Paediatric intussusception

Ileal-ileal intussusception: an unusual complication following enterocystoplasty

Postoperative ileal-ileal intussusception is an unusual and uncommonly cited complication of bladder augmentation. The preoperative diagnosis is difficult due to the vague clinical findings. We report a case of ileal-ileal intussusception that occurred following gastrocystoplasty in a child. Computed tomography accurately diagnosed the condition preoperatively, and led to early exploratory laparotomy and successful reduction.

Intussusception presenting to a paediatric accident and emergency department

In a retrospective study, 110 patients episodes with intussusception presenting to a paediatric accident and emergency (A&E) department were reviewed, with particular attention being paid to presenting symptoms, time to diagnosis, radiological investigation, management and outcome. Between 1983 and 1993 100 patients presented to this department with 110 episodes of intussusception. Delay in diagnosis of greater than 12 h from initial medical contact was associated with increased morbidity. Associated factors in delayed diagnosis were departure from the classical symptoms (pain, vomiting and blood per rectum) and the presence of diarrhoea. General practitioner (GP) referral was to the medical team (rather than the surgical team) in around 50% of cases. Irrespective of the specialty of the first hospital doctor to see the patient only 42% were diagnosed correctly within 3 h of admission. In this population diarrhoea is a common symptom of intussusception and should alert the clinician rather than reassure. Because of its many presentations and relative rarity, intussusception remains a difficult condition to diagnose.

Perforation during attempted intussusception reduction in children--a comparison of perforation with barium and air

This paper compares the effects on patients of perforation with barium and with air during attempted intussusception reduction by reviewing the clinical, radiological, surgical and pathological findings and sequelae in seven children who received barium and seven who received air. In both groups perforation occurred in infants under 6 months of age (with one exception) with a long duration of symptoms. All patients with barium enema required resection of bowel whereas only four with air enema required resection. Anesthetic times were longer in those patients with barium perforation in whom the intussusception did not move and there was a large leak. The patients with perforation due to air had a shorter hospital stay with decreased morbidity compared to those with perforation due to barium. Perforation occurred through areas of transmural necrosis in a minority of patients in each group. Perforations through normal bowel and shear injury (with air enema) indicate that increased pressure during the examination is an important factor in some patients. Because perforation with air is so much easier to deal with surgically and the children do better clinically, there is a tendency for some to consider perforation with air an inconsequential situation. However, a potential rare complication with this technique is tension pneumoperitoneum. Keeping this in mind, we continue to use air as the contrast of choice because the procedure in our hands is a safe, quicker and easier technique and we have achieved a substantial improvement in reduction rates. Overall reported perforation rates with air enema compare favourably with those due to barium enema.(ABSTRACT TRUNCATED AT 250 WORDS)

Partially reduced intussusception: when are repeated delayed reduction attempts appropriate?

The imaging techniques for diagnosis and monitoring of reduction of intussusception by fluoroscopy and ultrasound continue to evolve. The common goal of all protocols is to reduce the intussusception by enema in as many patients as possible and avoid laparotomy with its potential morbidity. We report two infants in whom the initial attempt at reduction by air enema only achieved partial reduction, from the descending colon to the transverse colon in one, and from the splenic flexure to the caecum in the other. Both patients became asymptomatic and clinically stable. In light of the clinical stability, and in consultation with the surgeons, laparotomy was deferred. Sonography was used to confirm the persistence of the intussusception before repeat air enema several hours later. Following three further air enemas in each child, the intussusceptions were successfully reduced after 20 h and 24 h respectively. Both patients remained asymptomatic and did not require surgery. In infants with partially reduced intussusception we suggest that if the patient becomes asymptomatic and stable, surgery can be safely delayed to permit further attempts at enema reduction. Sonography has a valuable role in determining the persistence of the intussusception prior to repeat enema. Close cooperation with the surgeon and careful clinical monitoring of the patient are essential requirements for this proposal.

Pneumatic reduction of intussusception in children

The use of an air enema in the diagnosis and reduction of intussusception, using a simple home-made device, was prospectively studied in 36 children with the tentative diagnosis of intussusception. Plain abdominal films were inconclusive in 19 patients (53%). Using an air enema, the diagnosis of intussusception was easily reached or excluded in all suspected cases. Twenty-nine patients had intussusception. Their ages ranged from 3 to 20 months (mean: 7 months), and all had ileo-colic involvement. Pneumatic reduction was successful in 23 cases (79%), and reduction was completed within 2-3 minutes in all successfully reduced cases. At operation, three children had a tear of the sero-muscular layer of the transverse colon, but there were no perforations or recurrences of the intussusception in the immediate post-reduction or follow-up period (1-25 months). An air enema is a safe, cheap, clean and reliable procedure for the diagnosis and reduction of intussusception, and can now be considered as the treatment of choice in uncomplicated intussusception.

Ultrasonography is accurate enough for the diagnosis of intussusception

For more than 10 years the authors have been using ultrasonography to confirm clinically suspected intussusception without performing a contrast enema. The aim of this study is to review this diagnostic policy. Between 1980 and 1989, 163 children who, on clinical examination and plain abdominal radiographs were suspected of having intussusception, underwent ultrasonography to confirm the diagnosis. In 33 children, ultrasonography did not show intussusception; of the remaining 130 children, intussusception was diagnosed in 128. In two children in whom intussusception was noted subsequently, the diagnosis was not established on ultrasound. Thus, ultrasonography had a sensitivity of 98.5% and a specificity of 100% in the diagnosis of intussusception. It is a quick, simple, noninvasive method to diagnose intussusception, with high accuracy. The role of contrast enema is limited to therapeutic application.

Pneumatic reduction of intussusception: clinical experience and factors affecting outcome

Between 1987 and 1992, 54 patients (32 male, 22 female) underwent 62 attempts at pneumatic reduction of intussusception. The mean age at presentation was 12.5 months (range 2.5 to 4 years 4 months). A retrospective review of all cases was performed to identify success rate and factors affecting it. Successful reduction was achieved in 46 cases (74%). One case was complicated by perforation and four cases (7%) by early recurrence. Patients with failed pneumatic reduction were more likely than those with successful reduction to have: (1) long duration of symptoms; (2) bleeding per rectum; (3) small bowel obstruction. Among the 16 cases of failed reduction, surgical findings were: five cases of ileo-ileo-colic intussusception, one with ileo-ileal, one with perforated ischaemic colon during air enema and one whose intussusception was found to be reduced at surgery. Three patients had lead points: Meckel's diverticula in two and a pinworm in one. Resection was required in three cases for non-viable bowel and in another two for the Meckel's diverticula. Pneumatic reduction of intussusception offers a high success rate with few complications. Performing an air enema earlier in the course of the disease may increase the chance of successful reduction.