Paediatric intussusception

Intussusception among young children in Europe

Intussusception, a potentially lethal condition with poorly understood etiology, is the most common cause of acute intestinal obstruction in children younger than 5 years old. In some cases, the condition has been associated with administration of the first licensed rotavirus vaccine, the reassortant rhesus-human tetravalent rotavirus vaccine (RRV-TV; RotaShield). No such association has to date been reported from large phase III safety trials with new rotavirus vaccines. As 2 new, live-attenuated oral rotavirus vaccines are currently under review for approval by the European Union regulatory authorities, a review of the clinical, etiologic and epidemiologic aspects of intussusception in Europe is urgently needed. We conducted a review of Medline literature, published from 1995 onwards on intussusception in the World Health Organization's European Region. The results are compared with data from previous reviews and other regions. The classic triad of intussusception symptoms (abdominal pain, abdominal mass, bloody stools) was present in 29-33% of patients according to the medical literature reviewed. Conservative treatment (barium, air or saline enema) was the rule (81% of cases), and few complications were observed during treatment. Treatment outcome was generally favorable, with recurrence occurring in approximately 1 in 10 patients, and only 1 death reported. Structural lead points were seen in 3% of patients; no other reliable data on the etiology of intussusception were found. The incidence of acute intussusception in young children in Europe, according to 6 heterogeneous hospital-based studies, ranged from 0.66 to 2.24 per 1000 children in inpatient departments and from 0.75 to 1.00 per 1000 children in emergency departments. Peak incidences were found in children 3-9 months of age. There are still gaps in our knowledge of intussusception with respect to its etiology and especially by which mechanisms RRV-TV might have caused it to occur. Data from regions outside Europe showed that rotavirus infection and disease are not associated with intussusception. As new rotavirus vaccines become available for use in Europe, postlicensure surveillance for intussusception is indicated and may be instrumental in further understanding the epidemiology of this condition and in further assessing the safety of future vaccines.

Intussusception of the small bowel associated with nephrotic syndrome

We report the case of a 2-year-old boy who developed a small bowel intussusception during treatment failure of his first episode of nephrotic syndrome. Despite the absence of typical symptoms other than abdominal pain, the intussusception was diagnosed by ultrasonography and computed tomography and successfully reduced by air enema. No pathological lead point was discovered, and no symptoms of Henoch-Schönlein purpura developed later. Intussusception should be considered in the differential diagnosis of abdominal pain in patients with nephrotic syndrome, especially in patients exhibiting prolonged edema. Ultrasonography or computed tomography should be performed, even in the absence of other typical symptoms suggestive of intussusception. We should also bear in mind that the intussusception associated with nephrotic syndrome might occur at regions other than the typical ileocolic region, such as within the small intestine.

Intussusception and rotavirus associated hospitalisation in New Zealand

AIMS

To describe the epidemiology of intussusception and its relation to rotavirus associated hospitalisation in New Zealand.

METHODS

National hospital discharge data between January 1998 and June 2003 for all children younger than 3 years of age with intussusception were reviewed. Independently, children from the same age group, admitted to eight paediatric units with rotavirus gastroenteritis between May 1998 and May 2000, were identified prospectively. Epidemiological characteristics of cases with intussusception were compared with those of hospitalised rotavirus disease.

RESULTS

During the 5.5 year study period, there were 277 cases of intussusception and no deaths. Most (72%) occurred in the first year of life (age adjusted incident rate 65 per 100,000 child-years, 95% CI 56 to 74). Risk of intussusception was less in females (risk ratio 0.58; 95% CI 0.43 to 0.78) and for Maori (risk ratio 0.52; 95% CI 0.35 to 0.77) when compared with European infants. In contrast to hospitalised rotavirus cases, intussusception peaked at a younger age and lacked seasonality.

CONCLUSIONS

This study provides national baseline data on intussusception for future rotavirus vaccine programmes in New Zealand. Wild-type rotaviruses do not appear to have a major role in triggering intussusception. Prospective surveillance systems, using standardised case definitions and nested case-control methodology, are needed to further our understanding of the aetiology and epidemiology of intussusception.

Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module

OBJECTIVE

This article uses case examples to review the current evidence for the management of children with clinically suspected intussusception.

CONCLUSION

In this educational module, we review the evidence for diagnostic and management strategies in children with clinically suspected intussusception.

Complex presentation of intussusception in childhood

The simultaneous occurrence of intussusception and volvulus in the paediatric age group is rare. We report the case of a volvulus of an ileoileal intussusception in an 8-year-old boy. This is the first time that computerised tomography (CT) images of a volvulus of an ileoileal intussusception have been published, and they clearly demonstrate both pathologies. This case highlights the use of CT in determining the nature of an abdominal mass and demonstrates how helpful it can be in diagnosing the cause of small bowel obstruction in children.

Laparoscopic vs open surgical approach for intussusception requiring operative intervention

PURPOSE

Laparoscopy has recently been used to treat intussusception that cannot be reduced radiologically. The effectiveness and practical nature of this approach has been questioned.

METHODS

This study retrospectively analyzed the authors' experience with this laparoscopic approach and compared this to the conventional open laparotomy procedure.

RESULTS

Sixteen patients were treated via laparoscopy, with 2 of these requiring conversions to an open procedure (12.5%). Twenty-five patients underwent an open reduction. Operative time was not significantly different (P = .698) between the laparoscopic (49.56 +/- 26.40 minutes) and open groups (45.00 +/- 24.74). Length of stay, however, was significantly reduced (P = .005) in the laparoscopic group (3.00 +/- 1.31 days) compared to the open group (4.52 +/- 1.98). Total hospital charges were lower in the laparoscopic group ($8171 +/- 2595) compared to the open group ($11,672 +/- 5466); this difference was not significant (P = .088). There were no significant differences in intra- or postoperative complication rates (P = .637) between the 2 approaches.

