Paediatric intussusception

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.

Bypassing the Delay: Directing Pediatric Intussusception Cases to the OR Through Inflammatory Marker Assessment

INTRODUCTION

Intestinal necrosis represents as one of the most severe complications of intussusception. Various markers of systemic inflammation, such as neutrophil counts, CRP levels, albumin concentrations, platelet counts, and lymphocyte counts as well as combined ratios, such as lymphocyte-to-CRP ratio (LCR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and CRP-to-albumin ratio (CAR), have been proposed as valuable predictors for a variety of inflammatory conditions, making them useful biomarkers for inflammation. We investigated the effectiveness of different combinations of inflammatory markers in predicting intestinal necrosis and the need for intestinal resection in cases of intussusception.

PATIENTS AND METHODS

This is a retrospective cohort study that included 100 patients diagnosed with intussusception and needed surgical intervention after failed nonoperative reduction of intussusception. The patients were divided into two groups based on whether they had intestinal resection. Analysis was conducted on combinations of inflammatory markers, such as NLR, PLR, LCR, and CAR, to correlate with intraoperative findings for detecting the markers with the highest correlation with intestinal necrosis in intussusception patients.

RESULTS

A statistically significant higher mean CAR was observed among cases with resection (15.27 ± 6.74) compared to the nonresection group (3.56 ± 4.06). Conversely, the mean LCR was significantly lower in the resection group (0.116 ± 0.12) compared to the nonresection group (0.509 ± 0.33). The ROC analysis showed that the area under the curve (AUC) for LCR in differentiating cases requiring resection was excellent, with a best-detected cutoff point of 0.1233, yielding a sensitivity of 85.7% and specificity of 90%. Similarly, the AUC for CAR in differentiating cases needing intestinal resection was excellent, with a best-detected cutoff point of 7.73, yielding a sensitivity of 92.6% and specificity of 90%. Additionally, the CAR was a statistically significant predictor of the need for resection, with each unit increase in CAR increasing the risk by 1.42 (95% CI: 1.25-1.61).

CONCLUSION

The mean CRP-to-albumin ratio (CAR) is significantly higher in cases requiring intestinal resection compared to those that do not require resection. LCR also provides useful information and should be used alongside the CAR in the decision-making process. If a patient's CAR exceeds 7.73 and if LCR is below 0.1233, they are more likely to need surgery due to necrosis. Given its statistical significance, CAR should be used as a key marker for predicting the need for intestinal resection. For each one-unit increase in CAR, the risk of needing intestinal resection increases by 1.42 times, which can aid in prioritizing patients for surgery, avoiding treatment delays, and enhancing patient outcome.

Australia's rotavirus immunisation program: Impact on acute gastroenteritis and intussusception hospitalisations over 13 years

BACKGROUND

Australia was one of the first countries to include rotavirus vaccines in its National Immunisation Program, in 2007. We compared trends in acute gastroenteritis (AGE) and intussusception-coded hospitalisations over 13-year post-vaccine period against five-year pre-vaccine baseline.

METHODS

In a descriptive before-after study, incidence of hospitalisations with ICD-code of rotavirus AGE (A08.0), other AGE (K52, A01-A09 excluding A08.0) or intussusception (K56.1) between 2002 and 2020 was calculated using population denominators by age and Indigenous status. We used 2002-2006 as pre-vaccine baseline and calculated Incidence Rate Ratios [IRRs] for 2008-2019 and 2020.

FINDINGS

In children aged <5 years, mean annual hospitalisation rate/100,000 decreased by 85% for rotavirus-coded AGE, from 248.3 in 2002-2006 to 37.6 (IRR 0.15; 95% CI 0.15-0.16) in 2008-2019 (61.4% for Indigenous children, from 680.2 to 262.2), and 46% for other AGE, from 1274.5 to 689.1 (IRR 0.54; CI 0.54-0.55), decreasing further in 2020 to 6.3 (rotavirus-coded) and 445.0 (other AGE). Rates for rotavirus-coded and other AGE declined in 2008-2019 in those aged 5-<20 years (IRR 0.52; CI 0.49-0.56 and 0.86; CI 0.85-0.87, respectively), but increased in 20-<65 years (IRR 2.38; CI 2.01-2.83 and 1.15; CI 1.15-1.16) and ≥65 years (IRR 2.24; CI 1.91-2.62 and 1.24; CI 1.23-1.25). Average annual hospitalisation rate for intussusception in infants was similar in pre-vaccine and post-vaccine periods (IRR 0.97; CI 0.90-1.04).

CONCLUSION

Over a 13-year period post-rotavirus vaccine introduction we document major sustained declines in hospitalisations coded as rotavirus and other AGE in age groups <20 years, with no change in intussusception hospitalisation rates in infants. Despite small increases in AGE hospitalisations in adults, likely due to increased PCR testing, our findings are consistent with highly favourable risk benefit ratio at whole-of-population level in Australia.

