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Three Part Question

In [children with abdominal symptoms] is [AXR] useful in [identifying intra-abdominal pathology and guiding management]?

Clinical Scenario

A 5 year old boy is brought into the Emergency Department by his mother. He complains ofconstipation. You consider ordering an AXR to rule out intra-abdominal pathology and guide management.

Search Strategy

National Library of Medicine 1978-2024 using the OVID interface.
({constipation vomiting pain abdominal radiograph children} LIMIT to human AND english.

Search Outcome

18 papers found of which 15 were irrelevant or of insufficient quality. The remaining 3 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kubiszewski K, Patterson S, Chalise S, Rivera-Sepulveda A. Diagnostic Yield of Abdominal Radiographs 2023 USA	Retrospective, cross-sectional study of patients aged 0 to 18 years with an AR who visited the PED between 2017 and 2019. Diagnostic yield was analyzed with sensitivity, specificity, positive predictive value, negative predictive value (NPV), and likelihood ratio.	Retrospective survey.	Abnormal AXR Rate	The incidences of an abnormal AR in abdominal pain, vomiting, and constipation were 26%, 37%, and 50%, respectively. There was a 13% rate of clinically significant diagnoses. The AR diagnostic yield showed 44% sensitivity, 70% specificity, 17% positive predictive value, and 90% NPV (P < 0.05).
Tareen F, Mc Laughlin D, Cianci F, Hoare SM, Sweeney B, Mortell A, Puri P. Abdominal radiography is 2015 USA	Index cases of intussusception presenting over 15 years (1998-2013) were analysed.	Retrospective survery	Outcome of pneumatic reduction of intussusception (PRI) between AXR and no AXR groups was compared.	The success rate of pneumatic reduction of intussusception did not differ between AR positive (82 %) and AR normal (84 %). Occult pneumoperitoneum was not detected in any patient by AR in our cohort.	Only specific to 1 condition (Intusseception)
Rothrock SG, Green SM, Hummel CB. Plain abdominal radiography in the detection of major disease in c 1992 USA	354 children 15 years old or younger who underwent plain abdominal radiography during a one-year period	Prospective, observational study	The presence of any of the following features--prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, abdominal distention, or peritoneal signs--was 93% sensitive and 40% specific in detecting diagnostic or suggestive radiographs in patients with major disease. Positive and negative predictive values were 11% and 99%, respectively. If only these criteria had been used to obtain radiographs, 38% of films would have been omitted (at an estimated savings of $20,000) with only 2 suggestive radiographs missed.	Restricting abdominal radiographs to patients with at least one of these five high-yield clinical features will detect most diagnostic and suggestive radiographs in children with major abdominal diseases.

Comment(s)

All studies stress the importance of history and physical examination in diagnosing abdominal pathology in children with questionable yield of AXR.

Clinical Bottom Line

AXR interpretation rarely alters the management of a child with abdominal complaints and should be ordered with careful consideration of clinical need evaluated from history and physical examination in view of high radiation dose.

References

1. Kubiszewski K, Patterson S, Chalise S, Rivera-Sepulveda A. Diagnostic Yield of Abdominal Radiographs Diagnostic Yield of Abdominal Radiographs in the Pediatric Emergency Department
2. Tareen F, Mc Laughlin D, Cianci F, Hoare SM, Sweeney B, Mortell A, Puri P. Abdominal radiography is Abdominal radiography is not necessary in children with intussusception
3. Rothrock SG, Green SM, Hummel CB Plain abdominal radiography in the detection of major disease in children: a prospective analysis