CONCLUSIONS

Although there remains a group who will require a conversion to an open procedure, the laparoscopic approach should be considered a safe and effective option for all children who do not respond to a radiological reduction.

Intussusception in early childhood: a cohort study of 1.7 million children

OBJECTIVE

To describe incidence and temporal trends of intussusceptions in Danish children during 1980 to 2001.

METHODS

A population-based cohort study was conducted of 1.67 million children who were younger than 5 years during 1980 to 2001 and were followed up for 6.66 million person-years. The Danish National Patient Registry was used to identify cases of intussusception in the cohort. Age-specific incidence rates were main outcome measure.

RESULTS

A total of 1814 cases of intussusception among children who were younger than 5 years were reported from 1980 to 2001. The incidence rate remained fairly constant during 1980 to 1990 but decreased by 55% (95% confidence interval: 43%-65%) from 1990 to 2001. The reduction was most pronounced among children aged 3 to 5 months.

CONCLUSIONS

The incidence of intussusception among Danish children declined significantly during the 1990s, particularly among infants 3 to 5 months of age.

Asymptomatic small bowel intussusception associated with post-transplant lymphoproliferative disease

A 2-yr-old boy who had undergone orthotopic liver transplantation for biliary atresia 6 months prior presented with generalized lymphadenopathy. Physical exam revealed lymphadenopathy only; the patient had no gastrointestinal signs or symptoms. CT was used to evaluate the patient's lymphadenopathy. The findings were consistent with PTLD, and an incidental intussusception causing small bowel obstruction was found. The intussusception was successfully managed expectantly, and the patient's PTLD responded to administration of rituximab. The etiology, diagnosis and management of intussusception is discussed.

Postreduction management of intussusception in a children's hospital emergency department

OBJECTIVE

To evaluate the current management of patients with intussusception who have undergone successful reduction by contrast enema in a tertiary care children's hospital. To compare differences in the incidence of recurrence and adverse events between those patients who were hospitalized after enema reduction and those who were observed in the emergency department (ED).

METHODS

This was a retrospective cohort study of children 0 to 18 years of age who underwent uncomplicated enema reduction for intussusception. Hospitalization versus ED observation management were compared for length of stay, incidence of recurrence, and adverse events.

RESULTS

One hundred twenty-three children were identified with an International Classification of Diseases, Ninth Revision code for intussusception. Of those, 106 patients (86%) had an enema reduction attempted. Three had a normal enema and were given the diagnosis of "resolved intussusception." Eighty-three (80%) of the patients had a successful reduction. Seventy-eight (94%) of those patients had no preexisting condition and had complete medical records. Of those 78 patients, 27 (35%) were hospitalized and 51 (65%) were observed in the ED. The mean length of hospitalization was 22.7 hours (range: 10-50 hours), and the mean length of ED observation was 7.2 hours (range: 0-21 hours). Eleven recurrences were observed in 8 of these 78 patients (10% recurrence rate). Four patients in the hospitalized group and 4 patients in the ED observation group had recurrences (5 hours-10.9 months). Four of the 8 patients had a recurrence within the first 48 hours. All first recurrences occurred after the patient had been discharged from the hospital or ED observation unit. No adverse events occurred in any of the patients who had a successful initial reduction (95% confidence interval [0%-4.6%]).

CONCLUSIONS

The postreduction management of intussusception is variable at our institution. Previously healthy patients who have undergone successful enema reductions are unlikely to have adverse outcomes. Postreduction observation in the ED or the hospital does not seem to affect outcomes in this clinical setting.

Intestinal obstruction in neonatal/pediatric surgery

Intestinal obstruction in the newborn infant and older child may be due to a variety of conditions, including atresia and stenosis, annular pancreas, malrotation, duplication cyst, meconium ileus, meconium plug syndrome and neonatal small left colon syndrome, Hirschsprung's disease, neoplasia, trauma, and other rarer causes. The mode of presentation can be acute or more chronic with systemic upset due to shock. Neonates, more so than older children, with unrecognized intestinal obstruction deteriorate rapidly, show an increase of associated morbidity and mortality and appropriate surgical treatment becomes more hazardous. Early diagnosis depends largely on the prompt detection of obstructive manifestations by the clinician and the subsequent accurate interpretation of radiographic findings and other investigations, leading to definitive treatment, which should always be preceded by appropriate resuscitation/preparation of the infant/child. Management of intestinal obstruction will almost always be surgical, apart from some notable exceptions and all are discussed in more detail. With the advent of pediatric and neonatal intensive care and multidisciplinary care, the morbidity and mortality of cases of intestinal obstruction reported in current series is generally extremely low and mainly determined by the coexistence of other major congenital anomalies (eg, cardiac), delays in diagnosis and treatment or coexisting medical conditions. Newer treatments and future developments may reduce the residual mortality in such cases as ultrashort-bowel syndrome.

Two year review of intestinal intussusception in six large public hospitals of Santiago, Chile

BACKGROUND

A need for updated information on different aspects of idiopathic intussusception resurged after the Rotashield experience. Variability of incidence rates worldwide and the possibility of a more severe outcome among infants that have intussusception at a younger age are two issues that remain unclear. We aimed to provide updated information on clinical aspects of intussusception in a large population of Chilean children <2 years of age, including a best estimate of incidence rate and a comparative analysis of the clinical evolution for children younger and older than 6 months of age.

METHODS

Several sources of information were used to recollect all intussusception cases 0 to 24 months of age treated in six public pediatric hospitals of the Metropolitan area during years 2000 and 2001 and to obtain updated estimates of the population covered by these hospitals. A thorough chart review of intussusception cases was performed using a standardized case report form.