Recurrent Ileocolic Intussusception in Children: A Scoping Review

Background: Intussusception is the most common cause of acute intestinal obstruction in children. It can be initial idiopathic intussusception or a recurrent intussusception (RI), and in this latter case, there is not a validated algorithm for optimal treatment. The aim of the study is to review the international literature to evaluate the incidence of RI, to determine the rates of surgical intervention and pathological leading point (PLP), and to define the most appropriate management for children with RI. We included English-written papers with pediatric population, excluding case reports, papers with adult or mixed cases, studies focusing on ileo-ileal or colo-colic intussusception, meta-analysis studies, or papers with unclear or replaced data. Results: A total number of 23 articles were included for a total of 26,731 patients affected by intussusception and 3164 recurrent patients (11.8%). The number of attempts of nonsurgical reduction ranged from 3 to 10 (median 5). On 2965 RI, 358 underwent surgery (12.1%). A pathologic leading point was found in 99 patients (3.95%). Conclusions: The presence of a PLP does not seem to be associated with the recurrence of intussusception. More than 85% of RI underwent successful nonsurgical management. RI should be safely approached in the same way as primary intussusception, and surgery should be reserved to cases where a PLP has been suspected. In cases of multiple episodes, surgery can be considered an effective way to avoid recurrences, and this possibility should be discussed with parents.

Adult ileocaecal intussusception caused by lipoma managed in a remote Western Australian hospital

Intussusception is rare in adults, making it a challenging and often delayed diagnosis. Patients may re-present with non-specific and subacute abdominal symptoms. Abdominal CT is the most sensitive imaging modality and is often required to make the diagnosis of intussusception. In contrast to the paediatric population, intussusception in adults is most often associated with a pathological lesion acting as a lead point. In adults, the lead point is often secondary to malignancy, though benign lesions can also be implicated. As such, surgical management with selective resection is the mainstay of treatment in adults. We describe a rare case of ileocaecal intussusception in an adult secondary to a large ileocaecal lipoma, successfully treated with laparotomy and resection in a remote Western Australian hospital. The increasing availability of CT imaging and skilled general surgeons in rural and remote Australia allows for the diagnosis and surgical management of such cases without inter-hospital transfer.

Developing and validating a nomogram for early predicting the need for intestinal resection in pediatric intussusception

Purpose

Develop and validate a nomogram for predicting intestinal resection in pediatric intussusception suspecting intestinal necrosis.

Patients & methods

Children with intussusception were retrospectively enrolled after a failed air-enema reduction in the outpatient setting and divided into two groups: the intestinal resection group and the non-intestinal resection group. The enrolled cases were randomly selected for training and validation sets with a split ratio of 3:1. A nomogram for predicting the risk of intestinal resection was visualized using logistic regression analysis with calibration curve, C-index, and decision curve analysis to evaluate the model.

Results

A total of 547 cases were included in the final analysis, of which 414 had non-intestinal necrosis and 133 had intestinal necrosis and underwent intestinal resection. The training set consisted of 411 patients and the validation cohort included 136 patients. Through forward stepwise regression, four variables (duration of symptoms, C-reaction protein, white blood cells, ascites) were selected for inclusion in the nomogram with a concordance index 0.871 (95% confidence interval: 0.834-0.908).

Conclusion

We developed a nomogram for predicting intestinal resection in children with intussusception suspecting intestinal necrosis after a failed air-enema based on multivariate regression. This nomogram could be directly applied to facilitate predicting intestinal resection in pediatric intussusception suspecting necrosis.

Intestinal ultrasonography in pediatric population

Bowel ultrasound (US) is a low-cost, non-invasive, bed side practice and a reproducible procedure that represents a high yield tool in clinical practice and in the diagnostic workup of a consistent group of acute and chronic gastrointestinal (GI) tract disease. Moreover, in case of GI diseases of neonatal and pediatric age, it allows an easier evaluation due to the small body size and scarce presence of fat tissue in the abdominal wall and peritoneal cavity and gas content. No particular preparation of the patient is needed, nevertheless a 3- to 5-hour fasting state improves the quality of the examination. The exam focuses on wall thickness and stratification, lumen content, distensibility and compressibility, presence of peristalsis of explorable segment of the GI tract and includes the investigation of mesentery, perivisceral tissues and nodes features. Color doppler flowmetry admits a qualitative evaluation of GI wall and mesentery vascularization. Healthy GI wall appears at a US evaluation as a multilayered structure in which hyperechoic and hypoechoic layers alternate sequentially. In this article we provide a quickly available overview on findings, signs and applications of US in major GI pediatric diseases.

The Changing Face of Childhood Intussusception: A Refinement in the Technique of Saline Reduction and Outcome

Aims

Intussusception is a common pediatric surgical emergency and an indicator for primary healthcare. We report our experience with childhood intussusception at a tertiary care hospital in the private sector in Central Kerala and add our refinement to the technique of hydrostatic saline reduction which had more desirable outcome.

Settings and Design

Children presenting with the diagnosis of intussusception which were managed in our department of pediatric surgery at a private hospital in Kerala, India.

Subjects and Methods

Eighty children, up to 15 years of age, (43 boys, 37 girls) confirmed to have intussusception on ultrasound and managed in our institution from October 2016 to July 2020 with hydrostatic saline reduction. Sixty-two (77%) of them were aged 3 months to 3 years (numbers <10 to be written in words); the age of idiopathic intussusception.

