: 2-12 years), and 55% were male. Group A comprised 16 patients (22.2%), and the remaining patients were in Group B 56 (77.8%). Group A showed higher rates of failure of conservative management (n=14, p=0.0002), with higher rates of single-band obstruction, bowel loss, perforation, matting of bowel loops, and difficult dissection. The Omega loop had a low sensitivity (43.7%) but high specificity (95%) and positive predictive value (87.5%) for the need for relaparotomy. Conclusion: The Omega loop suggests the possibility of more complications, and therefore, earlier operative intervention should be considered. [ABSTRACT FROM AUTHOR]

A well-established method does not exist to rule out a small bowel obstruction using an abdominal xray series with significant accuracy. The hypothesis of the study is that the ratio of an average small bowel diameter to lumbar spine diameter over 0.5 is most likely a small bowel obstruction. An x-ray abdominal series measurement technique was applied to 41 subjects with a chief complaint of "abdominal pain" as part of a randomized retrospective case review to predict an obstruction v. non obstruction. A total number of 81 abdominal pain subjects with a mean age of 46.7 years were selected with 40 excluded due to normal small bowel gas pattern. The subject's medical information was unknown to the authors when reading their images. The measurement technique involved averaging the largest and smallest small bowel short axis diameters with comparison to the lowest clearly visible lumbar body width. The subjects' medical course as described in the medical chart or subsequent computed tomography scans were used as the referencing standard to determine presence of obstruction vs non-obstruction. This method, called the Bowel-Spine Ratio (BSR), resulted in a sensitivity of 0.882 (0.622–0.979; 95% CI), specificity of 0.957 (0.760–0.998; 95% CI), accuracy of 94.7% (80.9%–99.1%; 95% CI) and a positive likelihood ratio of 21 for predicting a small bowel obstruction. The abdominal series Bowel-Spine Ratio is a simple yet effective technique to screen for a small bowel obstruction using limited resources and to avoid unnecessary computed tomography scans with the potential to reduce health care costs. Implications for practice: Clinicians could have increased confidence in utilizing abdominal radiographs to evaluate for small bowel obstruction. [ABSTRACT FROM AUTHOR]

Abstract Background Abdominal ultrasonography (AUS) has been suggested to be valuable in the early detection of necrotizing enterocolitis (NEC). Objective Here, we intended to assess the efficiency of abdominal ultrasound in terms of predicting bowel resection in infants with NEC. Methods From January 2018 to March 2021, 164 hospitalized children with NEC who underwent surgical management were enrolled. The enrolled infants were separated into two groups according to whether they underwent bowel resection. We reviewed the clinical data, as well as dynamic sonographic and abdominal radiographic (AR) parameters. The potential performance of AUS parameters was identified and compared with that of AR using a logistic regression analysis and receiver operating characteristic (ROC) curve analysis. Results Several parameters were detected to be statistically significant in predicting the occurrence of bowel resection, including thick to thin transformation [p

A 15-year-old girl presented with progressive abdominal distention for four months duration. An initial assessment by primary care and gynaecological teams concluded that ascites as the cause based on the clinical and initial ultra sonographic findings. However, an abdominal radiography revealed that a huge mature cystic teratoma as the actual cause of the presenting issue. Despite being a rare incidence, this case report highlights why a high index of suspicion of ovarian pathology in large abdominal fluid accumulation in the paediatric population should be raised. The case report also highlights the value of abdominal radiography, particularly in a primary care setting facility in differentiating intra-abdominal mass and ascites, especially when the massive volume of ovarian mass hampered the ultrasound findings. Though it is not specific, it may improve accuracy of initial diagnosis leading to an appropriate investigation with timely referral to the appropriate department. The unusual component of this case was the 'pseudoascites' presentation and the literature on the detail of distinction between the two conditions from the primary aspect point. [ABSTRACT FROM AUTHOR]

Background: Abdominal ultrasonography (AUS) has been suggested to be valuable in the early detection of necrotizing enterocolitis (NEC). Objective: Here, we intended to assess the efficiency of abdominal ultrasound in terms of predicting bowel resection in infants with NEC. Methods: From January 2018 to March 2021, 164 hospitalized children with NEC who underwent surgical management were enrolled. The enrolled infants were separated into two groups according to whether they underwent bowel resection. We reviewed the clinical data, as well as dynamic sonographic and abdominal radiographic (AR) parameters. The potential performance of AUS parameters was identified and compared with that of AR using a logistic regression analysis and receiver operating characteristic (ROC) curve analysis. Results: Several parameters were detected to be statistically significant in predicting the occurrence of bowel resection, including thick to thin transformation [p < 0.001, odds ratios (OR), 4.38; 95% confidence interval (CI) 2.26–8.52], absence of peristalsis certain areas (p = 0.001, OR, 2.99; 95% CI 1.53–5.86), absence of bowel wall perfusion (p < 0.001, OR 10.56; 95% CI 5.09–21.90), and portal venous gas (p = 0.016, OR, 2.21; 95% CI 1.12–4.37). Furthermore, the ROC curve analysis showed significant differences (p = 0.0021) in the area under the receiver operating curve (AUROC) for the logistic models of AUS (AUROC: 0.755, 95% CI 0.660–0.849) and AR (AUROC: 0.693, 95% CI 0.597–0.789) for the prediction of intestinal resection. Conclusions: A dynamic AUS examination play an important role to indicate the potential for bowel loss during the surgery. [ABSTRACT FROM AUTHOR]

