Intussusception. Part 2: An update on the evolution of management

High risk and low incidence diseases: Pediatric intussusception

INTRODUCTION

Pediatric intussusception is a serious condition that carries with it a high risk of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric intussusception, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Intussusception is one of the most common pediatric abdominal emergencies. This is associated with one part of the intestine telescoping into another, resulting in bowel edema. If the intussusception remains untreated, obstruction, ischemia, necrosis, and perforation may result. Most cases are idiopathic, with 10-25 % associated with a pathologic mass or lead point. The most common age group affected includes those between 3 months to 5 years. The triad of intermittent abdominal pain, currant jelly stool, and sausage-shaped mass is uncommon, though most patients will present with intermittent abdominal pain. Nonbilious emesis and bloody stools (gross blood or guaiac positive) are also common. Younger patients can present atypically, including altered mental status or lethargy. Thus, intussusception should be considered in pediatric patients with abdominal pain, emesis, and a sausage-shaped mass, as well as those with atypical presentations such as altered mental status or lethargy if there is no other etiology found on testing. The diagnostic modality of choice is ultrasound. Plain radiography may assist in evaluating for obstruction and perforation. Treatment includes prompt reduction of the intussusception. In patients who are stable and have no evidence of perforation, non-operative reduction with hydrostatic or pneumatic reduction should be attempted. Operative intervention is necessary in those who are unstable, peritonitic, or have a focal lead point. Discharge may be appropriate for patients following successful non-operative reduction if the patient is able to tolerate clear fluids, is asymptomatic, and can return for any recurrence of symptoms.

CONCLUSION

An understanding of pediatric intussusception and its many potential mimics can assist emergency clinicians in diagnosing and managing this high risk disease.

Risk factors of bowel perforation during hydrostatic enema reduction for paediatric intussusception

OBJECTIVE

Bowel perforation is a major, yet unstudied complication of ultrasound-guided hydrostatic enema reduction (UGHR). In this study, we aimed to explore the risk factors and determine the clinical characteristics of bowel perforation during UGHR for paediatric intussusception (P-UGHR).

METHODS

We retrospectively analysed the medical records of patients who underwent UGHR for intussusception at our institution between January 2011 and December 2021. The patients were divided into the P-UGHR and no P-UGHR groups. Univariate and multivariate logistic regression analyses were performed to analyse the risk factors for P-UGHR, and the clinical characteristics of patients with P-UGHR were determined.

RESULTS

The final analysis included 4961 intussusception episodes. We identified 15 patients [eight male (53.3%); median age, 8.73 months; age range, 3-17 months] with P-UGHR. All P-UGHR cases involved colonic perforations without necrosis distal to the intussusception mass. The perforations were located in the ascending [40% (6/15)], transverse [46.7% (7/15)] or descending colon [13.3% (2/15)]. Age ≤10.5 months [odds ratio (OR), 3.636; 90% confidence interval (CI), 1.274-10.38; P = 0.043], bloody stools (OR, 4.189; 90% CI, 1.352-12.978; P = 0.037) and symptom duration >17.5 h (OR, 0.188; 90% CI, 0.053-0.666; P = 0.03) were independent risk factors for P-UGHR.

CONCLUSION

Age ≤10.5 months, bloody stools and symptom duration >17.5 h were independent risk factors for P-UGHR. Caution should be exercised during UGHR in patients aged ≤10.5 months, with bloody stools or symptom duration >17.5 h.

Ileocolic Intussusception: Iterative Quality Improvement to Address a Recurring Problem

INTRODUCTION

Recent quality improvement (QI) initiatives indicate that pediatric patients with uncomplicated ileocolic intussusception can be safely discharged from the emergency department (ED) after fluoroscopic reduction. These programs improve patient experience and reduce cost. We sought to build on these efforts by developing a QI initiative at our own institution that included patients transferred from a satellite campus and focused on iterative improvement of our treatment pathway based on continual reassessment of our processes and data.

MATERIALS AND METHODS

We formed a multidisciplinary team, established a collaborative open-access clinical pathway, and implemented educational plans for each participating division. Data were tracked prospectively, and process adjustments were made as clinically indicated. In this report, we compare patients treated before and after the QI initiative.

RESULTS

There were 155 patients treated before the QI initiative (January 1, 2018-June 30, 2022) and 87 after the initiative began (July 1, 2022-October 31, 2023). There were significant improvements in the rate of ED discharge (4/155 (2.6%) versus 51/87 (59%), P < 0.001) and mean time to discharge (40.7 versus 23.1 h, P = 0.002), while the average cost of a visit fell by 30% (P = 0.012). The mean time to discharge from the ED increased (6.9 versus 11.0 h, P < 0.001), and the rate of readmission was unchanged. For patients transferred from the satellite campus, time to fluoroscopic reduction significantly improved during the initiative (9.4 versus 6.5 h, P = 0.048).

CONCLUSIONS

We implemented a QI program for patients with fluoroscopically reduced ileocolic intussusception that was serially adjusted based on continual reassessment of data. The protocol was associated with a decreased admission rate, total cost, and time to hospital discharge.

Ultrasound imaging of bowel obstruction in infants and children

We review the etiologies of bowel obstruction in infants and children that can be identified on ultrasound (US) including perforated appendicitis, intussusception, foreign body ingestion, colonic volvulus, intra-abdominal mass lesions, internal hernia, and stricturing inflammatory bowel disease. US can potentially identify the cause of bowel obstruction in these age groups, without the need for additional cross-sectional imaging, and can aid in patient management including interventional and surgical planning. Hence, it is important to be familiar with the sonographic imaging findings of bowel obstruction in infants and children.

A POCUS-first pathway to streamline care for children with suspected ileocolic intussusception

OBJECTIVES

As point-of-care ultrasound (POCUS) has emerged as a valuable tool for intussusception screening, this quality improvement study aimed to implement a "POCUS-first" pathway in a Pediatric Emergency Department (ED) to streamline workflow and expedite care for children with suspected intussusception.

METHODS

This was a prospective analysis of children diagnosed with ileocolic intussusception in a Pediatric ED between June 2022 and June 2023. The study compared the "POCUS-first" cohort with the group receiving only radiology-performed ultrasound. Key outcomes included physician initial assessment to radiology-performed US time and physician initial assessment to reduction time. Continuous improvement efforts incorporated pediatric emergency medicine physician training, education, and pathway dissemination through plan-do-study-act cycles.

RESULTS

The study included 29 patients in the "POCUS-first" pathway group and 70 patients in the non-POCUS group. The "POCUS-first" pathway demonstrated a significantly shorter physician initial assessment to reduction time compared to the non-POCUS group (170.7 min vs. 240.6 min, p = 0.02). Among non-transferred patients, the "POCUS-first" group also had a significantly shorter emergency department length of stay (386 min vs. 544 min, p = 0.047).

CONCLUSIONS

Implementation of a "POCUS-first" pathway for managing ileocolic intussusception led to notable improvements in process efficiency. The shorter physician initial assessment to reduction time highlights the potential for expedited decision-making and intervention. These study findings support the potential of this pathway to optimize the management and outcomes of children with ileocolic intussusception.

Ultrasound-guided pneumatic reduction of intussusception in children: 15-year experience in a tertiary children's hospital

BACKGROUND

International practice regarding the method used to nonoperatively reduce pediatric intussusception is variable.

OBJECTIVE

To provide an overview of ultrasound-guided pneumatic intussusception reduction and assess its safety and effectiveness.

MATERIALS AND METHODS

A single-center prospective study was conducted in a tertiary referral pediatric hospital during the 15-year period between January 2008 and February 2023. All patients with ileocolic intussusception underwent abdominal sonographic examination for diagnosis. An ultrasound-guided pneumatic reduction of intussusception was then attempted. Children who were hemodynamically unstable, with signs of peritonitis or bowel perforation and those with sonographically detected pathologic lead points were excluded.

