A 65-year-old farmer presents to the ED after his ankle was run over by a piece of farm equipment in the field. His x-ray is shown above (Figure 1: Case courtesy of Dr. Oyedepo Victor Olufemi, radiopaedia.org) He also has an associated soft tissue injury overlying the area that is grossly contaminated with mud and manure. (more…)
Which of the following medications is likely responsible for this urine discoloration in an intubated and sedated ICU patient?
Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric peripheral IV placement. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
Abigail is a 10-year-old girl with known sickle cell disease, who presents with severe atraumatic pain in her hips and back. She is afebrile, but tachycardic and tachypneic with 10/10 pain. Nurses have made several attempts but have been unsuccessful in establishing a peripheral IV(PIV) for giving IV fluids and medications. They now ask you to obtain access. You decide to perform an ultrasound-guided PIV placement.
| Vital Sign | Finding |
|---|---|
| Temperature | 37.6C |
| Heart rate | 135 bpm |
| Blood pressure | 135/90 |
| Respiratory rate | 23 |
| Oxygen saturation (room air) | 99% |
Veins and arteries can be difficult to distinguish. Below is a table to help differentiate using ultrasonography.
| Characteristic | Veins | Arteries |
|---|---|---|
| Diameter | Typically larger than arteries (is dependent on fluid status) | Relatively fixed in size, round in shape |
| Wall Thickness | Thin | Thick |
| Compressibility | Easy | More difficult |
| Color Doppler Flow | Non-pulsatile | Pulsatile |
| Vessel Valves | Present (but not always visible) | Absent |
Nerves can be confused with blood vessels when looking on ultrasound. The following are ways to identify a nerve.
Fun fact: Certain gemstones like tiger’s eye and figured woods like flamed maple exhibit chatoyance which is analogous to anisotropy, but occurs under visible light, rather than ultrasound beams like anisotropy.
Needles exhibit ultrasound artifacts which can help with identification.
Typically, pediatric patients receive a peripheral IV in the upper extremity in one of 2 locations:
If unable obtain upper extremity access, the lower extremity can also be accessed. This is more typically performed in infants and young children.
There are 2 approaches in using POCUS for cannulating peripheral veins based on if the operator is using the transverse or longitudinal orientation.
After the needle tip is visualized entering the vein and a flash of blood appears in the hub of the needle, advance the needle forward an additional 1-2 mm before threading the catheter. Why? The catheter does not extend fully to the tip of the needle. Thus the needle must be advanced past the initial flash of blood to ensure that the catheter has also penetrated the vein. If there is resistance when threading the angiocatheter into the vein, reassess the needle tip position using the ultrasound and confirm the needle is still positioned intravascularly.
After successful threading, retract the needle, attach pre-primed IV tubing, and flush and lock the tubing. Secure the catheter in place.
There have been many studies evaluating ultrasound-guided peripheral IVs in patients, and below are several key articles involving pediatric patients. Overall, ultrasound-guidance appears to be helpful in pediatric patients with difficult access, but the exact technique involved and the experience of the operator likely have an effect.
| Year | Authors | Title | Major Findings |
|---|---|---|---|
| 2009 | Doniger et al. [1] | Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients | Ultrasound-guided peripheral IV placement in difficult-access patients took less time, was more often successful, and required fewer needle re-directions. |
| 2010 | Oakley and Wong [2] | Ultrasound-assisted peripheral vascular access in a paediatric ED | Ultrasound-guidance was associated with slightly increased success rates in peripheral IV placement. This effect was more pronounced in cases with difficult-access patient. |
| 2018 | Otani et al. [3] | Ultrasound-guided peripheral intravenous access placement for children in the emergency department | In contrast to many other publications on ultrasound-guided peripheral IV procedures, the authors report a LOWER success rate for patients that had one failed IV attempt, as compared to the conventional method. An important potential confounder was that this study used a “dual-operator” method, in which one clinician operates the ultrasound, and the other places the IV. |
| 2018 | Desai et al. [4] | Longevity and complication rates of ultrasound guided versus traditional peripheral intravenous catheters in a pediatric emergency department | Ultrasound-guided peripheral IVs had a longer catheter survival time compared with traditionally-placed peripheral IVs. Complications from the peripheral IVs were similar between the two groups. |
Using POCUS, you begin by visualizing Abigail’s veins at the antecubital fossa and are able to identify the basilic and cephalic veins. Tracing the basilic vein proximally, you note that it is relatively large and straight; however, you see a honeycomb-like structure nearby it, which displays anisotropy and appears to be a nerve. You opt instead to follow the cephalic vein. There do not appear to be any nerves or other vessels nearby. You clean her skin appropriately and apply a sterile glove over the probe, and apply sterile gel. After these preparations, you re-identify the vessel in the transverse plane, use dynamic needle tip visualization with an out-of-plane approach, and successfully guide the tip of the needle into the vein.