Statistical Analysis Used

SPSS V25. Association between variables using Chi square test and independent t test.

Results

A total of 80 children met the criteria out of that (n = 79) had successful nonoperative reduction. Hydrostatic saline enema 73, One Barium and five air enema. A child presented in shock was taken up for laparotomy and reduced operatively. Six recurred within 24 h (7% early recurrence) and a second attempt at nonoperative reduction succeeded in all six of them. (numbers <10 in words). Eleven children (14%) had a late recurrence, the attempt at saline hydrostatic reduction was successful in only 3 (27%) and 8 went on to have surgery. Six were successfully reduced operatively and 2 had resection anastomosis.

Conclusions

After excluding those who need surgery on clinical grounds, we report a 98.7% success with nonoperative reduction for the first instance of intussusception, a 24 h recurrence of 7%, with successful repeat reductions in all. With the refinement in the technique, we could achieve a desirable outcome. At the first presentation, surgery was indicated in 1 of the 80 children. We report a late recurrence rate of 14%, with a 27% success rate for nonoperative reduction. No pathological lead points were identified even in this group. All the children had an uneventful and a faster recovery. In our series, we had 97.5% follow-up rate.

Neutrophil-to-Lymphocyte Ratio as a Predictor of the Need for Surgical Treatment in Children's Intussusception

OBJECTIVE

 Neutrophil-to-lymphocyte ratio (NLR) is an emerging inflammatory marker in abdominal pathologies. Ileocolic intussusception (ICI) involves a progressive intestinal inflammation, and the effectiveness of nonsurgical treatment (enema) might be related to the inflammation degree, although no previous studies have investigated this relationship. Our aim is to identify predictors of the need for surgical treatment in ICI.

MATERIALS AND METHODS

 A single-center, retrospective, case-control study was performed in children with ICI, who were treated with initial nonsurgical management between 2005 and 2019. Patients were divided in two groups: A (effective enema) and B (need for surgery). Admission demographic and clinical and laboratory data were analyzed. Specificity and sensitivity of the different parameters as predictors of the need for surgical treatment were determined by receiver operating characteristic (ROC) curves.

RESULTS

 A total of 511 patients were included (410: group A; 101: group B), without statistically significant demographic differences. Group B presented significantly higher frequency of vomiting, bloody stools, and longer median time since symptoms onset (24 vs. 8 hours; p < 0.001). Group B presented higher median laboratory inflammatory markers than group A: NLR (6.8 vs. 1.8; p < 0.001), neutrophils (10,148 vs. 7,468; p < 0.001), and C-reactive protein (CRP; 28.2 vs. 4.7; p < 0.001). In ROC curve analysis, NLR had an area under the curve of 0.925, higher than neutrophil count (0.776; p = 0.001), CRP (0.670; p = 0.001), and time since symptoms onset (0.673; p = 0.001). It was estimated a cut-off point of NLR greater than 4.52 (sensitivity: 73.2%; specificity: 94.5%).

CONCLUSION

 High NLR values imply a high degree of bowel inflammation and might anticipate the need for surgical treatment in ICI in children.

LEVEL OF EVIDENCE

 III.

Appendiceal mucocele as an exceptional cause of ileocecocolic intussusception in adults: a case report

BACKGROUND

Intussusception is a rare condition in adults, accounting for 5% of intestinal intussusception and being responsible for approximately 1% of all adult bowel obstructions. Neoplastic origin is the most common etiology of intestinal intussusception in adults, unlike pediatric intussusception, which is usually idiopathic. Intussusception due to the appendiceal mucocele is exceptional, and only a few cases have been reported in the medical literature.

CASE PRESENTATION

We report the case of a 25-year-old black African male patient with no medical history. He presented to the emergency department for abdominal pain, nausea, and bilious vomiting. The abdominal examination revealed typical signs of acute bowel obstruction. Enhanced abdominopelvic computed tomography showed an invagination of the last ileal loop, cecum, and ascending colon into the lumen of the transverse colon, with a rounded image with hypodense content and some calcifications compatible with an appendiceal mucocele. An emergency exploratory laparoscopy was performed and confirmed the ileocecocolic intussusception. Right hemicolectomy and ileocolic anastomosis were performed. The patient recovery postoperatively was uneventful, and he was discharged 4 days later. Histological examination of the surgical specimen confirmed the diagnosis of mucinous cystadenoma.

CONCLUSION

The symptoms of bowel intussusception with the appendiceal mucocele as the lead point in adults are similar to any other bowel intussusception. Differential diagnosis is often carried out thanks to the injected abdominal computed tomography scan.

Is enema reduction in pediatric intussusception with a history of over 48 h safe: A retrospective cohort study

BACKGROUND

Intussusception is one of the most common acute abdominal diseases in children. Enema reduction is the first-line treatment for intussusception in good condition. Clinically, a history of disease over 48 h is usually listed as a contraindication for enema reduction. However, with the development of clinical experience and therapy, an increasing number of cases have shown that the prolongation of the clinical course of intussusception in children is not an absolute contraindication for enema treatment. This study aimed to analyze the safety and efficacy of enema reduction in children with a history of disease longer than 48 h.