RESULTS

A total of 131 children (age range 2 months to 6 years) were enrolled in this study. Pneumatic intussusception reduction was successful in 128 patients (overall success rate 97.7%). In 117 patients, the intussusception was reduced on the first attempt and in the remaining on the second. In three cases, after three consecutive attempts, the intussusception was only partially reduced. As subsequently surgically proven, two of them were idiopathic and the third was secondary to an ileal polyp. No bowel perforation occurred during the reduction attempts. There was recurrence of intussusception in three patients within 24 h after initial reduction which were again reduced by the same method.

CONCLUSION

Ultrasound-guided pneumatic intussusception reduction is a well-tolerated, simple, safe and effective technique with a high success rate, no complications and no ionizing radiation exposure. It may be adopted as the first-line nonsurgical treatment of pediatric intussusception.

Cohort analysis of pediatric intussusception score to diagnose intussusception

BACKGROUND

Intussusception is a primary cause of intestinal obstruction in young children. Delayed diagnosis is associated with increased morbidity. Ultrasonography (USG) is the gold standard for diagnosis, but it is operator dependent and often unavailable in limited resource areas.

AIM

To study the clinical characteristics of intussusception including management and evaluation of the diagnostic accuracy of abdominal radiography (AR) and the promising parameters found in the pediatric intussusception score (PIS).

METHODS

Children with suspected intussusception in our center from 2006 to 2018 were recruited. Clinical manifestations, investigations, and treatment outcomes were recorded. AR images were interpreted by a pediatric radiologist. Diagnosis of intussusception was composed of compatible USG and response with reduction. The diagnostic value of the proposed PIS was evaluated.

RESULTS

Ninety-seven children were diagnosed with intussusception (2.06 ± 2.67 years, 62.9% male), of whom 74% were < 2 years old and 37.1% were referrals. The common manifestations of intussusception were irritability or abdominal pain (86.7%) and vomiting (59.2%). Children aged 6 mo to 2 years, pallor, palpable abdominal mass, and positive AR were the parameters that could discriminate intussusception from other mimics (P < 0.05). Referral case was the only significant parameter for failure to reduce intussusception (P < 0.05). AR to diagnose intussusception had a sensitivity of 59.2%. The proposed PIS, a combination of clinical irritability or abdominal pain, children aged 6 mo to 2 years, and compatible AR, had a sensitivity of 85.7%.

CONCLUSION

AR alone provides poor screening for intussusception. The proposed PIS in combination with common manifestations and AR data was shown to increase the diagnostic sensitivity, leading to timely clinical management.

Outcomes in pediatric patients with documented delays between ileocolic intussusception diagnosis and therapeutic enema attempt: evaluation of reduction efficacy and complication rate

BACKGROUND

Ileocolic intussusception is considered a pediatric emergency, with concerns for risk of significant morbidity in children with a prolonged intussusception state. Emergent therapy is standard of care, as prior studies have shown poor outcomes in patients with long delays (> 24 h) before intervention. Various factors can result in shorter delays, and there are limited studies evaluating outcomes in these patients. This study aimed to determine if there were differences in reduction success rates associated with short in-hospital time delays.

OBJECTIVE

This study is to determine enema success rate and morbidity in patients with documented time delays between intussusception diagnosis and therapeutic enema.

MATERIALS AND METHODS

A retrospective evaluation of pediatric patients with intussusception at a single children's hospital between 2007 and 2019 was performed. Patient's records were reviewed for time of symptom onset, radiologic diagnosis, and attempted enema. Ultrasounds and radiographs were reviewed for bowel obstruction, free peritoneal fluid, trapped fluid around the intussusceptum, and absent bowel wall perfusion. Patients were evaluated for efficacy of reduction attempt, requirement for surgical reduction, and complications including bowel resection and bowel perforation.

RESULTS

There were 175 cases of ileocolic intussusception requiring enema reduction. Successful reduction occurred in 72.2% (13/18) of cases performed within 1 h of diagnosis; 74.3% (78/105) between 1 and3 h; 73.2% (30/41) between 3 and 6 h; and 81.2% (9/11) with greater than 6 h. Need for bowel resection was not associated with short delays between diagnosis and reduction attempts (p = .07).

CONCLUSIONS

There was no difference in intussusception reduction efficacy or complication rate in patients with increasing time between imaging diagnosis of ileocolic intussusception and reduction attempt, including delay intervals up to 8 h.

Significance of Follow-Up Ultrasonography 24 Hours Post-Reduction in Detecting Intussusception Recurrence

PURPOSE

The objective of this study was to identify the significance of 24-hour post-reduction ultrasonography (US) in pediatric patients with intussusception.

METHODS

A total of 229 patients with intussusception who were treated with saline reduction at Severance Children's Hospital between January 2014 and September 2020 were retrospectively reviewed. The 229 patients with successful saline reduction were divided into two groups: a recurrence at 24 hours group (R, n=41) and a non-recurrence group (NR, n=188). The full patient sample was divided into two groups: follow-up US (FU) or no follow-up US (NFU); the recurrence group was divided into follow-up (R-FU) and non-follow-up (R-NFU) subgroups, and stratified analyses were performed.

RESULTS

There were no significant differences in age, sex, laboratory findings, symptoms, and sonographic findings between the NR and R groups. In the R group, 24 patients underwent follow-up US, and 17 patients did not. Specific sonographic findings were statistically significant in the R-FU group compared to the R-NFU group (p=0.002). The R-FU group had fewer admissions (p=0.012) and longer mean hospitalization times (p<0.001) than the R-NFU group. The NFU group had a 12.2% recurrence rate, while the R-FU group recurrence rate was 25.8% (p=0.0099), suggesting that the omission of some recurrent events and follow-up US was a significant variable in the recurrence of intussusception. The median time to recurrence was 21 hours which supports the 24-hour follow-up protocol.

CONCLUSION

Twenty-four-hour follow-up US was shown to be valuable for detecting early recurrence of intussusception.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests

STUDY OBJECTIVE

To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction.

METHODS

We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings.

RESULTS

The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23).

CONCLUSION

Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

A Retrospective Cohort Study of Optimal Contrast for Successful Intussusception Reduction: Institutional Practices Matter

BACKGROUND

The first-line treatment for intussusception is radiologic reduction with either air-contrast enema (AE) or liquid-contrast enema (LE). The purpose of this study was to explore relationships between self-reported institutional AE or LE intussusception reduction preferences and rates of operative intervention and bowel resection.

METHODS

Pediatric Health Information System (PHIS) hospitals were contacted to assess institutional enema practices for intussusception. A retrospective study using 2009-2018 PHIS data was conducted for patients aged 0-5 y to evaluate outcomes. Chi-squared tests were used to test for differences in the distribution of surgical patients by hospital management approach.

RESULTS

Of the 45 hospitals, 20 (44%) exclusively used AE, 4 (9%) exclusively used LE, and 21 (46%) used a mixed practice. Of 24,688 patients identified from PHIS, 13,231 (54%) were at exclusive AE/LE hospitals and 11,457 (46%) were at mixed practice hospitals. Patients at AE/LE hospitals underwent operative procedures at lower rates than at mixed practice hospitals (14.8% versus 16.5%, P< 0.001) and were more likely to undergo bowel resection (31.1% versus 27.1%, P= 0.02).

CONCLUSIONS

Practice variation exists in hospital-level approaches to radiologic reduction of intussusception and mixed practices may impact outcomes.

Ultrasound-guided hydrostatic enema reduction of intussusception and confirmation with single abdominal radiograph in children

PURPOSE

To detect false-positive reduction results after ultrasound (US)-guided hydrostatic intussusception reduction, we have incorporated water-soluble contrast material to the enema fluid and confirmed the reduction with a single abdominal radiograph. We present the results of the combined imaging method for the reduction of intussusception in children.