RESULTS

A total of 50 and 45 intussusception cases were detected for 2000 and 2001, respectively, and estimated intussusception rates for children 0 to 24 months and for the subgroup <12 months of age were 35 and 32 per 100 000, and 55 and 47 per 100 000. The monthly distribution of intussusception cases differed for both years without an identifiable reason, and no association between intussusception and rotavirus infection was observed. No intussusception-associated death was recorded. Overall complications occurred in 21% of children, and infants younger than 6 months of age did not have more complications or a more prolonged hospital stay than older children.

CONCLUSIONS

Idiopathic intussusception is not uncommon among Chilean infants with incidence rates similar to those reported in the United States. There was no clear association with preexisting rotavirus infection and occurrence of complications was not related to young age.

Lack of association between intussusception and oral polio vaccine in Cuban children

Two exploratory investigations found an increased risk of intussusception after oral polio vaccine (OPV). A large, national, population-based study was undertaken in Cuba to investigate a possible association. Three hundred and thirty-five cases of intussusception in children under 2 years of age occurring in 1995-2000 were identified and their OPV records retrieved. The relative incidence (RI) of intussusception in defined periods up to 42 days after OPV in children under 1 year was estimated using the self-controlled case series method, controlling for age and season. The RI was not significantly raised in any of the time intervals examined within the 0-42 day period after OPV. For the period 0-42 days as a whole the RI was 1.11, 95% CI 0.74-1.67. This study does not support the hypothesis that OPV causes intussusception.

The future of rotavirus vaccines

In 1998, a simian-human reassortant rotavirus vaccine was licensed and recommended for routine use in children. Within 1 year, however, the vaccine was found to be a cause of intussusception, estimated to be approximately 1 case per 10,000 immunized children, and the recommendations were withdrawn. Although the etiology and pathogenesis of vaccine-associated intussusception remain unclear, immunologic studies suggest several hypotheses. Development of new rotavirus vaccines necessitates the need for large, prelicensure, clinical trials to determine safety. Candidate vaccines currently in clinical trials include a bovine-human reassortant pentavalent vaccine and an attenuated human rotavirus monovalent vaccine. Important issues to be addressed include the acceptable, if any, degree of risk of developing intussusception and economic issues concerning the distribution of the vaccine in developing countries. The continuing interest of pharmaceutical companies in developing a safe and effective vaccine is encouraging, especially given the enormous burden of rotavirus disease in developing countries.

Lack of association between rotavirus infection and intussusception: implications for use of attenuated rotavirus vaccines

BACKGROUND

Withdrawal of the tetravalent rhesus-human rotavirus vaccine Rotashield because of its association with intussusception raised concerns about a potential link between natural rotavirus disease and intussusception. Our objective was to determine whether such an association exists.

METHODS

In the Southern California Kaiser Permanente Health Care Plan, a large health maintenance organization, from October, 1992, to July, 1999, we retrospectively identified by computerized data and medical charts all children <3 years old with intussusception, and from 1997 to 1999 we independently identified by prospective clinical and laboratory evaluation children <3 years old with rotavirus diarrhea. We compared the epidemiologic characteristics of intussusception and rotavirus infection in our study population and evaluated for the presence of both diseases in individual patients.

RESULTS

Using computerized data we identified 124 cases of intussusception, 101 (81%) of which were confirmed by medical chart and radiologic reviews. The incidences for infants <1 year old and for children <3 years old were 41 (95% confidence interval, 32 to 55) and 17 (95% confidence interval, 13 to 20) per 100,000 child years, respectively. Between November 1997 and July 1999, we identified 470 cases of rotavirus diarrhea and none had intussusception. Although rotavirus diarrhea had a distinct peak incidence between December and February, intussusception had no apparent seasonality. The age distributions overlapped, but intussusception occurred at an earlier age than rotavirus disease.

CONCLUSIONS

We found no epidemiologic evidence for an association between intussusception and natural rotavirus infection, but our study was limited by an insufficient number of cases to definitively exclude a causal link. The dramatic winter peak of rotavirus disease had no discernable parallel in the incidence of intussusception. Our data suggest that the association between tetravalent rhesus-human rotavirus vaccine and intussusception may possibly result from the nonhuman rotavirus components of that vaccine.

Intussusception associated with bacterial meningitis

Despite its common association with viral illnesses, intussusception has only rarely been found in the presence of bacterial infections. Two infants are described, both of whom were admitted to hospital with bilious vomiting, drowsiness, and dehydration. Both infants required urgent intravenous volume expansion. Intussusception was confirmed, and reduction was achieved by enema in both cases. Recovery was slow, and one infant developed a seizure. Evidence of meningococcal meningitis was found in both, with septicaemia in one. Neurological outcome is normal to date, and there has been no recurrence of intussusception in either case.

Intussusception among recipients of rotavirus vaccine: reports to the vaccine adverse event reporting system

BACKGROUND

Rotavirus vaccine was licensed on August 31, 1998, and subsequently recommended for routine use among infants. To assess rare adverse events, postlicensure surveillance was conducted.

OBJECTIVE

To describe the cases of intussusception among rotavirus vaccine recipients reported to the Vaccine Adverse Event Reporting System from October 1998 through December 1999.

SETTING AND PARTICIPANTS

Infants vaccinated with rotavirus vaccine in the United States.

OUTCOME MEASURES

Intussusception confirmed by radiology, surgery, or autopsy report with medical record documentation or confirmed by a primary health care provider.

RESULTS

There were 98 confirmed cases of intussusception after vaccination with rotavirus vaccine reported to the Vaccine Adverse Event Reporting System; 60 of these developed intussusception within 1 week after vaccination. Based on calculations using vaccine distribution data and intussusception incidence rates from 2 separate databases, an estimated 7 to 16 cases would have been expected to occur in the week after vaccination by chance alone.