Objective: To decrease the percentage of patients undergoing an abdominal radiograph for evaluation of constipation within 24 hours of their initial gastroenterology visit.Study Design: In January 2015, we implemented a quality improvement, evidence-based guideline (EBG) aimed at standardizing the initial assessment of patients presenting for a new outpatient gastroenterology visit with a primary complaint of constipation. Over the subsequent 5 years, we followed the clinical impact of this guideline initiation with the goal of decreasing unnecessary abdominal radiograph use by 10% within 1 year of EBG launch. Patients older than 6 months and younger than 19 years were included.Results: In total, 6723 patients completed new patient gastroenterology visits for a primary diagnosis of constipation between 2013 and 2019. Of these, 993 (14.8%) patients had abdominal radiographs taken within 24 hours of their initial visit. Over the 7 years of this project, a mean frequency of abdominal radiograph use decreased from 24% to less than 11%. In addition, a 57% decrease in hospital charges related to decreased radiograph use for constipation was found. No increases in subsequent emergency department visits or hospitalization for constipation within 30 days of patients' initial visits were seen.Conclusions: Through local adoption of an EBG, routine use of abdominal radiographs taken during a patient's initial outpatient gastroenterology visit for constipation decreased by more than 50%. This reduction was maintained over a subsequent 5-year period without any detrimental side effects. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated the diagnostic utility of abdominal ultrasound (AUS), an adjunct to abdominal X-ray (AXR), for necrotizing enterocolitis (NEC) in congenital heart disease (CHD) patients. Methods: 86 patients with suspected NEC from 2009 to 2018 were classified as with CHD (n = 18) if they required cardiac intervention versus without CHD (n = 68). Clinical and radiological data were collected, including AXR and AUS concordance. Wilcoxon rank-sum test and Fisher's exact test were performed. Results: CHD patients had higher birth weights (p < 0.001) and gestational ages (p < 0.001) than non-CHD patients. CHD patients presented more frequently with hypotension (p = 0.041) and less frequently with bilious emesis (p < 0.001). Overall, CHD patients were less likely to have AUS findings of pneumatosis (33.3 vs. 72.1%; p = 0.005) and decreased mural flow (0 vs. 20.6%; p = 0.035) compared to non-CHD patients. On concordance analysis, CHD patients had 3.9-fold more discordant studies with pneumatosis on AXR but not on AUS (33.3 vs. 8.8%; p = 0.016) compared to non-CHD patients. Urgent surgery was required in 5.6% of CHD patients versus 16.2% of non-CHD patients. Conclusion: CHD patients with suspected NEC represent a distinct clinical population. AUS has particular utility in assessing findings of bowel viability in the CHD NEC population, reflecting reduced rates of surgical NEC. [ABSTRACT FROM AUTHOR]

Purpose Preoperative endoscopic clipping is a popular method in identifying the location of tumors during total laparoscopic or robotic gastrectomy. We investigated the usefulness of additional intraoperative abdominal radiographs to identify the location of clips. Methods We retrospectively analyzed 331 patients with early gastric cancer who underwent endoscopic clipping before total laparoscopic or robotic gastrectomy between September 2012 and September 2018. Endoscopists applied two clips 1 cm from the proximal aspect of the upper margin of the tumor which was located above the angle of the stomach. We compared outcomes of patients who underwent preoperative abdominal radiographs only (group A) and those who underwent additional abdominal radiographs (group B). Results Of the total patients, 80 (24.2%) underwent additional intraoperative abdominal radiographs. The rates of positive frozen biopsy in the two groups were not significantly different (group A vs. group B: 2.8% vs. 3.8%, P=0.456). The additional resection rate was significantly higher in group B compared to group A (8.8% vs. 2.8%, P=0.048). The mean distance from the tumor was 3.3 cm (±2.4) in group A and 2.4 cm (±1.3) in group B (P

Background: To compare clinical history and measurements of fecal load on abdominal radiography (AR) in the prediction of urinary tract infection (UTI) recurrence in children. Methods: We combined data from two multicenter longitudinal studies in which children less than 6 years of age with a first or second UTI were followed for recurrence of UTI. Two radiologists reviewed the scout abdominal radiographs of initial voiding cystourethrograms obtained at enrollment from children at two participating sites and measured stool visible in various parts of the colon. We examined how well clinical variables (e.g., voiding and bowel history, use of laxatives at enrollment) and measurements of fecal load predicted recurrence of UTI within 12 months of enrollment. Results: One hundred and ninety-two children were included. On univariate analyses, age, vesicoureteral reflux (VUR), cecal diameter, rectal diameter, and total stool length on AR were associated with recurrence of UTI. After controlling for age, the odds of recurrent UTI in children with VUR at baseline was 3.85 (95% CI: 1.62, 9.14) higher than in children without VUR. Recurrent UTI was 2.57 (95% CI: 1.01, 6.55) times more likely in children with cecal diameter > 3.10 cm than children with lower cecal diameters; time to first recurrent UTI was shorter in children with elevated cecal diameters (p = 0.0023). Conclusions: Cecal diameter on abdominal radiographs predicts UTI recurrence in children with a previous UTI. However, its accuracy is suboptimal to serve as a screening test. Accordingly, its routine use for this indication is not supported. If cecal diameter on an AR ordered for another indication is > 3.10 cm, then management of constipation could be considered. [ABSTRACT FROM AUTHOR]