METHODS

We conducted a retrospective matched-pair cohort study of pediatric patients with acute intussusception between 2017 and 2021. All patients were treated with ultrasound-guided hydrostatic enema reduction. According to the length of history, the cases were classified into two groups: history <48 h (<48 h group) and history greater than or equal to 48 h (≧48 h group). We generated a 1:1 matched-pair cohort matched for sex, age, admission time, main symptoms, and concentric circle size on ultrasound. Clinical outcomes were compared between the two groups, including success, recurrence, and perforation rates.

RESULTS

From January 2016 to November 2021, 2701 patients with intussusception were admitted to the Shengjing Hospital of China Medical University. A total of 494 cases were included in the ≧48 h group, and 494 cases with a history of <48 h were selected for matched comparison in the <48 h group. The success rates of the ≧48 h and <48 h groups were 98.18% vs. 97.37% (p = 0.388), and the recurrence rates were 13.36% vs. 11.94% (p = 0.635), showing no difference according to the length of history. The perforation rate was 0.61% vs. 0%, respectively, with no significant difference (p = 0.247).The comparison of the different history groups showed that in patients with bloody stools, the length of history had no significant effect on the enema reduction outcome(94.90% vs. 86.76%, p = 0.064).

CONCLUSIONS

Ultrasound-guided hydrostatic enema reduction is safe and effective for pediatric idiopathic intussusception with a history of ≧48 h.

Association of meteorological factors with paediatric intussusception in Hangzhou: an 8-year retrospective cohort study

OBJECTIVES

This study aimed to investigate the seasonality of paediatric intussusception and the associations between meteorological factors and paediatric intussusception in Hangzhou, as well as aimed to compare the variance in sex and disease type.

DESIGN

An 8-year retrospective study was conducted from January 2014 to December 2021 in the Children's Hospital of Zhejiang University, Hangzhou, China.

SETTING

This was a single-centre retrospective study review of intussusception cases in a large Children's Hospital in Hangzhou.

PARTICIPANTS

There were 17 674 patients with intussusception in this study.

METHODS

A Spearman correlation analysis and Poisson regression analysis were used to determine the association between weekly intussusception cases and meteorological factors. The seasonality of paediatric intussusception was demonstrated via the t-test and visualised.

RESULT

In January, May and December, there were relatively more intussusception patients. In February, there was a trough in the number of intussusception patients. Both the Spearman correlation analysis and Poisson regression analysis proved that weekly intussusception cases had significant associations with temperature (λ=-0.205, p<0.01; β=-0.080, p<0.01), feels-like temperature (λ=-0.214, p<0.01; β=-0.012, p<0.01), dew (λ=-0.249, p<0.01; β=0.095, p<0.01), humidity (λ=-0.230, p<0.01; β=-0.037, p<0.01), precipitation (λ=-0.148, p<0.01; β=-0.001, p<0.01), windspeed (λ=-0.135, p<0.01; β=0.005, p<0.01), visibility (λ=-0.206, p<0.01; β=-0.066, p<0.01), sea level pressure (λ=0.171, p<0.01; β=-0.004, p<0.01) and a total of 20 of 25 dynamic meteorological factors (p<0.05). These associations reflected gender differences but showed stronger associations in groups that were prone to recurrence.

CONCLUSIONS

Paediatric intussusception in Hangzhou showed a seasonal tendency. Additionally, intussusception was significantly associated with certain meteorological factors in all of the cases. These findings suggest that parents and paediatricians should be more vigilant about the occurrence of intussusception in children regarding seasonal change times and climate change times.

Intussusception of the bowel in a young woman: A case report

Intussusception is a condition in which a segment of the gastrointestinal tract invaginates into the lumen of another segment. Adult intussusception is less common than juvenile intussusception in terms of cause, appearance, and treatment. Because the clinical picture can be quite atypical and difficult to interpret, it is frequently misdiagnosed at first. Herein, we report the case of a previously healthy 23-year-old female patient who presented to the Emergency Department (ED) with acute abdominal pain, vomiting, and diarrhea for 1 day following her last menstrual period. Ileocecal intussusception was discovered throughout the investigation. She was rushed for open abdominal surgery. Meckel's diverticulum was found as a pathologic lead point in the resected specimen, with no evidence of malignancy. Although intussusception is rare in adults, it should be considered in patients who have nonspecific stomach pain.

Unsuspecting Lead Points Causing Nonobstructing Intussusceptions in Pediatric Patients Presenting with Chronic Pain Abdomen

Intussusception is one of the common causes of bowel obstruction in pediatric age group and is of idiopathic variety in most of the cases. Nonobstructing intussusception presenting with nonspecific symptoms (or chronic pain abdomen) is rare and usually clinically misdiagnosed/difficult to diagnose. The authors present a pictorial review of 10 cases of pediatric nonobstructing intussusception presenting with acute/chronic abdominal pain which were not suspected clinically but diagnosed with a pathologic lead point radiologically.

Long-Term Impact of a Low-Cost Paediatric Intussusception Air Enema Reduction Simulation-Based Education Programme in a Low-Middle Income Country

INTRODUCTION

Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Low- and Middle-Income Countries (LMICs) undergo an invasive operative intervention. Supported by simulation-based education (SBE), the Air Enema (AE) non-operative technique was introduced in 2016 in Myanmar. This study assesses the long-term outcomes.