CONCLUSION

Using a passive surveillance system for vaccine adverse events, we observed at least a fourfold increase over the expected number of intussusception cases occurring within 1 week of receipt of rotavirus vaccine. Other studies were initiated to further define the relationship between rotavirus vaccine and intussusception. In light of these and other data, the rotavirus vaccine manufacturer voluntarily removed its product from the market, and the recommendation for routine use of rotavirus vaccine among US infants has been withdrawn.

Sonographic features of small-bowel intussusception in pediatric patients

OBJECTIVE

Small-bowel intussusception (SBI) for pediatric patients is unusual and difficult to diagnose preoperatively. This study sought to determine the sonographic findings of pediatric SBI.

METHODS

The sonographic features and surgical findings of 13 pediatric patients (7 boys, 6 girls; age range 4 months-15 years; average age 4 years and 2 months) with SBI encountered in the authors' hospital over a 12-year period were retrospectively reviewed.

RESULTS

Most of the patients presented with nonspecific symptoms, including vomiting, abdominal pain, and/or irritable crying. Sonographic screening in the emergency department revealed a doughnut or crescent-in-doughnut sign, or a multiple-concentric-rings sign for 11 of the 13 patients, and the lesions appeared short. Eight lesions were found in the paraumbilical or left abdominal regions. Sonographic measurement of the size of the lesions from these 11 patients ranged from 2 cm to 3.7 cm (average 2.77 cm). Subsequent barium enemas were performed for these 11 patients, none of which revealed colon lesions. Surgery revealed ileoileal intussusceptions for eight cases, jejunoileal for three, and jejunojejunal for the remaining two. Bowel ischemia or necrosis and pathologic lead points were demonstrated for seven and six patients, respectively, although none were recognized preoperatively.

CONCLUSIONS

Small-bowel intussusception is often over-looked due to nonspecific clinical presentations. Sonographic demonstration of a 2-3-cm sized, short, doughnut-like lesion, especially in the left abdomen or paraumbilical regions, should lead to strong suspicion of SBI.

Rotavirus infection and intussusception: a view from retrospect

A live orally-administrable rhesus rotavirus (RRV) tetravalent (TV) vaccine, licensed in the U.S.A. and the European Union, was recalled from the market because it was suspected to increase the risk of intussusception during the week following immunization. In contrast, natural rotavirus infection is generally believed not to cause intussusception. Because my experience contributed to the first paper that linked intussusception with rotavirus infection, I have re-examined our own data published 22 years ago and other studies on this issue. I also made a case study of adenovirus and intussusception as a paradigm to establish an etiological association of viral infection and intussusception. My hypothesis postulated in this review is that natural infection of susceptible (or predisposed) infants with some rotavirus strains, probably serotype G3 rotaviruses, will result in an appreciable fraction of idiopathic intussusception. Thus, the number of rotavirus-induced intussusception cases may change reflecting the relative frequency of G3 strains, which I believe was much higher in the 70s than during the last two decades. The epidemiological data indicate that the RRV-TV vaccine triggers intussusception at a rate significantly higher than the background incidence rate following the week of vaccination, particularly after the first dose. In contrast, the data do not suggest that the cumulative incidence among the vaccine recipients increases accordingly, implicating that the risk of intussusception attributable to the RRV-TV vaccine may be minimal.

Rotavirus vaccine and intussusception. Where do we go from here?

Since the discovery of rotavirus in 1973, vaccine technology has moved from the use of monovalent attenuated animal rotavirus strains to the development of multivalent human-animal reassortment vaccines. The first licensed vaccine, a rhesus-human tetravalent vaccine, was licensed in 1998. This vaccine was withdrawn from the market a year later when it was noted that administration of vaccine was associated with an increased risk of intussusception. The future of rotavirus vaccine is dependent on the reasons for this association that have yet to be discovered.

Intussusception among infants given an oral rotavirus vaccine

BACKGROUND

Intussusception is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment. Our investigation began on May 27, 1999, after nine cases of infants who had intussusception after receiving the tetravalent rhesus-human reassortant rotavirus vaccine (RRV-TV) were reported to the Vaccine Adverse Event Reporting System.

METHODS

In 19 states, we assessed the potential association between RRV-TV and intussusception among infants at least 1 but less than 12 months old. Infants hospitalized between November 1, 1998, and June 30, 1999, were identified by systematic reviews of medical and radiologic records. Each infant with intussusception was matched according to age with four healthy control infants who had been born at the same hospital as the infant with intussusception. Information on vaccinations was verified by the provider.

RESULTS

Data were analyzed for 429 infants with intussusception and 1763 matched controls in a case-control analysis as well as for 432 infants with intussusception in a case-series analysis. Seventy-four of the 429 infants with intussusception (17.2 percent) and 226 of the 1763 controls (12.8 percent) had received RRV-TV (P=0.02). An increased risk of intussusception 3 to 14 days after the first dose of RRV-TV was found in the case-control analysis (adjusted odds ratio, 21.7; 95 percent confidence interval, 9.6 to 48.9). In the case-series analysis, the incidence-rate ratio was 29.4 (95 percent confidence interval, 16.1 to 53.6) for days 3 through 14 after a first dose. There was also an increase in the risk of intussusception after the second dose of the vaccine, but it was smaller than the increase in risk after the first dose. Assuming full implementation of a national program of vaccination with RRV-TV, we estimated that 1 case of intussusception attributable to the vaccine would occur for every 4670 to 9474 infants vaccinated.

CONCLUSIONS

The strong association between vaccination with RRV-TV and intussusception among otherwise healthy infants supports the existence of a causal relation. Rotavirus vaccines with an improved safety profile are urgently needed.