MATERIALS AND METHODS

The records of the patients who were treated for intussusception were analyzed retrospectively. Patients were divided into two groups: a US-guided reduction group and a US-guided reduction plus radiographic control group. The patient characteristics, symptoms, treatment methods, outcomes, and complications and follow-up were analyzed.

RESULTS

A total of 164 intussusception episodes were treated in 153 patients. Hydrostatic reduction of intussusception was performed in 59 patients in the US-guided group and in 94 patients in the US-guided plus radiographic control group. Recurrence rate in the US-guided group was 15.7%, vs 3.5% in the US-guided plus radiography group (P = .029). In the US-guided plus radiographic control group, 5 (5.3%) false positive reductions under US guidance were determined by abdominal radiography.

CONCLUSION

In order to decrease false positive reduction rate and early recurrence, US-guided intussusception reduction can be performed with saline plus water-soluble contrast material and confirmation of reduction obtained with a single direct abdominal radiograph.

Effect of general anesthesia on delayed repeat enema in pediatric intussusception

BACKGROUND

The study aimed to assess the efficacy and safety of delayed repeated enema (DRE) and to evaluate the effect of general anesthesia (GA) on DRE.

METHODS

A retrospective analysis was conducted of all children below 3 years with primary intussusception who were offered DRE in our tertiary center, from 2014 until 2019. Following a standardized pneumatic enema protocol, those who showed a partially successful result were offered DRE 2 h later, either awake (Group A) or under GA (Group B). DRE under GA was our preferred procedure unless there were no pediatric anesthetists available at that time. Data collected for each group included age, sex, duration of symptoms, success rate of the DRE, and any complications noted.

RESULTS

The study included 57 children (32 males and 25 females). The median age in Group A (31 patients) was 10 months while in Group B (26 patients) it was 11 months. The number of patients with duration of symptoms < 24 h vs > 24 h was 12:19 and 9:17 in Group A and B patients respectively. DRE was successful in 14/31 (45.2%) of Group A patients with one complication and in 9/26 (34.6%) of Group B patients with no complications. There was no statistically significant difference between both groups' success rate and complication rate. Both groups were similar in age, sex, and duration of symptoms.

CONCLUSIONS

DRE can effectively increase the overall success rate of pneumatic enema in selected patients with pediatric intussusception. However, the current evidence does not justify the routine use of GA during attempts DRE attempts.

Point-of-care ultrasound diagnosis of pediatric intussusception: a case series

Intussusception is an intestinal emergency caused by the telescoping of proximal bowel into an adjacent distal bowel segment. Nearly 50% of cases are missed on initial presentation leading to an increased risk of intestinal obstruction, ischemia, and perforation. The authors present two cases of pediatric intussusception whereby point-of-care ultrasound expedited the diagnosis and treatment in a non-pediatric dedicated emergency department. Given the risks of an undiagnosed intussusception and its nonspecific presentations, a prompt and precise diagnosis remains crucial to its successful management. The ubiquity and accuracy of point-of-care ultrasound make it an ideal adjunct for the diagnosis of intussusception.

Ultrasound-guided hydrostatic reduction versus fluoroscopy-guided air reduction for pediatric intussusception: a multi-center, prospective, cohort study

Background

Intussusception is the most common abdominal emergency in children. The first line treatment of uncomplicated pediatric intussusception is enema reduction. Until now, there have been no multi-center studies comparing the effectiveness and safety of UGHR and FGAR in the treatment of pediatric intussusception. The aim of this study was to compare the effectiveness and safety of the two most commonly used enema methods of pediatric intussusception: ultrasound-guided hydrostatic reduction (UGHR) and fluoroscopy-guided air reduction (FGAR).

Methods

From November 1, 2017 to October 31, 2018, we conducted a multi-center, prospective, cohort study. Children diagnosed with intussusception in four large Children’s Medical Centers in China were divided into UGHR and FGAR groups. Stratified analysis and subgroup analysis were used for further comparison. The success and recurrence rates were used to evaluate the effectiveness of enema reduction. The perforation rate was used to evaluate the safety of enema reduction.

Results

A total of 2124 cases met the inclusion criteria (UGHR group: 1119 cases; FGAR group: 1005 cases). The success and recurrence rates in the UGHR group were higher than in the FGAR group (95.80%, 9.28% vs. 93.13%, 10.65%) (P < 0.05, P > 0.05), respectively. The perforation rate in the UGHR group was 0.36% compared with 0.30% in the FGAR group (P > 0.05). Subgroup analysis showed the success rates in the UGHR group were higher than in the FGAR group of patients with onset time between 12 and 24 h (95.56% vs. 90.57%) (P < 0.05). Of patients aged 4 to 24 months, the success rates in the UGHR group were also higher than in the FGAR group (95.77% vs. 91.60%) (P < 0.05). Stratified analysis showed the success rates in the UGHR group were higher than in the FGAR group in patients with the symptom of bloody stool (91.91% vs 85.38%) (P < 0.05).

Conclusions

UGHR and FGAR are safe, nonsurgical treatment methods for acute pediatric intussusception. UGHR is superior to FGAR, no radiation risk, its success rate is higher, without a difference in perforation rate, especially for patients aged 4–24 months.

Level of evidence

Level II.

Periprocedural analgesia and sedation in air enema reduction for intussusception: A retrospective Australian cohort study

AIM

Periprocedural analgesia or sedation for air enema reduction (AER) of intussusception is a matter of debate. We set out to review Australian periprocedural pain management in AER.

METHODS

Retrospective electronic medical record review of emergency department presentations of intussusception at an Australian children's hospital over 2 years for periprocedural analgesia and sedation and short-term outcomes.

RESULTS

A total of 73 patients (mean age 23 months) had ultrasound-confirmed intussusception. Prior to AER, analgesia was administered to 61 of 73 (83.5%) patients. Opioids were administered in 48 of 73 (65.8%) and 8 of 73 (11.0%) received sedation. Thirteen of 73 (17.8%, 95% confidence interval 9.0-26.6) had spontaneously reduced; 60/73 that underwent primary AER had successful reduction in 54 (90.0%, 95% confidence interval 82.4-97.6). A total of seven patients required surgery. No AER attempts were complicated by bowel perforation.

CONCLUSION

The use of periprocedural analgesia for AER in this Australian series was common, whilst sedation use was infrequent. No perforations occurred.

Tension Pneumoperitoneum Following Attempted Pneumatic Reduction of Intussusception

Tension pneumoperitoneum is a life-threatening complication of pneumatic reduction for intussusception if not immediately recognized and treated. We describe a 3-month-old woman who presented with intussusception, underwent attempted pneumatic reduction, and subsequently developed tension pneumoperitoneum with associated hemodynamic instability requiring emergent laparotomy. This is a known, rare complication of pneumatic reduction which highlights the need to have a high index of suspicion for early surgical management to obtain a positive outcome.

Sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception: 20 year experience

BACKGROUND

Ileocolic intussusception is a common abdominal emergency in children, diagnosed routinely with ultrasound and treated most frequently with fluoroscopic pneumatic reduction without sedation. Alternatively, ultrasound can also be used to obviate ionizing radiation and sedation can be used to avoid discomfort from the procedure. The purpose of this study was to present our experience with sedation using saline enema under ultrasound guided control to reduce ileocolic intussusception.

MATERIALS AND METHODS

This is a retrospective study of patients with ileocolic intussusception presenting to a tertiary care hospital between 1998 and 2018. We excluded the data of patients that underwent either fluoroscopic guided reduction with barium enema or primary surgery. All patients received sedation with propofol and subsequently underwent our sedated ultrasound guided saline reduction (SUR) protocol until reduction was confirmed.