METHODS

Mixed methods study design over 4 years including clinical outcomes and surgeon's attitudes towards the AE technique and SBE. Prospectively collected clinical outcomes and semi-structured interview with reflexive thematic analysis (RTA). Primary outcome measure was a long-term shift to non-operative intervention.

SECONDARY OUTCOMES

Length of Stay (LoS), recurrence rates, intestinal resection rates, compared to the operative group. The data was analysed according to intention to treat. Quantitative data analysis with Mann-Whitney U test, Fisher's exact test, Student's T-Test or Wilcoxon Signed-Rank Test utilised. A p-value of <.05 was considered significant.

RESULTS

A total of 311 infants with intussusception were included. A sustained shift to AE was revealed with high success rates (86.1-91.2%). AE had a reduced LoS (4 vs. 7 days p ≤ 0.0001), Duration of Symptoms (DoS) was lower with AE (1.9/7 vs. 2.5/7, p = 0.002). Low recurrence rates (0-5.8%) and intestinal resection rates stabilised at 30.5-31.8% vs.15.3% pre-intervention. Four RTA themes were identified: Expanding conceptions of healthcare professional education and training; realising far reaching advantages; promoting critical analysis and reflective practice of clinicians; and adapting clinical practice to local context. RTA revealed an overall positive paradigm shift in attitudes and application of SBE.

CONCLUSIONS

A sustained change in clinical outcomes and appreciation of the value of SBE was demonstrated following the intervention.

The impact of social distancing during the COVID-19 pandemic on rates of pediatric idiopathic intussusception

BACKGROUND

The causes of idiopathic ileocolic intussusception are unknown, with infection as the most likely culprit. Recently, social distancing measures were implemented during the coronavirus disease 2019 (COVID-19) pandemic to decrease transmissible infectious diseases, creating an opportune setting to study the role of infection on the pathogenesis of intussusception on a population level.

OBJECTIVE

To investigate the impact of social distancing on intussusception.

MATERIALS AND METHODS

We retrospectively reviewed air contrast enemas and pylorus ultrasounds performed between March 2010 and March 2021 to identify cases of ileocolic intussusception and hypertrophic pyloric stenosis (HPS), using the latter as a negative control. The study time frame was divided into two periods: pre-pandemic (March 2010-February 2020) and pandemic (April 2020-March 2021). The number of cases that occurred in these two time periods were compared using the Poisson regression model.

RESULTS

Of the 407 cases of idiopathic ileocolic intussusception identified, 396 occurred in the pre-pandemic time period (mean = 39.6 per 12-month period) and 11 occurred in the 12-month pandemic time period. The mean monthly number of intussusceptions showed a decline of 72% (95% confidence interval [CI] 49-85%) between the pre-pandemic and pandemic time periods (3.3 vs. 0.9 monthly cases; P < 0.001). In contrast, the mean monthly number of HPS did not differ significantly (P = 0.19).

CONCLUSION

Social distancing-imposed to curb the spread of infection during the COVID-19 pandemic-resulted in a significant decline in ileocolic intussusception, lending strong support to the theory that infection is the dominant cause of intussusception.

A promising new predictive factor for detecting bowel resection in childhood intussusception: the lymphocyte-C-reactive protein ratio

Background

The most critical concern for the management of childhood intussusception is bowel resection due to intestinal ischemia and necrosis. The early prediction of this problem is of great importance. We investigated the value of various combinations of inflammatory factors to predict intestinal necrosis and resection.

Methods

We retrospectively reviewed the medical records of pediatric patients with intussusception who underwent surgical management. During the research period, 47 patients who underwent intestinal resection due to intestinal necrosis and 68 patients who did not undergo intestinal resection were enrolled. We evaluated the diagnostic value of various combinations of inflammatory markers from preoperative laboratory analyses using the receiver operating characteristic (ROC) method.

Results

In the current cohort, 115 patients underwent operations for intussusception; among them, 47 patients (40.9%) underwent intestinal resections. In the patients with intestinal resection, the neutrophil count(p = 0.013), CRP level(p = 0.002), platelet–lymphocyte ratio (PLR, p = 0.008), NLR (neutrophil–lymphocyte ratio, p = 0.026), and LCR (lymphocyte–CRP ratio, p < 0.001) values were significantly higher than those in the patients without any resection. The receiver operating characteristic (ROC) analysis results showed that the combination of lymphocytic count along with C-reactive protein levels (LCR) demonstrated the highest correlation with intestinal resection due to intussusception compared with other parameters in the patients, with a sensitivity of 0.82 (0.73–0.86) and specificity of 0.80 (0.57–0.94) for the diagnosis of strangulation.

Conclusion

The preoperative LCR level is a useful marker to predict the need for intestinal resection due to intestinal necrosis in patients with intussusception.

COVID-19 Can Cause Severe Intussusception in Infants: Case Report and Literature Review

COVID-19 may cause intussusception in infants. We report on a case of severe ileo-colic intussusception in an infant with COVID-19 who required an ileo-colic resection. A literature review revealed 9 other cases with COVID-19 and intussusception. In this article, we will discuss the management and treatment of the first reported case of intussusception associated with COVID-19 in Italy.