Intussusception: hospital size and risk of surgery

OBJECTIVE

To determine whether the risk of operative management of children with intussusception varies by hospital pediatric caseload.

DESIGN

A cohort of all children with intussusception in Washington State from 1987 through 1996.

SETTING

All hospitals in Washington State.

METHODS

Five hundred seventy children with a hospital discharge diagnosis of intussusception were identified. Sixty-two were excluded because of missing data. Procedure codes for operative management and radiologic management were also identified.

RESULTS

Fifty-three percent of the children had operative reduction and 20% had resection of bowel. Children with operative reduction did not differ from those with nonoperative care by median age or gender; however, children with operative care were significantly more likely to receive care in hospitals with smaller pediatric caseloads and to have a coexisting condition associated with intussusception. Sixty-four percent of children who received care in a large children's hospital had nonoperative reduction, compared with 36% of children who received care in hospitals with 0 to 3000 annual pediatric admissions and 24% of children who had care in hospitals with 3000 to 10 000 annual pediatric admissions. Median length of stay and charges were significantly less in the large children's hospital, compared with other centers.

CONCLUSIONS

Children who received care for intussusception in a large children's hospital had decreased risk of operative care, shorter length of stay, and lower hospital charges compared with children who received care in hospitals with smaller pediatric caseloads.

Patterns of management of intussusception outside tertiary centres

BACKGROUND/PURPOSE

Intussusception is a common problem in young children and should have an excellent outcome in expert hands. Many children are treated in district general hospitals (DGH), which do not have specialist paediatric surgeons. The aim of this study was to clarify current patterns of management for such patients.

METHODS

The authors conducted a postal survey of DGH consultant paediatricians, radiologists, and general surgeons in a populous region of England.

RESULTS

One hundred forty-one (44%) consultants who responded comprised similar proportions of consultants from each specialty. Most respondents (79%) thought that in their location paediatricians should take responsibility for resuscitation of children with suspected intussusception. Two-thirds indicated that abdominal ultrasound scan, either alone or in combination with another modality, was their investigation of choice for confirming the diagnosis. Preferences for contrast medium for radiologic reduction varied; paediatricians favoured air (46%) or saline (28%), surgeons preferred water-soluble contrast (58%), and radiologists preferred to use barium (49%). Fifty-three percent of consultants indicated they would transfer a child with confirmed intussusception to a tertiary centre before attempting reduction, 42% would attempt reduction locally, and 5% would operate locally without attempting radiologic reduction. After failed reduction, a further 23% of consultants would consider transfer, but the remainder would operate locally. Only 13% of paediatricians thought that their surgeons had appropriate facilities and support to operate on intussusception, but 36% of surgeons claimed to be doing so. Most consultants (84%) admitted seeing fewer than 5 cases per year; 98% of surgeons were in this group. Only 16% of consultants (mostly paediatricians) were aware of any written clinical policy for managing paediatric intussusception in their hospital.

CONCLUSION

This study shows that the management of paediatric intussusception outside tertiary centres is not uniform or standardised, and that improvements are necessary. J Pediatr Surg 36:312-315.

Trends in intussusception-associated hospitalizations and deaths among US infants

CONTEXT

The newly licensed tetravalent rhesus-human reassortant rotavirus vaccine has been withdrawn following reports of intussusception among vaccinated infants.

OBJECTIVE

To describe the epidemiology of intussusception-associated hospitalizations and deaths among US infants.

DESIGN

This retrospective cohort study examined hospital discharge data from the National Hospital Discharge Survey for 1988-1997, Indian Health Service (IHS) for 1980-1997, California for 1990-1997, Indiana for 1994-1998, Georgia for 1997-1998, and MarketScan for 1993-1996, and mortality data from the national multiple cause-of-death data for 1979-1997 and linked birth/infant death data for 1995-1997.

PATIENTS

Infants (<1 year old) with an International Classification of Diseases, Ninth Revision, Clinical Modification code for intussusception (560.0) listed on their hospital discharge or mortality record, respectively.

RESULTS

During 1994-1996, annual rates for intussusception-associated infant hospitalization varied among the data sets, being lowest for the IHS (18 per 100 000; 95% confidence interval [CI] = 9-35 per 100 000) and greatest for the National Hospital Discharge Survey (56 per 100 000; 95% CI = 33-79 per 100 000) data sets. Rates among IHS infants declined from 87 per 100 000 during 1980-1982 to 12 per 100 000 during 1995-1997 (relative risk =7.6, 95% CI = 3.2-18.2). Intussusception-associated hospitalizations were uncommon in the first 2 months of life, peaked from 5 to 7 months old, and showed no consistent seasonality. Intussusception-associated infant mortality rates declined from 6.4 per 1 000 000 live births during 1979-1981 to 2.3 per 1 000 000 live births during 1995-1997 (relative risk = 2.8, 95% CI = 1.8-4.3). Infants whose mothers were <20 years old, nonwhite, unmarried, and had an education level below grade 12 years were at an increased risk for intussusception-associated death.

CONCLUSIONS

Intussusception-associated hospitalization rates varied among the data sets and decreased substantially over time in the IHS data. Although intussusception-associated infant deaths in the United States have declined substantially over the past 2 decades, some deaths seem to be related to reduced access to, or delays in seeking, health care and are potentially preventable.intussusception, hospitalizations, deaths, risk factors, infants.

Small bowel intussusception in celiac disease

Intussusception is not a widely recognized complication of celiac disease and yet it is not rare. The authors report on 3 children with spontaneously resolving small bowel intussusception in association with celiac disease. Small bowel intussusception in a child with suspected celiac disease initially should be managed expectantly rather than by early surgical reduction. The finding of transient small bowel intussusception, either by contrast radiology or sonography, should prompt investigation for celiac disease.