After visualizing the tip of the needle in the vein, you slightly advance the needle another 2 mm and then thread the catheter. You are able to obtain bloodwork. After flushing the catheter and cleaning the surrounding skin, you secure the catheter. Abigail is now able to get pain medications and fluids.
She soon feels much improved after 3 hours. Her laboratory results are similar to her baseline values. She is able to return home with ongoing management as an outpatient basis with close follow-up.
The PEM POCUS series was created by the UCSF Division of Pediatric Emergency Medicine to help advance pediatric care by the thoughtful use of bedside ultrasonography.
Read other PEM POCUS tutorials. Learn more about bedside ultrasonography on the ALiEM Ultrasound for the Win series.
Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric hip effusion. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
Sarah is a 4-year-old girl who comes into the emergency department complaining of a limp for the last day. She had an upper respiratory infection which started a week ago for which she had been taking acetaminophen and ibuprofen with her last dose of either being 2 days ago. Those symptoms have improved. Yesterday, she started complaining of diffuse right leg pain primarily at her hip, thigh, and knee. Today, her parents noted she was walking with a limp.
On arrival, her vital signs are:
| Vital Sign | Finding |
|---|---|
| Temperature | 100.1F |
| Heart rate | 100 bpm |
| Blood pressure | 97/50 |
| Respiratory rate | 19 |
| Oxygen saturation (room air) | 100% |
She is well appearing and walks with an antalgic gait favoring the left leg. She has a normal HEENT, neck, cardiac, respiratory, abdominal, and back examination. She points to her right anterior thigh when you ask her where her pain is. She has limited range of motion with internal and external rotation of her right hip and complains of pain. She cries when you palpate any part of her leg, but is able to range her knee, ankle, and foot fully. She has 2+ dorsalis pedis and posterior tibialis pulses and intact sensation to light touch throughout.
Given her pain with range of motion at her hip, you order a hip radiograph, but while waiting for it, decide to perform a hip point of care ultrasound (POCUS) examination.
It can be difficult for children to locate the exact area of pain and often hip pain can present with referred knee and thigh pain. A thorough physical examination along with hip POCUS can help localize the area of discomfort. When we use POCUS to evaluate the hip, we are primarily looking for a joint effusion in the synovial space. This is best visualized anterior to the femoral neck.
A hip effusion will appear anechoic (black) in the synovial space anterior to the femoral neck (anterior synovial recess). Measure the distance between the anterior surface of the femoral neck and the posterior surface of the iliopsoas muscle. Examples are illustrated in figures 5 and 6.
There have been different methods used to assess if an effusion is present including:1,2
Note that hip POCUS does not tell you the cause of an effusion but rather only whether an effusion is present or not. Effusions can result from infectious, inflammatory, and traumatic etiologies, and thus it is important to take into account the context of the patient’s presentation.
There have been multiple case reports of hip POCUS identifying hip effusions in children with fractures, septic joints, and in the work-up of children with limps [1–4]. There are limited studies examining the accuracy of hip POCUS compared to radiology-performed ultrasounds in children. The studies that exist show high sensitivity and specificity when hip POCUS is performed by pediatric emergency medicine (PEM) physicians (Table 1).
Additional studies have explored the development of hip effusion clinical decision-making tools to support POCUS in the diagnosis of transient synovitis and differentiate it from other causes of non-traumatic arthritis in patients with a hip effusion, including septic arthritis, Lyme arthritis, and osteomyelitis [5]. For example, one retrospective pilot study found that the combination of POCUS performed by PEM physicians and a clinical decision rule could correctly rule in transient synovitis in 63 of 67 patients with a hip effusion [6].