Purpose: Stool burden on abdominal radiographs is not reflective of constipation, perhaps because of variable fecal shadowing or limited inter-rater agreement. These limitations are hypothetically mitigated by computed tomography (CT). This research aimed (i) to evaluate whether bowel movement frequency, stool form, or a diagnosis of functional constipation correlate or associate with stool burden identified on CT, and (ii) to investigate whether physicians use CT in their assessment of a patients' bowel function. Methods: Patients attending for non-emergent abdominal CT imaging were invited to participate by completing a bowel questionnaire. Stool burden identified on imaging was determined and inter-rater reliability was evaluated in a subgroup of patients (n = 20). Descriptive and comparative analyses were performed. An online questionnaire evaluated the use of abdominal imaging in assessing patients' bowel function in a cross-section of ordering physicians. Results: The patient response rate was 19% (96/516). No clinically useful associations between fecal burden and stool form, bowel motion frequency, gastrointestinal symptoms or a diagnosis of constipation was identified. The physician response rate was 35% (33/94). Opportunistic use of data was more common than deliberate use. However, an abdominal radiograph or CT scan had been requested by 42% and 18% of physicians respectively to assess patient's chronic bowel habit. Approximately 30% of physicians believed evidence supported this practice. Conclusions: Physicians may use abdominal CT in their assessment of patients' chronic bowel habits. However, objective assessment does not support this practice. Colonic stool burden does not correlate with patient-reported symptoms or a criteria-based diagnosis of constipation. [ABSTRACT FROM AUTHOR]

Purpose: To determine if symptomatic patients referred for radiographic stool quantification have equivalent stool burden to asymptomatic patients.Method: This was an IRB-approved HIPAA-compliant retrospective equivalence cohort study. An a priori equivalence power calculation was performed. Consecutive abdominal radiographs performed in adult outpatients with bloating, constipation, diarrhea, or abdominal pain to assess "fecal loading" [n = 242 (fecal cohort)] were compared to those performed in asymptomatic adult outpatients to assess "renal stones" [n = 242 (renal cohort)]. Radiographs were randomized and reviewed by two blinded independent abdominal radiologists. Exclusion criteria, designed to avoid unblinding, included urinary tract calculi ≥ 0.5 cm, multiple urinary tract calculi, and ureteral stent(s). Readers scored all radiographs (n = 484) for stool burden using validated Leech criteria [scale: 0 (none) to 15 (extreme diffuse)]. Mean Leech scores and 95% confidence intervals were calculated. Multivariable generalized linear modeling was performed to adjust for baseline medication use, age, and gender. The adjusted parameter estimate was used to test for equivalence in the mean difference between cohorts using Schuirmann's method of two one-sided t-tests. Inter-reader agreement was assessed with intraclass correlation coefficients.Results: Overall mean Leech scores for fecal [6.9 (95% CI 6.7, 7.2)] and renal [7.3 (95% CI 7.1, 7.5)] cohorts were equivalent within a margin of 0.75 (adjusted mean difference: − 0.4 [90% CI − 0.7, − 0.04]; p value = 0.02). Inter-reader agreement was good [ICC: 0.62 (95% CI 0.56, 0.68)].Conclusion: Radiographic stool quantification produces equivalent results in symptomatic and asymptomatic adults and is of uncertain value. [ABSTRACT FROM AUTHOR]

A prospective study was performed over a 3-month period in a tertiary referral centre to evaluate the appropriateness and contribution of plain abdominal radiographs (PAR) in the diagnosis and management of adult patients presenting with acute abdominal pain. Methods: Forward stepwise logistic regression was used to examine the correlation between PAR findings and the final diagnosis. The Chi-squared test was used to determine any changes in patient management including requirement for surgical intervention based on PAR findings (p < 0.05). Results: Of 168 patients (246 PAR), 59 (35%) had positive findings on PAR. PAR were most sensitive in cases of intestinal obstruction (odds ratio, OR = 33.548, r = 0.561). The sensitivity was further increased if three of the following predictive signs were present: exaggerated bowel sounds (OR = 13.350, r = 0.154), abdominal distension (OR = 2.993, r = 0.234) and age over 50 years (OR = 2.301, r = 0.027). PAR were non-diagnostic in 82% of patients with acute abdominal pain (p < 0.001). Conclusion: PAR do not play a major role in influencing the management of patients with acute abdominal pain without coexisting bowel obstruction.