Intussusception

Intussusception is the invagination of one portion of the intestine into another and is the most common form of intestinal obstruction in infants. This report reviews the clinical presentation and diagnostic and treatment options available for intussusception. The etiologies of childhood intussusception are discussed. Details and literature review are provided on the advantages and disadvantages of ultrasonography, barium enema, air contrast enema, and surgery in the diagnosis and treatment of intussusception.

Intussusception in a tropical country: comparison among patient populations in Jakarta, Jogyakarta, and Amsterdam

BACKGROUND

Intussusception is the most common cause of intestinal obstruction in young children, and high mortality rates remain a problem in developing countries. The purpose of this study was to describe and elucidate the differences in outcome between groups of children with intussusception in Indonesia, a developing country, and The Netherlands, a developed country.

METHODS

In this retrospective review, 176 patients were studied in three types of hospitals. A comparison was made among children treated at a primary care rural hospital in Indonesia, at a secondary care urban hospital in Indonesia, and at a tertiary care urban hospital in The Netherlands.

RESULTS

Children in the rural community hospital in Indonesia were more severely ill at arrival and had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality rate of 20%, in contrast to a mortality rate of 3% in the urban hospital in Indonesia and no deaths in the Dutch hospital.

CONCLUSIONS

The mortality of children with intussusception in rural Indonesia is much higher than in urban Indonesia or in The Netherlands, probably because of delayed treatment, which results in more patients undergoing surgery in worse physical condition.

Heterotopic pancreas as lead point in intussusception: new variant of vitellointestinal tract malformation

Two cases of intussusception are reported with heterotopic pancreatic tissue attached to and draining into the ileum. The first patient, a boy aged 16 months, presented with ileoileal intussusception. The diagnosis was confirmed on ultrasound scan. Laparotomy and resection were performed. A 12-mm nodule of heterotopic pancreatic tissue was identified in the ileal serosa at the apex of the intussusceptum, fully formed with acinar tissue, islets, and draining duct. The second patient, also a boy aged 16 months, presented with obstructed ileocolic intussusception in which the lead point at surgery resembled a Meckel's diverticulum. Histopathology revealed a similar 10-mm nodule of fully formed pancreatic tissue in the ileal serosal tissues, with some acinar tissue extending through the wall of the intestine alongside ductal structures. In both cases there was ectopic gastric mucosa either in the distal part of the draining duct or in the small intestine itself at the opening. Heterotopic pancreas is a rare cause of intussusception. We propose that this lesion is of vitellointestinal tract origin, conceptually similar to a Meckel's diverticulum but without a diverticulum as such. Heterotopic pancreatic tissue occurring alone is more common in the proximal small intestine, duodenum, and stomach than in the ileum, and it is often asymptomatic.

Intussusception in children: current concepts in diagnosis and enema reduction

Intussusception cannot be reliably ruled out with clinical examination and plain radiography. However, a contrast material enema study and ultrasonography (US) allow definitive diagnosis of intussusception. The components of an intussusception produce characteristic appearances on US scans. These appearances include the multiple concentric ring sign and crescent-in-doughnut sign on axial scans and the sandwich sign and hayfork sign on longitudinal scans. Indicators of ischemia and irreducibility are trapped fluid at US and absence of blood flow at Doppler imaging. The aim of enema therapy is to reduce the greatest number of intussusceptions without producing perforation. Barium, water-soluble contrast media, water, electrolyte solutions, or air may be used with radiographic or US guidance. The differences in reduction and perforation rates between the various types of enemas are probably due more to perforations that occurred before enema therapy and the pressure exerted within the colon than to the contrast material used. The pressure within the colon is more constant with hydrostatic reduction than with air reduction; this fact may explain the lower risk of perforation with hydrostatic reduction. Radiation exposure is lower with air enema therapy than with barium enema therapy and is absent in US-guided enema therapy.

Intra-abdominal manifestations of Henoch-Schönlein purpura

Gastrointestinal involvement occurs in approximately two thirds of children with Henoch-Schönlein Purpura (HSP) and usually is manifested by abdominal pain. Abdominal symptoms precede the typical purpuric rash of HSP in 14-36%; the symptoms may mimic an acute surgical abdomen and result in unnecessary laparotomy. Major complications of abdominal involvement develop in 4.6% (range 1.3-13.6%), of which intussusception is by far the most common. The intussusceptum is confined to the small bowel in 58%; its frequent inaccessibility to demonstration by contrast enema means that ultrasonography is the investigation of choice. Ultrasonography complements serial clinical assessment, clarifies the nature of the gastrointestinal involvement and reduces the likelihood of unnecessary surgery. Bowel ischaemia and infarction, intestinal perforation, fistula formation, late ileal stricture, acute appendicitis, massive upper gastrointestinal haemorrhage, pancreatitis, hydrops of the gallbladder and pseudomembranous colitis are seen infrequently. Earlier diagnosis and prompt treatment of intra-abdominal complications has reduced the mortality from 40% to almost zero.

Bacterial wall lipopolysaccharide as a cause of intussusception in mice

BACKGROUND

There is evidence that intussusception is associated with bacterial infection. It was hypothesized that a component of the bacterial wall may induce the intussusception. This study was intended to determine whether lipopolysaccharide from Escherichia coli or Salmonella can initiate intussusception in mice.

METHODS

Lipopolysaccharide was injected intraperitoneally in mice, and the animals were examined for the presence of intussusception from 2 to 192 hours after injection. Gastrointestinal transit was assessed by measuring the passage of charcoal in the small intestine. Transit index was defined as the ratio between the distance traveled by charcoal and the total length of the small intestine.