RESULTS

414 total reductions were performed in the 338 children who underwent our SUR protocol, of which 86.0% were successful. Zero perforations occurred during attempted reduction. 58 patients required surgery after a failed reduction (14.0%). There were 76 recurrent episodes that underwent our SUR protocol, of which 93.4% had a successful reduction.

CONCLUSION

The success rate of reduction was high and compared similarly to techniques that either use pneumatic reduction under radiation or refrain from administering a sedative prior to enema.

LEVEL OF EVIDENCE

Treatment study level III.

Clinical management and recommendations for children with more than four episodes of recurrent intussusception following successful reduction of each: an institutional review

AIM

To describe patterns and risk factors of multiple recurrences to optimise management for pediatric patients with more than four episodes of intussusception.

MATERIALS AND METHODS

Following IRB approval, all sonographic evaluations for intussusception in patients <18 years over a 6-year period were reviewed. Data extracted included age at onset of first intussusception, gender, presenting symptoms, symptoms upon recurrence, presence of pathological lead points, and surgical findings.

RESULTS

During a 6-year period, five cases had four or more instances of recurrence after enema reduction attempts. All patients were male with an average age of 16 months. Two of the five cases resolved after the fourth enema reduction and no lead points were identified. Two other cases involved surgical reduction with intraoperative findings of Meckel's diverticulum and juvenile polyp. The final case had five recurrence episodes and six separate enema reductions. Ultimately, lymphoid hyperplasia was discovered on colonoscopy and the patient never recurred after being treated with steroids.

CONCLUSION

Given the favorable reduction rate in re-recurrent cases and complete lack of perforation observed, up to four attempts at enema reduction is recommended before considering an alternative strategy. If recurrence continues past the fourth reduction attempt, computed tomography (CT) is recommended to identify a lead point. If CT remains inconclusive, then consider exploratory laparotomy.

Imaging of Acute Abdominal Pain in the Pediatric Population

Acute abdominal pain is a common complaint in pediatrics. Although age and location of pain can help focus differential diagnosis, imaging plays an essential role in clinical evaluation. In this review, we discuss the optimal imaging approach to pediatric patients with acute abdominal pain and important imaging findings in the most common causes of abdominal pain in the pediatric population. [Pediatr Ann. 2020;49(9):e380-e388.].

Intussusception: A 14-year experience at a UK tertiary referral centre

AIMS

Intussusception is the most common cause of acute intestinal obstruction in infants. First line management in uncomplicated cases at our centre is fluoroscopy guided air enema reduction. This study reports a 14 year UK single centre experience highlighting management and outcomes of intussusception in children.

METHODS

All cases of intussusception (ICD 10-code K56.1) at a single tertiary referral centre from 2004 to 2017 were analyzed. Data evaluated included patient demographics, clinical presentation, treatment modality(s), complications and outcome(s).

RESULTS

Two hundred ninety confirmed cases (69% male) of intussusception were identified during the study period. The median age at presentation was 9.5 months (range 4 days-15 years). One hundred eighty-six (64%) cases occurred in children who were transferred to Alder Hey from peripheral district hospitals. One hundred ninety-six cases (68%) proceeded directly to air enema reduction and successful reduction was achieved in 129 cases (66%). A single case (0.5%) of attempted air enema reduction was complicated by perforation. Early recurrence rate following air enema reduction was 9%. Operative management was indicated in 140 (48%) cases of which 66 required bowel resection (47%). There were no deaths.

CONCLUSIONS

We highlight one of the largest single centre UK studies defining practice outcomes for intussusception across the British Isles. Our centre has achieved a 66% success rate of non-operative reduction over 14 years in line with the British Society Pediatric Radiology (BSPR) recommendations and within 5% of the national median metric (71%). Moreover these outcomes were achieved with a very low complication rate (0.5%) from air enema reduction and no mortality in the series.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Diagnosis and treatment of childhood intussusception from 1997 to 2016: A population-based study

OBJECTIVES

Describe changes in the diagnostic approach and treatment for pediatric intussusception over two decades.

STUDY DESIGN

Administrative universal healthcare data were used to conduct a population-based cohort study of intussusception between January 1997 and December 2016 in Ontario, Canada. A validated case definition was used to identify all patients (<18 years) treated for intussusception in the province at community or tertiary care centers. Treatment modality was determined using physician billing data and databases linked at ICES; it was categorized as nonoperative alone, surgical alone, or failed nonoperative. Descriptive statistics, Cochrane-Armitage for trend analyses, and graphical and multinomial logistic regression were performed.

RESULTS

Over 20 years, 1895 pediatric patients were treated for intussusception. Pretreatment imaging use rose from 57.5% to 99.3%. Nonoperative management increased from 23.4% to 75.2%. However, 43% of children who presented to a community hospital underwent immediate surgical management, compared with just 11% of children at tertiary centers (RR 0.39, 95% CI: 0.25-0.62). Among children who underwent surgery, there was an increase in bowel resection over time (41.7% to 57.6%).

CONCLUSIONS

Over the 20 year period of study, pretreatment imaging became universal, and management shifted from predominantly surgical to nonoperative reduction in Ontario. The rate of surgical intervention remains higher in community versus tertiary centers.

LEVEL OF EVIDENCE

Treatment study, III.

An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital

Background

Intussusception in adults is considered rare in surgical practice. It is the causative lesion in a small proportion of cases of intestinal obstruction and lower gastrointestinal bleeding. In the last decade, the incidence of adult intussusception appears to be increasing at our centre.

Aims

This study aims to document the pattern of presentation and management outcome of adult intussusception at our institution during the last decade. We also observed the occurring trends of this lesion.

Patients and Methods

This was a 10-year retrospective study of consecutive adult patients with intussusception seen at our institution from July 2008 to June 2018. Information on biodata, clinicopathological features and management outcome retrieved from case notes and pathology records were analysed on a personal computer using SPSS version 23.

Results

Twenty adult patients who had intussusception were seen during this period. There were 9 (45%) males and 11 (55%) females giving a male-to-female ratio of 1:1.2. The mean age of presentation was 45 (range 18-66) years. Clinical features were abdominal pain (85%), abdominal distension (80%), vomiting (70%), rectal bleeding (70%) and palpable abdominal mass (35%). Majority of patients (70%) presented with features of intestinal obstruction. Idiopathic intussusception (55%) accounted for more than half of the cases with the jejunoileal variety (30%) as the most common pathological type. One patient who had intussusception in the postoperative period was treated with manual reduction at laparotomy. Bowel resections were performed in the remaining 19 (95%) patients.

Conclusion

Adult intussusception is still uncommon in our general surgical practice. Bowel resection is the mainstay of treatment.

Intussusception Protocol Implementation: Single-Site Outcomes With Clinician and Family Satisfaction

BACKGROUND

The objective of this study was to evaluate clinical outcomes, costs, and clinician and parent satisfaction after implementation of a protocol to discharge patients from the emergency department (ED) after successful reduction of uncomplicated ileocolic intussusception.

MATERIALS AND METHODS

In March 2017, an intussusception management protocol was implemented for children presenting with ultrasound findings of ileocolic intussusception. Those meeting inclusion criteria were observed after successful radiological reduction in the ED and discharged after 6 h with resolution of symptoms. Retrospective chart review was completed for cases before and after protocol implementation for clinical outcomes and costs. Clinicians and parents were surveyed to assess overall satisfaction.

RESULTS

Charts were reviewed before (42 encounters, 37 patients) and after (30 encounters, 23 patients) protocol implementation. After implementation, admission rates decreased from 95% (40/42) to 23% (7/30; P < 0.001) and antibiotic use was eliminated (91% to 0%, P < 0.001). There was no difference in recurrence rates (17% versus 23%, P = 0.44). Median total length of stay decreased from 18.87 to 9.52 h (P < 0.001), whereas median ED length of stay increased from 4.37 to 9.87 h (P < 0.001). In addition, there was an overall hospital cost saving of over $2000 ($9595 ± 3424 to $7465 ± 3723; P = 0.009) per encounter. Clinicians and parents were overall satisfied with the protocol and parents showed no changes in patient satisfaction with protocol implementation.