Gastroduodenal Intussusception Due to Gastric Mucosal Prolapse Polyp in a 2-Year-Old Child

Gastroduodenal intussusception is an invagination of a portion of the stomach into the duodenum. It predominately occurs in adults. Case Report: We present a gastroduodenal intussusception in an hypochromic microcytic anemic 2-year-old girl. A large filling defect in the second and third parts of the duodenum, indenting the pyloric antrum, was due to a gastroduodenal intussusception secondary to a cauliflower-like gastric mucosal prolapse polyp, a type of gastric hyperplastic polyp. Conclusion: Anemia may accompany a gastric mucosal prolapse polyp.

Epidemiology of Intussusception Hospitalizations in Children Under 2 Years of Age Post Rotavirus Vaccine Introduction in Tamil Nadu and Puducherry, India

OBJECTIVE

High burden of rotavirus associated diarrhea has been documented among Indian children. The phased introduction of an indigenous rotavirus vaccine 'ROTAVAC' in India's national immunization programme began in 2017. Phase-III trial showed the vaccine to have a low-intussusception-risk profile. However, evaluation of post-licensure trends of intussusception is necessary to assess potential vaccine-associated intussusception risk. This study's objective was to describe the epidemiology of intussusception hospitalizations in children under two years of age in Tamil Nadu and Puducherry following ROTAVAC introduction.

METHODS

A cross-sectional surveillance was established in six hospitals in Tamil Nadu and Puducherry. Children under two years of age with intussusception fulfilling Brighton Collaboration's criteria for level 1 diagnostic certainty were enrolled. Patient and disease characteristics were captured using a standardized questionnaire. Descriptive and inferential statistical analyses were performed using Stata Version 13.

RESULTS

Overall, 287 cases were enrolled and had a median age of seven months. Frequently presenting symptoms were vomiting (78%), abdominal pain (76%), and blood in stool (71%). Abdominal ultrasonography or radiography confirmed diagnosis in 65% of cases and managed by nonoperative measures. Remaining 35% of cases were diagnosed and managed with surgery. Over 98% of the cases had positive treatment outcomes. Age less than five months (OR = 4.36), and hospitalization at a state government health facility (OR = 5.01) were significant predictors for children to receive surgical management.

CONCLUSIONS

The present study documents the epidemiology of intussusceptions immediately after the rollout of rotavirus vaccine in Tamil Nadu and Puducherry. No appreciable increase in intussusception hospitalizations was seen in the study hospitals after vaccine introduction.

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.

Deep learning algorithms for detecting and visualising intussusception on plain abdominal radiography in children: a retrospective multicenter study

This study aimed to verify a deep convolutional neural network (CNN) algorithm to detect intussusception in children using a human-annotated data set of plain abdominal X-rays from affected children. From January 2005 to August 2019, 1449 images were collected from plain abdominal X-rays of patients ≤ 6 years old who were diagnosed with intussusception while 9935 images were collected from patients without intussusception from three tertiary academic hospitals (A, B, and C data sets). Single Shot MultiBox Detector and ResNet were used for abdominal detection and intussusception classification, respectively. The diagnostic performance of the algorithm was analysed using internal and external validation tests. The internal test values after training with two hospital data sets were 0.946 to 0.971 for the area under the receiver operating characteristic curve (AUC), 0.927 to 0.952 for the highest accuracy, and 0.764 to 0.848 for the highest Youden index. The values from external test using the remaining data set were all lower (P-value < 0.001). The mean values of the internal test with all data sets were 0.935 and 0.743 for the AUC and Youden Index, respectively. Detection of intussusception by deep CNN and plain abdominal X-rays could aid in screening for intussusception in children.

Clinical predictors and outcome of bowel resection in paediatric intussusception

Introduction

Surgery remains the mainstay in treating intussusception in developing countries, with a correspondingly high bowel resection rate despite a shift to non-operative reduction in high-income countries.

Objective

To assess factors associated with bowel resection and the outcomes of resection in childhood intussusception.

Methods

A review of children with intussusception between January 2006 and December 2015 at the University College Hospital, Ibadan, Nigeria. The patients were categorized based on the need for bowel resection and analysis done using the SPSS version 23.

Results

121 children were managed for intussusception during this period. 53 (43.8%) had bowel resection, 61 (50.4%) did not require resection and 7 (5.8%) were unknown. 40 (75.5%) of the resections were right hemi-colectomy. The presence of fever, abdominal pain, distension, rectal mass, age < 12 months, heart rate > 145/min and duration of symptoms > 2 days were associated with the need for bowel resection (p < 0.05). However, only age and abdominal pain independently predicted need for resection. Bowel resection was more associated with development of post-operative complications and prolonged hospital stay (p < 0.05).

Conclusion

Infants presenting with abdominal pain and abdominal distension after two days of onset of symptoms were more likely to require bowel resection. Resection in intussusception significantly increased post-operative complications and length of hospital stay.