RESULTS

Intussusceptions were found in as much as 25.9% of lipopolysaccharide-injected animals, whereas in control animals, the incidence was zero. The threshold for the lipopolysaccharide effect was at 4 mg/kg and incidence reached a plateau at 8 mg/kg to 16 mg/kg. The incidence of intussusception peaked 6 hours after injection of lipopolysaccharide and declined to zero after 15 hours. To test the possibility that lipopolysaccharide induces intussusception by altering motility, its effect on transit index was measured. A dose of 12 mg/kg lipopolysaccharide reduced the transit index from 56.2+/-1.4% to 37.7+/-2.1% (p < 0.05). No microscopic histologic changes were found in the bowels with intussusception.

CONCLUSIONS

Intraperitoneal bacterial wall lipopolysaccharide causes intussusception in mice by disturbing gastrointestinal motility.

Where should paediatric surgery be performed?

We have tried to review the evidence for the organisation of paediatric surgical care. Difficulties arise because of the lack of published data from district general hospitals concerning paediatric surgical conditions. Hence much of the debate about the surgical management of children is based on anecdotal evidence. However, at a time when the provision of health care is being radically reorganised to an internal market based on a system of purchasers and providers it is more important than ever to understand the issues at stake. Two separate issues have been discussed: the role of the specialist paediatric centre and the provision of non-specialist paediatric surgery in district general hospitals. There are arguments for and against large regional specialist paediatric centres. The benefits of centralisation include concentration of expertise, more appropriate consultant on call commitment, development of support services, and junior doctor training. The disadvantages include children and their families having to travel long distances for care, and the loss of expertise at a local level. If specialist paediatric emergency transport is available the benefits of centralisation far outweigh the adverse effects of having to take children to a regional paediatric intensive care centre. Specialist paediatric centres are aware of the importance of treating children and their parents as a family unit as highlighted by the Platt committee; this is an important challenge and enormous improvements have occurred to provide proper accommodation for families while their children are treated in hospital. To keep these arguments of large distances and separation from the home in context, one paediatric intensive care unit in Victoria, Australia, providing a centralised service to a region larger in are than England and with a similar admission rate, has a lower mortality rate than the decentralised paediatric intensive care provided in the Trent region of the UK. There is clear evidence that all neonatal surgery and anaesthesia should be conducted only by specialists. The debate now centres around the number of complex surgical cases a unit should treat to maintain its specialist status. The NHS executive, in its guidelines on contracting for specialist services, emphasises that "Sensible contracting needs to take into account the optimum population size not only for the stability of contracted referrals but also to give sufficient 'critical mass' for clinical effectiveness." Achieving this balance has consequences, not just for the maintenance of surgical expertise, but for the essential ancilliary services. There is clear evidence in anaesthesia that anaesthetists doing small numbers of neonatal procedures had significantly worse results. The same seems to be true in the fields of oncology, radiology, pathology, and intensive care. The reasons why the results of management of certain paediatric conditions are better at specialist centres are open to speculation. Presumably greater exposure to rare complex cases, concentration of expertise, more peer review, and a trickle down effect of the multidisciplinary approach all help to keep health care workers up to date with current world practice. In addition, it allows for appropriate specialist on call rotas and dedicated junior staff. If insufficient numbers of specialist surgical cases are being treated at a centre then the whole multidisciplinary team suffers. The 1989 NCEPOD report states "that paediatricians and general surgeons must recognise that small babies differ from other patients not only in size, and that they pose quite separate problems of pathology and management." The need for large centres of paediatric surgical expertise is now accepted by the Royal College of Surgeons of England, the British Association of Paediatric Surgeons, the Senate of Surgery of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, the Royal College of Anaesthetists, the Audit

Ileo-colic intussusception with an unusual retrograde colo-colic intussusception

An interesting case with both antegrade and retrograde intussusception in an infant is reported. There was no apparent predisposing cause.

Intussusception: agonal phenomenon or cause of death?

This paper describes two cases of small intestinal intussusception, one in a child and one in an adult, where the findings at autopsy were atypical. The significance of intussusception in this situation is discussed and the literature related to deaths accompanied by acute small intestinal intussusception in the adult and paediatric population is reviewed. It is concluded that the findings represent a true pathological entity and not an 'agonal' event.

Ileoileocolic intussusception in children: diagnosis and significance

The ileoileocolic type of childhood intussusception is difficult to diagnose pre-operatively and is associated with increased morbidity. This study describes the clinical and imaging features of 10 consecutive ileoileocolic intussusceptions diagnosed ultrasonically in 10 patients over a 36 month period. Ultrasound-guided hydrostatic reduction using Hartmann's solution was attempted in all 10 patients. Clinical and imaging features were compared with those of 28 ileocolic intussusceptions in 25 patients diagnosed and treated using the same methods during the same period. Most of the clinical and plain radiographic features of the patients with the ileoileocolic and ileocolic types of intussusception were similar. The two types of intussusception had the classical doughnut or pseudokidney, or both, signs on pre-reduction ultrasound scans. During the reduction process, when surrounded by fluid within the caecal lumen, the ileoileocolic type of intussusception had a typical complex appearance due to frond-like loops of intussuscepted small bowel. This finding was present in all cases. The hydrostatic reduction rate was only 10% (1/10) for ileoileocolic intussusception, compared with 92.9% (26/28) for the ileocolic type. All unsuccessfully-reduced cases underwent surgery, with surgical confirmation of the intussusception type in all cases. Only one patient was found to have a lead point, caused by a Meckel's diverticulum. In conclusion, the diagnosis of ileoileocolic intussusception can be made pre-operatively and these patients require surgical management.

Bilious vomiting in a 9-month-old infant

A case of bilious vomiting in a 9-month-old male is reported. The differential diagnosis of infantile bilious vomiting is reviewed, and appropriate diagnostic studies are discussed. The child was found to have intussusception. The common manifestation of this pediatric surgical emergency may vary considerably from classic descriptions. Bilious emesis in infants must be considered a surgical emergency until proven otherwise; intussusception may manifest as bilious vomiting only.