The use of POCUS in the ED has also been associated with cost savings and greater clinical efficiency. In pediatric patients, hip POCUS has demonstrated potential cost-saving benefits compared with radiology-performed ultrasound. One Australian economic evaluation estimated annual savings of approximately AU$35,800 (about US$25,000), mainly by shortening the time children spent in an ED bed waiting for an ultrasound [7]. Additionally, in a case series of 10 children with septic arthritis of the hip, POCUS-guided hip aspiration by a PEM-trained physician was associated with a shorter time to antibiotic administration [1].
Although standardized training requirements for hip effusion POCUS in pediatric patients have not been established, scanning accuracy appears to be influenced by operator experience and confidence. As illustrated in Table 1, sensitivity and specificity were higher among physicians who had performed more hip POCUS scans and among those with greater confidence in their ultrasound skills [8,9,11]. These findings highlight the importance of continued practice and experience in developing proficiency in hip POCUS, ultimately improving diagnostic accuracy and supporting timely clinical decision-making. So, make sure to keep scanning!
| Study | N | Sensitivity | Specificity | Comments |
|---|---|---|---|---|
| Vieira et al., Ann Emerg Med, 2010 [8] | 28 | 85% | 93% | If the pediatric emergency physician had a high confidence in ultrasound accuracy, the sensitivity increased to 90% and specificity to 100%. |
| Cruz et al., Am J Emerg Med, 2018 [9] | 516 | 85% | 98% | For each additional hip POCUS performed, the odds of an accurate scan increased by 2.4%. |
| Katz-Dana et al., CJEM, 2024 [10] | 95 | 89.8% | 91.3% | Strong positive LR of 10.33 and negative LR of 0.11 for PEM physician-performed POCUS. |
| Jones et al., Ann Emerg Med, 2025 [11] | 161 (322 hips) | 89.3% | 99.2% | For the 3 high-volume pediatric emergency physicians, sensitivity and specificity increased to 98.1% and 97.8%, respectively. Sensitivity and specificity are per hip. |
The patient’s hip plain film radiographs are unremarkable. You decide to incorporate hip POCUS to your evaluation. You place a linear, high-frequency transducer and visualize the patient’s bilateral hips. You observe the following:
Though the child complained of hip, knee, and thigh pain, your POCUS evaluation identifies a right hip effusion which helps you narrow the location of her pain.
The patient’s labs result, and she has reassuring labs, which include a serum WBC 8.3 x109/L and ESR 34 mm/hr. The patient receives ibuprofen during her visit and within 1 hour is able to walk without a significant limp and states she feels better. The patient’s family notes they have spent the last few weeks of summer in a Lyme-endemic region, and so you send off Lyme titers.
Given the resolution of limp, lack of fever, and reassuring lab values, you do not believe the patient has a septic joint. Her effusion is more likely the result of a transient synovitis. You recommend close pediatrician follow-up.
At her pediatrician clinic visit 1 week later, her Lyme titers return negative, and the patient continues to be limp-free.
The PEM POCUS series was created by the UCSF Division of Pediatric Emergency Medicine to help advance pediatric care by the thoughtful use of bedside ultrasonography.
Read other PEM POCUS tutorials. Learn more about bedside ultrasonography on the ALiEM Ultrasound for the Win series.
Millions of Muslims around the world observe the holy month of Ramadan. Some may have mild or chronic medical conditions that can become exacerbated, requiring emergent medical attention. Emergency Physicians ought to have a working knowledge about the religious rules of Ramadan and their medical implications. In this article, we will provide an overview of the significance of Ramadan to Muslims, its practices, and discuss the important considerations for emergency physicians when providing care to Muslim patients in the Emergency Department (ED). Lastly, we will explore ways to mitigate the ethical dilemma when a fasting patient refuses a life-saving treatment or intervention.
Ramadan is the holiest month of the year for 1.9 billion Muslims around the world [1]. Muslims believe that the month of Ramadan is the month during which the prophet Muhammad received the initial revelations of the Quran, the holy book for Muslims [2].