CONCLUSIONS

An intussusception protocol can facilitate early discharge from the ED and improve patient care without increased risk of recurrence. Additional benefits include decreased hospital- and patient-related costs, elimination of antibiotic use, and parent as well as clinician satisfaction.

Outpatient management of intussusception: a systematic review and meta-analysis

BACKGROUND

Variability in management of intussusception after enema reduction exists. Historically, inpatient observation was recommended; however, there is a lack of evidence-based guidelines for this practice.

METHODS

A systematic review and meta-analysis evaluating outcomes between inpatient (IP) and outpatient (OP) management after enema reduction was performed. The following databases were searched: PubMed, EBSCOhost CINAHL, EMBASE, Web of Science, and Cochrane Database. Data from an institutional review were included in the meta-analysis.

RESULTS

Ten studies of patients aged 0-18 years with intussusception who underwent successful enema reduction that reported outcomes of outpatient management were included. Overall recurrence rates were 6% for IP and 8% for OP (p = 0.20). Recurrences within 24 (IP: 1% vs OP: 0%, p = 0.90) and 48 h (IP: 1% vs OP: 2%, p = 0.11) were similar. There was no significant difference in the rate of return to the emergency department (IP: 6% vs OP: 14%, p = 0.11). Both groups had a similar rate of requiring an operation (IP: 2% vs OP: 1%, p = 0.84).

CONCLUSIONS

Outpatient management of intussusception after enema reduction results in a shorter hospital stay with no difference in the rate of return to the emergency department, recurrence, need for operation, or mortality. The findings of the meta-analysis suggest that outpatient management may be safe and could reduce hospital resource utilization.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Perforated gangrenous ileo-colic intussusception in a 9 month old Nigerian infant presenting at a private hospital: A case report

•

The current case presented late with complication of gangrene and perforation because it was first managed as a case of gastroenteritis.

•

Gastroenteritis is among the various differential diagnosis of intussusception a high index of suspicion is required for timely diagnosis.

•

Being available, cheap and free of radiation, using ultrasound more often in infants can aid diagnosis.

Introduction

Intussusception is the process of invagination of a bowel segment into the adjoining intestinal lumen which may cause bowel obstruction and gangrene. It commonly occurs in infants at a mean age of 9-months with male preponderance. The condition has excellent prognosis if diagnosis is made early and appropriate treatment commenced and mortality rate from intussusception in children can be less than 1%. However, if diagnosis or treatments are delayed it can be fatal in a few days.

Presentation of case

We present a case of Ileo-colic perforated ileum due to delayed diagnosis. It was initially misdiagnosed as gastroenteritis at another hospital. The infant was resuscitated with intravenous fluid and had laparotomy. A signed consent was obtained before the surgery and media consent was signed for publication. A gangrenous terminal ileum was resected and ileo-colic anastomosis was done. Post-operative course was uncomplicated and the patient was discharged after 5days.

Discussion

The index case presented late with complication of gangrene and perforation because it was first managed as a case of gastroenteritis. Gastroenteritis is among the various differential diagnosis of intussusception. Complications have been reported to increase numbers of surgical treatment and sometimes mortality, but rarely occur with good diagnostic acumen.

Conclusion

We conclude that high clinical suspicion, interaction with senior surgeons and regular use of ultrasound in infants with gastrointestinal symptoms will aid diagnosis. Although surgery was performed in the index case, non-surgical reduction is a very efficient treatment modality in uncomplicated cases.

Prenatal and postnatal urinary tract dilation: advantages of a standardized ultrasound definition and classification

Urinary tract dilatation is identified sonographically in 1-2% of fetuses and reflects a spectrum of possible nephro-uropathies. There is significant variability in the clinical management of individuals with prenatal urinary tract dilatation to postnatal urinary pathologies, because of a lack of consensus and uniformity in defining and classifying urinary tract dilation. Ultrasonography is the first step to screen and diagnose kidneys and the urinary tract diseases of the children. The need for a correct ultrasound approach led to the realization of algorithms aimed at standardizing the procedures, the parameters and the classifications. Our objective was to highlight the strengths of the Classification of Urinary Tract Dilation (UTD) suggested by the Consensus Conference which took place in 2014 with the participation of eight Scientific Societies and was subsequently published on the Journal of Pediatric Urology. Before its spread out, the definition of UTD was not uniform and the ultrasonographic measurements were not clearly defined, leading to misunderstandings between physicians. The Classification by the Consensus Conference of 2014 represents a revolutionary tool for the diagnosis and management of UTD. Furthermore, the parameters suggested by the classification proposed are applicable for both prenatal and postnatal classification, ensuring a correct follow-up in children with UTD whose diagnosis had been already made during pregnancy.

The incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception in children: A retrospective analysis

BACKGROUND

There is a lack of studies addressing the occurrence of negative intraoperative findings (that is the absence of intussusception) after an unsuccessful hydrostatic reduction of an ileocolic intussusception. The aim of this study is to determine the incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception.

METHODS

We conducted a multicentre retrospective study of all children aged 0-18 years treated for ileocolic intussusception from January 1, 2010 to December 31, 2015 in 9 Dutch hospitals. Primary outcome measure was the percentage of children without an intussusception during surgical exploration after unsuccessful hydrostatic reduction.

RESULTS

In the study period 436 patients were diagnosed with an ileocolic intussusception. Of these, 408 patients underwent hydrostatic reduction of an ileocolic intussusception. 112 patients (27.5%) underwent surgery after an unsuccessful hydrostatic reduction. In 13 (11.6%) patients no intraoperative evidence of intussusception was found. Patients who underwent surgical intervention after unsuccessful hydrostatic reduction were significantly younger than patients who had a successful hydrostatic reduction; there was no gender difference.

CONCLUSION

A substantial number of children (11.6%) underwent a laparotomy after unsuccessful hydrostatic reduction in whom no intussusception was found intraoperatively. We suggest initiating laparoscopy instead of laparotomy when surgery is necessary.

LEVEL OF EVIDENCE

Level II.

Atropine Premedication Facilitates Ultrasound-Guided Reduction by Saline Enema in Children With Intussusception

Background and Objective: Intussusception is the most frequent pediatric abdominal emergency. Intestinal spasm, ischemia, necrosis and even death may occur without prompt diagnosis and treatment. The ultrasound-guided reduction by saline enema is a preferred non-surgical procedure for intussusception. Muscular relaxants can relieve the intestinal spasm and edema by relaxing the intestinal smooth muscle, which may facilitate the treatment of intussusception. However, controversy persists on whether muscular relaxants are effective in the procedure. Therefore, the purpose of our study was to assess the efficacy of atropine known as a muscular relaxant in ultrasound-guided reduction by saline enema in children with intussusception. Methods: All patients with intussusception diagnosed and treated in our department from July 2016 to February 2018 were included. Four hundred and thirty-seven children were enrolled and randomly divided into two groups: an atropine group and a control group. Intramuscular atropine at a dose of 0.02 mg per kilogram of body weight was administrated 15 min before ultrasound-guided reduction by saline enema in the atropine group. In the control group, the ultrasound-guided reduction was performed without using any muscular relaxants. The success rate, duration of the reduction, volume of saline, maximum intra-rectal pressure and complications were recorded and compared between the two groups. Results: The success rate was 95.9% (212 out of 221) and 94.9% (205 out of 216) in the atropine group and the control group, respectively. No significant difference was observed in the success rate between the two groups (P > 0.05). The duration of reduction was significantly lower in the atropine group than in the control group (P < 0.01). The volume of saline was also significantly lower in the atropine group than in the control group (P < 0.05). The maximum intra-rectal pressure showed no difference between the two groups (P > 0.05). Conclusion: Atropine premedication can facilitate ultrasound-guided reduction by saline enema in children with intussusception, by reducing the duration of reduction and the volume of saline in the procedure.