Ileocecal intussusception of small-bowel lymphoma: diagnosis by colonoscopy

Intussusception is rare in adults. There is little information on the role of colonoscopy in colonic intussusception. We report, to our knowledge, the first adult case of small-bowel lymphoma causing ileocecal intussusception in which the diagnosis was made by colonoscopy. Colonoscopy has a useful role in the diagnosis and management of ileocecal intussusception.

Controversies in abdominal imaging

Technologic improvement in ultrasound equipment, together with new clinical information, has altered the imaging of the abdomen in infants. Improvements in ultrasound equipment have allowed this to become the diagnostic test of choice for hypertrophic pyloric stenosis. Barium upper gastrointestinal radiography still remains the diagnostic test of choice for malrotation. New technologies for reduction of intussusception include air reduction and saline enemas with ultrasound monitoring. Controversies surrounding the different technologies and imaging strategies are discussed.

The contribution of inflammatory mediators and nitric oxide to lipopolysaccharide-induced intussusception in mice

Intussusception is a major cause for intestinal obstruction in children. Its etiology is unclear, but it is often associated with some kind of infection. We have developed a model for intussusception in mice using intraperitoneal (IP) injection of lipopolysaccharide (LPS). The objective of this study was to identify the putative mediators that participate in this LPS-induced intussusception. LPS (12 mg/kg) was injected into adult mice (N = 52) and 6 hr later, 25% of the animals demonstrated intussusception in the small or large intestine. We next tested whether nitric oxide (NO) or various inflammatory mediators contributed to this effect: Indomethacin (10 mg/kg) injected with LPS (12 mg/kg) completely prevented the effect of LPS (N = 20). The tumor necrosis factor (TNF) blocker pentoxifylline (200 mg/kg) significantly reduced the incidence of intussusception to 6.6% (N = 30). The platelet-activating factor (PAF) antagonist BN52021 (10 and 20 mg/kg) reduced the incidence of intussusception to 13.3% in both doses (N = 15 for each dose). Addition of 2% arginine (NO precursor) to the drinking water 36 hr before the injection of LPS increased the incidence of intussusception to 30.7% (N = 32). In mice injected with the NO synthase inhibitor L-NAME (20 mg/kg) only 3.8% developed intussusception (N = 26). Our results indicate that the induction of intussusception by LPS proceeds via parallel pathways involving cytokines, prostaglandins, and NO. Our previous pathological study showed that LPS did not cause any changes that may act as a lead point for the intussusception, suggesting that LPS induced intussusception by altering gut motility. We therefore propose that these mediators combine to induce disturbed gut motility that results in the formation of intussusception.

Intussusception: a 9-year survey (1986-1995)

BACKGROUND

Acute intussusception has different clinical features in various parts of the world. The goal of this study was to determine the clinical presentation in different ethnic groups in Israel.

METHODS

A retrospective chart review of a 9-year period (1985-1995) was carried out at a university medical center. Data extracted included age, sex, ethnic origin, presenting symptoms and signs, the type of enema (barium or air), and the success rate of non-surgical reduction of the intussusception.

RESULTS

Ninety patients suffering from intestinal obstruction due to acute intussusception were admitted. The triad of intermittent screaming attacks, lethargy, and vomiting was observed in 37.5% of study subjects. The majority of patients were admitted during the warmer months of the year. The average age of the patients was 7.8 +/- 3.7 months; 70% of them were between the ages of 4 and 9 months and 92.5% under 1 year of age. The female-to-male ratio was 1:2.1. Air enema was superior to the barium enema in achieving reduction (p < 0.01). The incidence in the Jewish population was similar to that observed in other surveys, and twice that found in the Arab population in our region (p < 0.05).

CONCLUSIONS

The overall clinical presentation of acute intussusception found in our study does not differ from other studies. The lower incidence of acute intussusception found in the Arab population can be explained by ethnic, genetic, or nutritional factors.

A comparison of colo-colic and ileo-colic intussusception

There are many differences in the clinical features of intussusception between African and temperate countries. The records of 192 patients with intussusception who presented to the Pediatric Surgical Service at King Edward VIII Hospital, Durban, South Africa during a 10-year period were reviewed. Compared with temperate countries, the patients were older (median, 1 year 7 months), presented later (median, 4.2 days), had a higher proportion of colo-colic lesions (17%), had absence of primary bowel pathology, and had a high surgical rate (82%). To define clinically important differences, the clinical and pathological features of 158 cases of ileo-colic intussusceptions were compared with 34 colo-colic cases. Compared with the ileo-colic group, colo-colic lesions occurred in older children (median, 3.8 years) (v 1.5 years; P < .001). In the colo-colic group, there were fewer shocked and pyrexial patients, and the rate of successful nonoperative reduction was higher. The groups had a similar incidence of surgical intervention (82%). In the ileo-colic group, there was a higher mortality rate and more complications, but only the higher resection rate (P < .001) was statistically significant.

Intussusception associated with Yersinia pseudotuberculosis infection

Intussusception associated with Yersinia pseudotuberculosis infection was developed in three boys; two of them had a history of drinking untreated water. All intussusceptions were localized at the ileocolic region, and all patients completely recovered with Gastrografin enema and supportive treatment without complication and operation.

Pediatric abdominal surgical emergencies

Pediatric abdominal surgical emergencies may present the primary physician with a diagnostic challenge. A systematic approach will help to minimize missed diagnoses and resultant complications. It always must be kept in mind that children often have atypical presentations of common entities. Prudent and directed use of laboratory and imaging studies will minimize misdiagnosis. The early involvement of surgical consultants in the care of pediatric patients who have significant abdominal symptoms or findings is always appropriate.