Ramadan is a time of spiritual reflection, self-improvement, heightened devotion, and worship. Muslims are expected to put more effort into following the teachings of Islam. Fasting is one of the five fundamental principles of Islam; known as the Five Pillars of Islam. The pillars include shahada (a declaration of faith: “There is no deity but God, and Muhammad is the messenger of God”); prayer (Muslims pray five times a day); zakat (charitable giving); fasting and pilgrimage (Muslims are supposed to make a trip, or “hajj,” to the city of Mecca, Saudi Arabia, at least once in a lifetime if they are physically and financially able).
The fast begins at dawn and ends at sunset [3]. The act of fasting is said to redirect the heart away from worldly activities. It serves the purpose of cleansing the soul by freeing it from harmful impurities. Muslims believe that Ramadan teaches them to practice self-discipline, self-control, sacrifice, and empathy for those who are less fortunate, thus encouraging actions of generosity and communal charity.
Many mosques (Islamic places of worship) host daily community dinners where Muslims can break their fast together. Since Ramadan is a time for Muslims to be especially charitable and fasting helps Muslims feel compassion for the hungry and less fortunate, many mosques hold food drives or fundraisers for charity during Ramadan. It is also common for mosques to host open houses for their friends and neighbors of other faiths to join them for their fast-breaking feast or iftar at the end of the fasting day.
A 2017 study estimated that 3.45 million Muslims were living in the United States, about 1.1 percent of the total U.S. population [4]. Emergency physicians should be aware of the health considerations for their Muslim patients during the month of Ramadan.
Ramadan is the ninth month of the 12-month Islamic calendar, a lunar calendar that’s based on the phases of the moon. The lunar calendar falls short of the solar calendar by 11 days. As a result, Ramadan doesn’t start on the same date each year and instead, over time, passes through all the seasons. In 2021, Ramadan began on April 13th and ended on May 13th. Depending on its timing of the year and the location in the world, some patients may be fasting for up to 20 hours. This extended period without food, water, and medications may pose a serious health risk to patients with certain medical conditions.
Exemptions to fasting include anyone who is traveling, women who are pregnant, breastfeeding, or menstruating, or those with acute or chronic illnesses [5].
However, many Muslims with medical conditions insist on fasting to satisfy their spiritual needs. Although Islam does not recommend it, as medical professionals, we must respect our patients’ choices. Those excused can make up the fast later or feed one poor person for each day missed. “And anyone who is ill or on a journey should make up for the lost days by fasting on other days later. God wants ease for you, not hardship.” (Quran 2:185)
As previously stated, Muslims with acute or chronic conditions such as diabetes are exempt from fasting. However, they may still choose to fast. They may discontinue their medications or alter treatment regimens with or without involving their primary care physician. As a result, serious complications may develop. Patients can present to the ED with dehydration, syncope, hypo- or hyperglycemia, diabetic ketoacidosis, or congestive heart failure. ED clinicians need to approach the care of these patients with empathy and support, along with shared decision-making regarding their treatment plans and expectations.
Another important aspect of caring for these patients is the knowledge that many ED interventions can invalidate fasting. Intravenous fluid is one such example. Before you empirically order that liter of saline solution for the fasting patient who presents to the ED with dehydration, recognize that it will invalidate their fast and consider other options or have a discussion with the patient and/or their family members. The table below lists some medications and procedures that can be applied without breaking the fast [4,6].
There are unique challenges in managing patients who are critically ill and refuse to break their fast. Spirituality, religiosity, and personal beliefs are essential components of the social determinants affecting patients’ health behavior and acceptance of treatment. Depending on their cultural and religious upbringing, some patients believe their hardship, patience, and perseverance through challenges will grant them God’s mercy and forgiveness. This religious context will help guide the emergency physician when caring for the critically ill fasting patient. Fasting that endangers health or increases morbidity is not in accordance with Islamic jurisprudence. For example, if a patient presents to the ED with an acute illness that requires a blood transfusion, then they are exempt from fasting. A gentle reminder to your patients that even if they break their fast, they can make it up on another day.