Status survey on enema reduction of paediatric intussusception in China

Objective

Intussusception is a common paediatric abdominal emergency in infants. The first-line treatment of choice in uncomplicated paediatric intussusception is enema reduction. The study aim was to provide an overview of the current national practice of enema reduction of paediatric intussusception in China.

Methods

A questionnaire on enema reduction of paediatric intussusception was sent to respondents (members of the Pediatric Anorectal Group, the Neonatal Group, the Society of Pediatric Surgery and the China Medical Association).

Results

Data from 128 questionnaires were analysed. Of these, 78.1% (100/128) reported the use of fluoroscopy, 17.2% (22/128) use of ultrasound monitoring, 78.9% (101/128) use of air and 17.9% (23/128) use of normal saline. A total of 78.9% (101/128) reported a success rate of 90%, 25.8% (33/128) reported that a paediatric surgeon managed the reduction, 18.8% (24/128) that a radiologist managed the reduction and 44.5% (57/128) that a paediatric surgeon and radiologist jointly managed the reduction.

Conclusions

There is large variation in the techniques of enema reduction of intussusception in China. Fluoroscopy-guided air enema reduction is mainly used. Enema reduction of uncomplicated cases of paediatric intussusception in China lacks standardization of equipment and personnel involvement.

Factors associated with ultrasound-guided water enema reduction for pediatric intussusception in resource-limited setting: potential predictive role of thrombocytosis and anemia

BACKGROUND/PURPOSE

Although ultrasound-guided hydrostatic reduction (USGHR) is increasingly used in managing pediatric intussusception, there is limited literature concerning its use in Malaysia. We aim to examine the experience and factors associated with the effectiveness of USGHR using water.

METHODS

This is a single-center retrospective observational study in a Malaysian tertiary referral center. Children with intussusception admitted between year 2012 and 2016 were included and medical records reviewed. Factors associated with success or failure of USGHR were identified using multivariable logistic regression.

RESULTS

Of the 172 cases included, 151 cases (87.8%) underwent USGHR, of whom 129 cases were successfully reduced (success rate of 85.4%). One perforation (0.7%) was reported. Age more than 3years old (aOR=7.16; 95% CI=1.07-47.94; p=0.042), anemia (aOR=10.12; 95% CI=1.12-91.35; p=0.039), thrombocytosis (aOR=11.21; 95% CI=2.06-64.33; p=0.005) and ultrasound findings of free fluid (aOR=9.39; 95% CI=1.62-54.38; p=0.012) and left-sided intussusception (aOR=8.18;95% CI=1.22-54.90, p=0.031) were independently associated with USGHR irreducibility. Symptom duration, blood in stool, vomiting and other clinical presentations, however, showed no association.

CONCLUSIONS

USGHR with water is effective in the non-operative management of pediatric intussusception. Prolonged symptom duration need not necessarily preclude USGHR. The findings of anemia and thrombocytosis as independent predictors of USGHR irreducibility deserve further study.

TYPE OF STUDY

Treatment study LEVEL OF EVIDENCE: III.

Comparative safety and efficacy of balloon use in air enema reduction for pediatric intussusception

BACKGROUND

Intussusception, a common cause of bowel obstruction in young children, is primarily treated with air enema reduction. There is little literature comparing the safety and efficacy of air reduction without or with a rectal balloon.

OBJECTIVE

To determine the safety and efficacy of a rectal balloon seal in air enema reduction.

MATERIALS AND METHODS

We retrospectively reviewed the records of children who underwent air reduction for ileocolic or ileo-ileocolic intussusception over an 8-year period. We sorted data from 566 children according to whether a rectal balloon was used in the reduction, and further sorted them by type and experience level of the practitioner. Using logistic regression analyses, we identified risk factors for iatrogenic bowel perforation or failed reduction.

RESULTS

Significant associations with bowel perforation included balloon use (P=0.038), age <1 year (P<0.0001), and attending physician's level of experience <5 years (P=0.043). Younger age was associated with both perforation (P<0.0001) and procedural failure (P=0.001). The risk-adjusted predicted probability of perforation decreased with age, approaching zero by 10 months regardless of balloon use. For cases without bowel resection, the risk-adjusted predicted probability of failure decreased toward zero by 30 months with balloon use, while remaining constant at 3-12% regardless of age when not using a balloon.

CONCLUSION

The likelihood of a successful air reduction might be safely increased by using an inflated rectal balloon in children older than 9 months. Use of a balloon in younger infants is associated with a higher risk of iatrogenic bowel injury.

A randomized trial of pneumatic reduction versus hydrostatic reduction for intussusception in pediatric patients

OBJECTIVES

Data of randomly controlled trials comparing the hydrostatic and pneumatic reduction for intussusception in pediatric patients as initial therapy are lacking. The aim of this study was to conduct a randomly controlled trial to compare the effectiveness and safety of the hydrostatic and pneumatic reduction techniques.

STUDY DESIGN

All intussusception patients who visited West China Hospital of Sichuan University from January 2014 to December 2015 were enrolled in this study in which they underwent pneumatic reduction or hydrostatic reduction. Patients were randomized into ultrasound-guided hydrostatic or X-ray-guided pneumatic reduction group. The data collected includes demographic data, symptoms, signs, and investigations. The primary outcome of the study was the success rate of reduction. And the secondary outcomes of the study were the rates of intestinal perforations and recurrence.

RESULTS

A total of 124 children with intussusception who had met the inclusion criteria were enrolled. The overall success rate of this study was 90.32%. Univariable analysis showed that the success rate of hydrostatic reduction with normal saline (96.77%) was significantly higher than that of pneumatic reduction with air (83.87%) (p=0.015). Perforation after reduction was found in only one of the pneumatic reduction group. The recurrence rate of intussusception in the hydrostatic reduction group was 4.84% compared with 3.23% of pneumatic reduction group.

CONCLUSION

Our study found that ultrasound-guided hydrostatic reduction is a simple, safe and effective nonoperative treatment for pediatric patients suffering from intussusceptions, and should be firstly adopted in the treatment of qualified patients.

LEVEL OF EVIDENCE

Therapeutic study TYPE OF STUDY: Prospective study.

Applications of contrast-enhanced ultrasound in the pediatric abdomen

Contrast-enhanced ultrasound (CEUS) is a radiation-free, safe, and in specific clinical settings, highly sensitive imaging modality. Over the recent decades, there is cumulating experience and a large volume of published safety and efficacy data on pediatric CEUS applications. Many of these applications have been directly translated from adults, while others are unique to the pediatric population. The most frequently reported intravenous abdominal applications of CEUS in children are the characterization of focal liver lesions, monitoring of solid abdominal tumor response to treatment, and the evaluation of intra-abdominal parenchymal injuries in selected cases of blunt abdominal trauma. The intravesical CEUS application, namely contrast-enhanced voiding urosonography (ceVUS), is a well-established, pediatric-specific imaging technique entailing the intravesical administration of ultrasound contrast agents for detection and grading of vesicoureteral reflux. In Europe, all pediatric CEUS applications remain off-label. In 2016, the United States Food and Drug Administration (FDA) approved the most commonly used worldwide second-generation ultrasound contrast SonoVue®/Lumason® for pediatric liver and intravesical applications, giving new impetus to pediatric CEUS worldwide.

Contrast-enhanced voiding urosonography (ceVUS) with the intravesical administration of the ultrasound contrast agent Optison™ for vesicoureteral reflux detection in children: a prospective clinical trial

BACKGROUND

Contrast-enhanced voiding urosonography (ceVUS) is widely used outside the United States to diagnose vesicoureteral reflux (VUR) in children and is highly sensitive while avoiding exposure to ionizing radiation. At the onset of this study, two ultrasound (US) contrast agents were available in the United States. Pediatric safety data for intravenous administration was published for one, Optison™.