Radiographic findings predictive of irreducibility and surgical resection in ileocolic intussusception

BACKGROUND

Ileocolic intussusception is a common cause of intestinal obstruction in young children. Radiographs may be of limited value in the diagnosis of intussusception and are sometimes utilized primarily to exclude pneumoperitoneum before therapeutic enema reduction.

OBJECTIVE

The goal of this study was to determine if radiographic findings in ileocolic intussusception can offer prognostic information regarding the outcome of therapeutic air enema and, for those requiring surgical intervention, surgical outcomes and/or complications.

MATERIALS AND METHODS

A single institution retrospective study was performed including all enemas for intussusception performed during a 5-year period from September 2012 to August 2017. Radiographs obtained before therapeutic enema, including our institution radiographs, outside facility radiographs, or scout images obtained during fluoroscopy or computed tomography (CT), were independently scored by two pediatric radiologists for normal bowel gas pattern, soft-tissue mass, paucity of bowel gas, meniscus sign and bowel obstruction. The reviewers were blinded to enema and surgical outcomes at the time of review. Differences were resolved by consensus. Cases were excluded in which there was no adequate pre-procedure radiograph. In total, 182 cases were reviewed. The medical records were reviewed for enema and surgical outcomes.

RESULTS

Radiographic findings included normal bowel gas pattern in 13%, soft-tissue mass in 26%, paucity of bowel gas in 65%, meniscus sign in 12% and obstruction in 10% of the cases, with 17.5% of patients having more than one finding. In patients with bowel obstruction on radiographs, there was a statistically significant decrease in success of therapeutic enema (83% vs. 21%, P=0.0001), increase in complicated surgical reductions (47% vs. 4%, P=0.0012), and increase in bowel resection (42% vs. 4%, P=0.003) compared to patients with normal bowel gas pattern.

CONCLUSION

Radiographs can offer prognostic information regarding the potential for therapeutic enema success, as well as potential surgical outcomes in patients failing enema reduction. Particularly, bowel obstruction significantly decreases the success of therapeutic enema and increases the need for bowel resection.

Incidence of recurrent intussusception in young children: A nationwide readmissions analysis

BACKGROUND/PURPOSE

Recurrent intussusception following successful nonoperative reduction has previously been reported with a frequency of 8%-12% based on data from individual institutions. Meanwhile, the timing of discharge after successful reduction continues to be debated. Here, we evaluate readmissions for recurrent intussusception in young children using a large-scale national database.

METHODS

The National Readmissions Database (2010-2014) was queried to identify young children (age < 5 years) diagnosed with intussusception. We compared procedures performed during the index admission and frequency of readmissions for recurrent intussusception. Results were weighted for national estimates.

RESULTS

We identified 8289 children diagnosed with intussusception during an index admission. These patients received definitive treatment with nonoperative reduction alone (43%), surgical reduction (42%), or bowel resection (15%). Readmission for recurrent intussusception was required for 3.7% of patients managed with nonoperative reduction alone, 2.3% of patients that underwent surgical reduction, and 0% of those that underwent bowel resection. Median time to readmission was 4 days after nonoperative reduction, and only 1.5% of these patients experienced recurrence within 48 h of discharge.

CONCLUSIONS

Recurrent intussusception may be substantially less common than previously reported. Our findings support the practice of discharge shortly after successful nonoperative reduction.

TYPE OF STUDY

Retrospective, prognosis study.

LEVEL OF EVIDENCE

III.

Pediatric emergency gastrointestinal ultrasonography: pearls & pitfalls

Ultrasonography is an essential tool in pediatric imaging, particularly in the emergency setting. Although ultrasound is often the favored initial modality for abdominal imaging in children, it is highly operator-dependent and therefore prone to misinterpretation which can lead to false positive or negative exams, or even incorrect diagnoses. Conditions discussed in this series include ileocolic intussusception, hypertrophic pyloric stenosis, appendicitis, and ingested foreign bodies. We will review diagnostic criteria, highlight crucial findings, and illustrate commonly-encountered difficulties and mimics.

Risk Factors Associated With Increased Mortality From Intussusception in African Infants

OBJECTIVES

Morbidity and mortality from intussusception, the leading cause of bowel obstruction in infants, is higher in Africa than in other regions of the world, but the reasons have not been well examined. We sought to identify risk and protective factors associated with death or intestinal resection following intussusception.

METHODS

Infants with intussusception from 7 sub-Saharan African countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) were enrolled through active, hospital-based surveillance from February 2012 to December 2016. We examined demographic, clinical, and socioeconomic factors associated with death or intestinal resection following intussusception, using multivariable logistic regression.

RESULTS

A total of 1017 infants <1 year of age with intussusception were enrolled. Overall, 13% of children (133/1017) died during the hospitalization, and 48% (467/966) required intestinal resection. In multivariable analyses, female sex [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.2-3.3], longer duration of symptoms before presentation (OR 1.1; 95% CI 1.0-1.2), and undergoing intestinal resection (OR 3.4; 95% CI 1.9-6.1) were associated with death after intussusception. Diagnosis by ultrasound or enema (OR 0.4; 95% CI 0.3-0.7), and employment of a household member (OR 0.7; 95% CI 0.4-1.0) were protective against intestinal resection.