The holy month of Ramadan ends with Eid al-Fitr which is a holiday celebrated by Muslims around the world to mark the end of the sunset-to-dawn fasting of Ramadan. The festivities start with a morning prayer followed by family gatherings and sharing of food and gifts with neighbors and the local communities. It is important for physicians and ED clinicians to know that some Muslims may elect to observe six days of fasting after the day of Eid al-Fitr. In Islamic traditions, these six days of fasting along with the Ramadan fast are equivalent to fasting all year. In Islam, every good deed is rewarded 10 times, hence fasting 30 days of Ramadan and 6 days during the following month (Shawwal) is equivalent to a whole year fast. Many Muslims religiously follow this practice throughout their lifetimes. Some Muslims will follow the tradition (or Sunna) of the prophet Muhammad by fasting on Mondays and Thursdays every week. Therefore, physicians could care for a fasting patient throughout the year, beyond Ramadan, and should have an understanding of the religious and cultural context of the Muslim traditions when caring for these patients in the ED.
Figure 1. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9601
Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric intussusception. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
Johnny is a 2-year-old boy who comes into the emergency department for abdominal pain for the last day. His parents are concerned that he has been having intermittent abdominal pain and has seemed very tired all day. Parents deny bloody stool.
On arrival, his vital signs are:
| Vital Sign | Finding |
|---|---|
| Temperature | 36.9C |
| Heart rate | 110 bpm |
| Blood pressure | 97/50 |
| Respiratory rate | 22 |
| Oxygen saturation (room air) | 99% |
He is tired appearing, and his abdominal exam is soft but diffusely tender. Given his intermittent abdominal pain, you decide to perform an intussusception point of care ultrasound (POCUS) exam.
Intussusception is when one part of the bowel telescopes, or gets stuck, in another part of the bowel. Typically intussusception refers to ileocolic intussusception where the ileum becomes stuck in the colon. To perform the ultrasound, start in the right lower quadrant and trace the colon. See below for a step-by-step technique.
Abnormal findings
Pro Tip
It can be difficult to distinguish intussusception of the small bowel-small bowel (i.e., when the ileum or part of the small bowel telescopes into itself) versus ileocolic (i.e., when the ileum becomes telescopes into the colon). The former often does not require a procedure for reduction, while the latter typically does. If the target sign diameter is <2 cm and transient, a small bowel-small bowel intussusception should be suspected. The length of the intussusception, or how many quadrants are involved, can also be measured for an idea of how much bowel is involved.
There are additional pathologies that can be mistaken for intussusception such as an intussuscepted appendix, appendicitis surrounded by abscess, and Meckel’s diverticulum, which are beyond the scope of this course. Any concerning finding for intussusception should be followed by a confirmatory study by the radiology department.
There have been several studies examining point-of-care ultrasonography (POCUS) for intussusception, which have shown excellent test characteristics and a decreased length of stay when using POCUS. POCUS also has no radiation exposure and may further help reduce morbidity by reducing delays in diagnosis of intussusception [1].
POCUS performed by PEM physicians has demonstrated a high level of accuracy in diagnostic agreement with radiologist-performed ultrasounds. For example, in a study by Arroyo et al., POCUS agreement with radiologist-performed ultrasounds occurred in 97 of 100 cases [1]. There is also research comparing positive ultrasound diagnosis (including POCUS and radiologist-performed ultrasound) of intussusception to confirmatory surgical or contrast enema, as exhibited by the table below.
Below is a table of test characteristics of POCUS for intussusception.