OBJECTIVE

This study aimed to evaluate the diagnostic performance and safety of ceVUS using Optison™ and compare its diagnostic efficacy with voiding cystourethrogram (VCUG) for VUR detection and grading in children.

MATERIALS AND METHODS

The United States Food and Drug Administration and institutional Investigational New Drug authorizations were obtained to conduct a prospective comparative study of ceVUS with Optison™ and VCUG. CeVUS was performed with intravesical administration of 0.2% Optison™/normal saline solution. A standard VCUG followed. Safety assessment included physical examination, and heart rate, pulse oximetry and adverse reactions monitoring before, during and immediately after the examinations. A follow-up questionnaire was completed by telephone 48-h after the studies.

RESULTS

Sixty-two pelviureteric units were studied in 30 patients with a mean age of 3.5 years (range: 0.1-17 years) including 21 girls and 9 boys. No severe adverse events occurred. All patients had normal heart rate and blood oxygenation saturation prior to, during and after the studies. At the 48-h follow-up, one patient (3.3%) reported transient dysuria. Taking the VCUG as the reference standard, ceVUS had a sensitivity of 91.7% (95%; confidence interval [CI]: 61.5%-99.8%) and specificity of 98% (95%; CI: 89.4%-99.9%). The concordance between ceVUS and VCUG for VUR detection and grading was 84.3% and 81.8%, respectively. VUR grades were discrepant in 4/11 refluxing pelviureteric units, with VCUG upgrading VUR in 2.

CONCLUSION

Detection of VUR with Optison™ ceVUS was comparable to VCUG without exposure to ionizing radiation. CeVUS with Optison™ is a well-tolerated diagnostic procedure with a favorable safety profile.

The 'ins' and 'outs' of intussusception: Where best practice reduces the need for surgery

Intussusception may be difficult to diagnose because the classical triad of symptoms is evident at the time of presentation in only about 20% of cases. This may lead to delays in making the correct diagnosis. The most common presenting features are colicky abdominal pain, vomiting, pallor, lethargy and listlessness. In recent years, the algorithms of management of intussusception have changed significantly: a routine plain abdominal X-ray has been replaced by ultrasonography, previously perceived contraindications to attempting an enema reduction no longer apply, gas has largely replaced barium for enema reduction, incomplete initial reduction is an indication for a delayed repeat enema if the child is stable clinically and partial reduction has been achieved, the indications for surgery have been tightened and laparoscopy affords an alternative surgical approach. This commentary expands on the rationale behind some of the recent advances in the management of children who present with suspected intussusception.

Effects of esketamine sedation compared to morphine analgesia on hydrostatic reduction of intussusception: A case-cohort comparison study

BACKGROUND

Hydrostatic or pneumatic reduction of intussusception is an invasive procedure that is stressful and may be painful for a child. Resistance of the child may increase the duration of the procedure and decrease success rate of reduction. Analgesia can help to reduce pain, but not necessarily resistance. General anesthesia increases success rate of reduction. However, it requires the presence of an anesthesiologist, and may lead to anesthesia-related complications. Procedural sedation with esketamine could be a safe alternative.

AIM

The aim of this study was to compare hydrostatic reduction using morphine analgesia compared to procedural sedation with esketamine in terms of success rate, adverse events, and duration of reduction.

METHODS

A retrospective case-cohort comparison study was performed with two groups of patients who had undergone hydrostatic reduction for ileocolic intussusception and received morphine analgesia (n = 37) or esketamine sedation (n = 20). Until July 2013, reduction was performed after intravenously administered morphine. Hereafter, a new protocol for procedural sedation was implemented and reduction was performed after administration of esketamine. Cases were matched for age and duration of symptoms.

RESULTS

No adverse events requiring intervention other than administration of oxygen were reported for either group. Success rate of reduction using esketamine sedation was 90% vs 70% using morphine analgesia, risk ratio (RR) 1.29, 95% CI[0.93-1.77]. Recurrence rate using esketamine sedation was 10% vs 15% using morphine analgesia, RR 0.67, 95% CI[0.12-3.57]. Reduction time was shorter using esketamine sedation (Median 5 minutes, IQR 9 minutes) vs morphine analgesia (Median 8 minutes, IQR 16 minutes, P = .04, Median difference 3, 95% CI[-1.50-8.75]). Median hospital stay in the esketamine group was 1.5 days (IQR 1.8) vs 2 days (IQR 5.3) in the morphine group.

CONCLUSION

No serious adverse events were recorded. In comparison to morphine analgesia, with esketamine there was weak evidence for a higher success rate, lower recurrence rate, shorter duration, and shorter length of hospital stay.

The role of dexamethasone in decreasing early recurrence of acute intussusception in children: A retrospective study

BACKGROUND

Early recurrent intussusception (RI) is a concern after a successful pneumatic reduction. Steroids have been suggested as a treatment that decreases early RI. The purpose of this study was to examine the role of dexamethasone in decreasing early RI.

METHODS

A retrospective review of 174 pediatric patients that underwent successful pneumatic reduction was conducted. Two groups were identified: group 1 that received intravenous dexamethasone (0.5mg/kg/dose) on diagnosis or immediately after the reduction maneuver, and group 2 that were not given dexamethasone.

RESULTS

There were 113 boys and 61 girls ranging in age from 2 to 36months. There were no statistical differences between the groups except for younger age in the dexamethasone group (P=0.03). There was no significant difference (p=0.08) in the rate of early RI between the non-steroid group (5.4%, 4/74) and the steroid group 14% (14/100). Mean admission length was 30h. The majority of RIs occurred in the first 8h of admission.

CONCLUSIONS

We found that premedication of children with idiopathic intussusception with dexamethasone did not decrease early RI.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

Management for intussusception in children

BACKGROUND

Intussusception is a common abdominal emergency in children with significant morbidity. Prompt diagnosis and management reduces associated risks and the need for surgical intervention. Despite widespread agreement on the use of contrast enema as opposed to surgery for initial management in most cases, debate persists on the appropriate contrast medium, imaging modality, pharmacological adjuvant, and protocol for delayed repeat enema, and on the best approach for surgical management for intussusception in children.

OBJECTIVES

To assess the safety and effectiveness of non-surgical and surgical approaches in the management of intussusception in children.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library; Ovid MEDLINE (1950 to September 2016); Ovid Embase (1974 to September 2016); Science Citation Index Expanded (via Web of Science) (1900 to September 2016); and BIOSIS Previews (1969 to September 2016).We examined the reference lists of all eligible trials to identify additional studies. To locate unpublished studies, we contacted content experts, searched the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (September 2016), and explored proceedings from meetings of the British Association of Paedatric Surgeons (BAPS), the American Soceity of Pediatric Surgery, and the World Congress of Pediatric Surgery.

SELECTION CRITERIA

We included all randomised controlled trials comparing contrast media, imaging modalities, pharmacological adjuvants, protocols for delayed repeat enema, and/or surgical approaches for the management of intussusception in children. We applied no language, publication date, or publication status restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study selection and data extraction and assessed risk of bias using a standardised form. We resolved disagreements by consensus with a third review author when necessary. We reported dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We analysed data on an intention-to-treat basis and evaluated the overall quality of evidence supporting the outcomes by using GRADE criteria.

MAIN RESULTS

We included six randomised controlled trials (RCTs) with a total of 822 participants. Two trials compared liquid enema reduction plus glucagon versus liquid enema alone. One trial compared liquid enema plus dexamethasone versus liquid enema alone. Another trial compared air enema plus dexamethasone versus air enema alone, and two trials compared use of liquid enema versus air enema. We identified three ongoing trials.We judged all included trials to be at risk of bias owing to omissions in reported methods. We judged five of six trials as having high risk of bias in at least one domain. Therefore, the quality of the evidence (GRADE) for outcomes was low. Interventions and data presentation varied greatly across trials; therefore meta-analysis was not possible for most review outcomes. Enema plus glucagon versus enema alone It is uncertain whether use of glucagon improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 218 participants; RR 1.09, 95% CI 0.94 to 1.26;low quality of evidence). No trials in this comparison reported on the number of children with bowel perforation(s) nor on the number of children with recurrent intussusception. Enema plus dexamethasone versus enema alone Use of the adjunct, dexamethasone, may be beneficial in reducing intussusception recurrence with liquid or air enema (two trials, 299 participants; RR 0.14, 95% CI 0.03 to 0.60; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 13 (95% CI 8 to 37). It is uncertain whether use of the adjunct, dexamethasone, improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 356 participants; RR 1.01, 95% CI 0.92 to 1.10;low quality of evidence). Air enema versus liquid enema Air enema may be more successful than liquid enema for reducing intussusception (two trials, 199 participants; RR 1.28, 95% CI 1.10 to 1.49; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 6 (95% CI 4 to 19). No trials in this comparison reported on the number of children with bowel perforation(s) or on the number of children with recurrent intussusception nor any intraoperative complications, such as bowel perforation, or other adverse effects. Only one trial reported postoperative complications, but owing to the method of reporting used, a quantitative analysis was not possible. We identified no studies that exclusively evaluated surgical interventions for management of intussusception.

AUTHORS' CONCLUSIONS

This review identified a small number of trials that assessed a variety of interventions. All included trials provided evidence of low quality and were subject to serious concerns about imprecision, high risk of bias, or both. Air enema may be superior to liquid enema for successfully reducing intussusception in children; however, this finding is based on a few studies including small numbers of participants. Dexamethasone as an adjuvant may be more effective in reducing intussusception recurrence rates following air enema or liquid enema, but these results are also based on a few studies of small numbers of participants. This review highlights several points that need to be addressed in future studies, including reducing the risk of bias and including relevant outcomes. Specifically, surgical trials are lacking, and future research is needed to address this evidence gap.

Comparative Effectiveness of Imaging Modalities for the Diagnosis and Treatment of Intussusception: A Critically Appraised Topic

RATIONALE AND OBJECTIVES

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of intussusception and methods used in the treatment of ileocolic intussusception.

METHODS

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome (PICO) method comparing radiography, ultrasound, and computed tomography in the detection of intussusception. The same methods were used to compare pneumatic (gas) reduction and hydrostatic (liquid) reduction using saline, water-soluble contrast, and barium. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

RESULTS

The retrieved sensitivity for the diagnosis of intussusception using plain radiography is 48% (95% confidence interval [CI], 44%-52%), with a specificity of 21% (95% CI, 18%-24%). The retrieved sensitivity for the diagnosis of intussusception using ultrasound is 97.9% (95% CI, 95%-100%), with a specificity of 97.8% (95% CI, 97%-99%). Based on a good quality meta-analysis, the combined success rate of gas enema reduction was shown to be 82.7% (95% CI, 79.9%-85.6%) compared to a combined success rate of 69.6% (95% CI, 65.0%-74.1%) for liquid enema reduction.

CONCLUSIONS

The best available evidence recommends ultrasound as the diagnostic modality of choice for the diagnosis of ileocolic intussusception in children. In stable children without signs of peritonism, nonoperative reduction is the treatment of choice. Pneumatic (gas) reduction enema has been shown to be superior to hydrostatic (liquid) enema reduction.

Rectal Bleeding and Abdominal Pain Following Vaccination in a 4-Month-Old Infant

Intussusception is one of the most frequent causes of intestinal obstruction in infants. Rotavirus vaccination has been associated with intussusception in the medical literature. We report a case of a 4-month-old female with intussusception requiring hemicolectomy one week following rotavirus vaccination. We review the pathophysiology, presentation, and management of intussusception with a distinct focus on the history of rotavirus vaccination and risks of intussusception associated with timing of rotavirus vaccine administration. The discussion makes a strong case for rotavirus vaccine counseling regarding signs of intestinal obstruction and the importance of early recognition.

Predictors for bowel resection and the presence of a pathological lead point for operated childhood intussusception: A multi-center study

BACKGROUND

Intussusception may require bowel resection. Here, we aim to define factors that predict the need of bowel resection and the presence of pathological lead point.

METHODS

A retrospective review was taken from three tertiary centers for all operated intussusception patients from January 2010 to December 2014. Patient demographics were recorded. Statistical analysis was performed, and risk factors were derived by binary logistic regression.

RESULTS

Five thousand ninety-six patients were treated for intussusception with 73 (57 male, 16 female) operated. The median age was 23.2months, and median duration of symptoms was 2days. Twenty-eight patients (38.4%) required bowel resection. Logistic regression demonstrated that older age (p=0.018) and longer duration of symptoms (p=0.009) were associated with bowel resection. Furthermore, older age was a predictive factor for the presence of a pathological lead point (p=0.01). A palpable abdominal mass was also found to be associated with the need of bowel resection (risk ratio 2.3) and the presence of pathological lead point (risk ratio 2.3) independently.

CONCLUSION

Older age at presentation and a longer duration of symptoms are positive predictors for the need of bowel resection in intussusception. The presence of a pathological lead point is more likely in older children.

LEVEL OF EVIDENCE

Case series with no comparison group - Level IV.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Failed Intussusception Reduction in Children: Correlation Between Radiologic, Surgical, and Pathologic Findings

OBJECTIVE

The objective of this study was to identify causes of irreducible intussusception after contrast enema and to correlate imaging findings with surgical and histopathologic findings.

MATERIALS AND METHODS

Between 2005 and 2013, a total of 543 children underwent reduction of intussusception with the use of an enema technique (hereafter referred to as "enema reduction"). The medical records of 72 children (56 boys [mean age, 24.8 months; range, 3.8 months to 10.9 years] and 16 girls [mean age, 14.2 months; range, 1.5 months to 6.9 years) who underwent unsuccessful reduction and were treated surgically were retrospectively analyzed. The data collected included information on the cause of intussusception, the risk factors noted on ultrasound, operative management, outcome, and the length of the hospital stay. The imaging findings for these patients were compared with findings for statistically similar age-matched control subjects.

RESULTS

Ultrasound detected 56 of 57 cases of intussusception, but it failed to detect the lead point in three cases and failed to detect ischemic necrosis in seven cases. Positive predictors of failed enema reduction were the presence of a distal mass and observation of the dissecting sign. Of the 72 patients who underwent surgical treatment of intussusception, 26 (36.1%) underwent laparoscopy, 38 (52.8%) underwent laparotomy, and eight (11.1%) underwent conversion from laparoscopy to laparotomy. Surgical reduction was performed in 61.1% of cases, small bowel resection in 19.4%, ileocecectomy in 12.5%, and self-reduction in 69%. Pathologic lead points (noted in 25% of cases) included lymphoid hyperplasia (n = 7), Meckel diverticulum (n = 3), Burkitt lymphoma (n = 3), enteric duplication cyst (n = 2), juvenile polyp (n = 2), and adenovirus appendicitis (n = 1). The length of the hospital stay was significantly longer after laparotomy.

CONCLUSION

The distalmost location of the intussusception mass and presence of the dissecting sign on images obtained during contrast enema have a higher positive predictive value for failed reduction. Screening ultrasound decreases the number of unnecessary contrast enemas performed; however, classic pathologic lead points, such as Burkitt lymphoma and Meckel diverticulum, may be difficult to diagnose with the use of ultrasound. Laparotomy and laparoscopy are equally safe and efficacious in reducing intussusception, with the length of the hospital stay after laparoscopy significantly shorter than that noted after laparotomy. Most failed enema reductions are idiopathic, and pathologic lead points are noted in 25% of cases.