| Publication | Methodology | Sensitivity | Specificity |
|---|---|---|---|
| Riera et al. (2012) [2] | Prospective study of 82 patients who underwent POCUS by pediatric emergency medicine (PEM) providers. The gold standard was a comprehensive radiology ultrasound. | 85% | 97% |
| Trigylidas et al. (2019) [3] | Retrospective study of 102 POCUS exams in 101 patients by PEM providers. The gold standard was pediatric radiologist confirmation by review of the POCUS images, a radiology department ultrasound, or an air enema. | 96.0% | 92.6% |
| Lee et al. (2020) [4] | This retrospective study included 575 scans from 549 patients aged 1 month to 6 years with clinically suspected ileocolic intussusception, who underwent POCUS performed by PEM physicians of a tertiary hospital. The gold standard for comparison was radiologist-performed ultrasound. | 100% | 95.6% |
| Bergmann et al. (2021) [5] | This prospective study of 256 children across 17 sites (35 PEM physicians with experience/extra training in POCUS) compared POCUS and radiologist-performed ultrasound using a gold standard of clinically important intussusception which was defined as an intussusception that required radiographic or surgical reduction during or within 7 days of the incident ED visit. | 96.6% | 98% |
| Tonson la Tour et al. (2021) [6] | This prospective study included 131 children evaluated by POCUS, of whom 45 (34%) had an intussusception. Twenty-four PEM physicians with various levels of training performed POCUS and were able to identify 39 of 45 intussusception cases. PEM-performed POCUS was then compared to the gold standard, radiologist-performed ultrasound. Interestingly, diagnostic accuracy did not differ significantly between novice and experienced sonographers. | 87% | 97% |
| Lin-Martore et al. (2022) [7] | This systematic review and meta-analysis of diagnostic accuracy of POCUS for intussusception included 2400 patients and 11 studies. The POCUS evaluation of the lesion was performed by an adult or pediatric emergency physician. Each study consisted of a gold standard test including radiologist-performed ultrasonography, other radiology diagnostic imaging, air enema, or patient follow-up. | 95.1% | 98.1% |
| Rahmani et al. (2023) [8] | This meta-analysis included 37 studies to calculate the pooled sensitivity and specificity of ultrasound diagnosis of intussusception. The studies included used POCUS results from EM physicians and residents, sonography technicians, and one used a PEM physician certified in pediatric gastroenterology. It also included radiology-performed ultrasound. Each study consisted of comparison to a gold standard including radiologist-performed ultrasound, clinical follow-up, surgical report, and air or barium enema. | 96% | 97% |
| Alsabri et al. (2026) [9] | This meta-analysis includes a total of 44 studies (prospective and retrospective cohort studies, cross-sectional studies, and case-control studies) for pooled sensitivity and specificity of ultrasound for diagnosing intussusception. It includes POCUS from PEM physicians and radiology ultrasounds. The gold standard of confirmation included surgical findings, clinical follow-up, and contrast enema (barium and air). | 96.3% | 95.7% |
In terms of Emergency Department (ED) length of stay (LOS), Kim et al. (2020) reported that after the introduction of an intussusception POCUS scanning protocol for PEM physicians to implement in the ED, the LOS decreased by more than 200 minutes [10]. An additional study has shown that a POCUS-first pathway can be a way to expedite care for children with suspected intussusception in the ED, leading to reduced physician initial assessment to reduction time by an average of 69.9 min when compared to traditionally waiting for radiologist-performed ultrasound evaluation [11].
In general, true ileocolic intussusceptions are:
There have been studies looking at distinguishing small bowel-small bowel intussusception (SB-SBI) from ileocolic intussusception (ICI). Most of these, however, have been radiology-based rather than POCUS studies, making generalizability to the ED setting challenging. Thus, if there is a concern for an intussusception, a radiology ultrasound should be ordered.
In a small study of 27 patients, Wiersma et al. (2006) [12] found that SB-SBI had smaller mean diameters and shorter lengths than ICI. Consistent with these findings, a more recent study reported similar findings, with all ICI cases in the study having lesion diameters greater than 2 cm [13]. This study also suggested a difference in age distribution between the two intussusception lesions studied: patients with SB-SBI tended to be older and exhibited a wider age range, whereas the ICI group consisted predominantly of infants younger than 1 year [13].
| Study author and year | N (patients) | Age (mean or median) | Mean diameter | Mean length | Notes |
|---|---|---|---|---|---|
| Wiersma et al. (2006) [12] | SB-SBI: 10 ICI: 14 |
SB-SBI: 3.1 yr (mean) ICI: 1.9 yr (mean) |
SB-SBI: 1.5 cm ICI: 3.7 cm |
SB-SBI: 2.5 cm ICI: 8.2 cm |
SB-SBI: Lesions were located throughout the abdomen (6 paraumbilical, 2 RUQ, 2 RLQ, 1 LLQ). All ICI lesions were located on the right side of the abdomen. |
| Park et al. (2019) [13] | SB-SBI: 21 ICI: 16 |
SB-SBI: 54 mo (median) ICI: 8 mo (median) |
SB-SBI: 1.68 cm ICI: 2.74 cm |
Not reported | SB-SBI was identified more frequently than ICI in this cohort when using POCUS screening tool, which may be due to rapid detection by POCUS and/or lower threshold for evaluating for intussusception. |
| Goel et al. (2020) [14] | SB-SBI: 21 ICI: 33 |
SB-SBI: 17.3 mo ICI: 22.2 mo |
SB-SBI: 2.13 cm ICI: 3.24 cm |
SB-SBI: 3.17 cm for obstructive cases and 1.93 cm for transient cases ICI: Not reported |
The team noted an optimal threshold of 2.5 cm to distinguish between transient and obstructive SB-SBIs. Lymph nodes were present in 18 (33.3%) out of 54 surgically confirmed cases, and all were ICI. |
Lioubashevsky et al. (2013) [15] evaluated a larger cohort of 174 patients and reported similar findings. In addition to assessing the inner fat core-to-outer wall thickness ratio, the authors examined the presence or absence of lymph nodes within the intussusception. These findings were supported by Zhang et al. (2021) [16], who identified lymph nodes in only one case of SB-SBI, compared with 56 cases (93%) of ICI. Zhang et al. also found that the fat core was visible on ultrasound in all cases of ICI but was absent in 16% of SB-SBI cases [16]. Similarly, Goel et al. reported an inner fat core-to-outer wall thickness ratio > 1 in all cases of ICI and < 1 in all cases of SB-SBI, further supporting the diagnostic utility of this sonographic feature [14].
These differences may be explained by the underlying anatomical and physiological characteristics of the involved bowel segments [14,15]. The mesentery associated with the ileocolic region contains greater amounts of adipose tissue and lymph nodes than the mesentery involved in SB-SBI [14-16]. This could explain why ileocolic intussusceptions tend to demonstrate greater lymph node and fat involvement, appearing as hyperechoic structures on ultrasound [15-17]. The increased proportion of mesenteric fat and lymphatic tissue may also contribute to the larger diameter of ICI lesions [14,16,17]. In contrast, the shorter length of SB-SBI lesions reported in previous studies may be attributable to active bowel peristalsis and the greater likelihood of spontaneous resolution in these cases [16,17].
Subramaniam et al. (2022) [18] looked at POCUS differentiating SB-SBI from ICI. Similar to above, they noted the predominant location of SB-SBI in the periumbilical or left abdomen compared with the right-sided predominance of ICI; the larger diameter of ICI, typically greater than 2.5 cm; the greater length of ICI, typically exceeding 3 cm; the presence of lymph nodes within ICI; the presence of peristalsis within SB-SBI; and the larger core-to-wall index associated with ICI [18].
While beyond the scope of this module, there is some evidence that POCUS may facilitate the treatment of intussusception in addition to its diagnostic utility. Zymerman et al. (2026) [19] reported a case series of 9 reductions with an 88.9% success rate for POCUS-guided hydrostatic reduction of ICI performed at the bedside by a pediatric emergency medicine physician. Similarly, Atia et al. (2026) [20] reported a retrospective chart review with 24 of 28 ICI (86%) successfully reduced when ICI was diagnosed using POCUS and bedside ultrasound-guided hydrostatic reduction was performed by a pediatric radiologist. This study also reported a mean time from admission to reduction of 126 minutes and a mean hospital length of stay of 407 minutes [20]. Together, these findings suggest that POCUS may serve not only as a reliable diagnostic tool for differentiating ICI from SB-SBI but also as a means of facilitating timely and effective bedside therapeutic intervention.
You place a linear, high-frequency probe on the right side of the patient’s abdomen. You perform a bedside ultrasound scan, viewing transversely and longitudinally through the upper and lower abdomen. You observe the following:
This is an intussusception!
The intussusceptum (red) is the part of the bowel that has telescoped into the intussuscipiens (blue). When ileum becomes trapped in the colon, this can lead to ischemia and necrosis over time. This is what causes the classic “currant jelly stools”, which are bloody stools.
Tip: The classic triad of colicky abdominal pain, palpable mass and bloody stool are present in less than 50% of patients, and intussusception should be suspected for patients with vomiting, abdominal pain, and/or lethargy.1
Johnny underwent an air enema reduction in the Radiology department, which successfully reduced the ileocolic intussusception.
The PEM POCUS series was created by the UCSF Division of Pediatric Emergency Medicine to help advance pediatric care by the thoughtful use of bedside ultrasonography.
Learn more about bedside ultrasonography on the ALiEM Ultrasound for the Win series