CONCLUSIONS

Delays in hospital presentation and female sex were significantly associated with death, whereas higher socioeconomic status and availability of radiologic diagnosis reduced likelihood of undergoing resection. Efforts should be intensified to improve the awareness, diagnosis, and management of intussusception in sub-Saharan African countries to reduce morbidity and mortality from intussusception in these resource-limited settings.

Colocolic intussusceptions in children: a pictorial essay and review of the literature

Colocolic intussusception is a variation of intussusception that is rarely encountered in pediatric patients and as such can prove to be a diagnostic challenge for both the emergency clinician and radiologist. Knowledge of the presentation and imaging findings in these cases can expedite diagnosis and guide the patient to appropriate treatment. The demographics, clinical symptoms, imaging findings, and eventual surgical and pathologic outcomes of 8 children with colocolic intussusception will be presented in this pictorial essay, with a review of the available literature.

Clinical characteristics and surgical outcome in children with intussusceptions secondary to pathologic lead points: retrospective study in a single institution

BACKGROUND

Intussusception secondary to pathologic lead points (PLPs) is a potential surgical emergency and almost all cases need surgery. The aim of this study was to evaluate the clinical manifestations, physical examinations and surgical outcomes of secondary intussusception (SI) caused by PLPs, as well as to improve the diagnosis and treatment of PLPs in children and infants.

MATERIALS AND METHODS

We retrospectively reviewed the records of 83 children and infants who were diagnosed with intussusception secondary to PLPs in our institution. The ultimate diagnosis was dependent on histopathological findings under a microscope by a pathologist. Patients were divided into a younger group (< 2 years old) and the older group (> 2 years old) according to age. Patient demographics, clinical manifestations, duration of symptoms, auxiliary examinations, and the presence of pathological lead point were recorded.

RESULTS

A total of 83 patients were found with intussusception secondary to PLPs in this study. Patients were aged from 4 days to 14 years, with a mean age of 3.8 years (median 1.5; range 0-14 years). There were 47 cases in the younger group and 36 cases in the older group. The main clinical symptoms were intermittent crying or abdominal pain. PLPs were observed in only ten patients on US (12%). Ten patients underwent enteroscopy examination for further diagnosis, and all the patients had positive findings including seven cases of Peutz-Jeghers syndrome and three cases of benign polyps. Technetium-99 m pertechnetate scans were performed in ten patients and five patients had positive results (50%). Based on the surgical findings, complex/compound is the most common type of intussusception, followed by small intestinal and ileo-colic type. The main types of PLPs were Meckel's diverticulum (n = 31), duplication cyst (n = 19) and benign polyps (n = 13). Meckel's diverticulum and intestinal duplication were the most common causes of secondary intussusception among children younger than 2 years, accounting for 81% (38/47) of the cases. The most common causes of secondary intussusception in children older than 2 years were intestinal polyps, Meckel's diverticulum and Peutz-Jeghers syndrome, accounting for 72% (26/36) of the cases.

CONCLUSIONS

The presence of a pathological lead point is more likely in older children. The most common types of intussusception secondary to PLPs are complex/compound and small intestinal. Meckel's diverticulum and intestinal duplication were the most common causes of secondary intussusception among younger children and Peutz-Jeghers syndrome and intestinal polyps were commonly seen in older children.

Clinical presentation of intussusception in Swedish children under 3 years of age and the validity of diagnostic coding

PURPOSE

Intussusception has been associated with rotavirus vaccine. The rotavirus vaccine will soon be introduced in the Swedish national immunization program. A validation of the diagnosis of intussusception among Swedish children in the Swedish National Patient Register is needed, as a basis for future vaccine safety surveillance by Swedish registers.

METHODS

This diagnostic study reviewed the medical admission records of 392 Swedish children with intussusception from 1987 to 2013. The records were randomly selected by The National Board of Health and Welfare from all Sweden and from both pediatric and pediatric surgery care. Positive predictive values (PPV) were calculated to study the concordance between the diagnosis coded in the Swedish Patient Register and the accepted international criteria of case definitions.

RESULTS

The PPV for a definitive diagnosis, based on certain radiology findings or surgery, was 84%. When clinically probable cases were added the PPV was 87%. When cases of possible intussusception were added the PPV was 89%. The PPV for the 240 children under 1 year was 88%.

CONCLUSION

Swedish health care registers can be used in the evaluation of incidences of intussusception when rotavirus vaccine will be introduced, due to a high validity of the diagnosis of intussusception in the registers.

Safety study of live, oral human rotavirus vaccine: A cohort study in United States health insurance plans

As part of a regulatory commitment for post-licensure safety monitoring of live, oral human rotavirus vaccine (RV1), this study compared the incidence rates (IR) of intussusception, acute lower respiratory tract infection (LRTI) hospitalization, Kawasaki disease, convulsion, and mortality in RV1 recipients versus inactivated poliovirus vaccine (IPV) recipients in concurrent (cIPV) and recent historical (hIPV) comparison cohorts. Vaccine recipients were identified in 2 claims databases from August 2008 – June 2013 (RV1 and cIPV) and January 2004 – July 2008 (hIPV). Outcomes were identified in the 0–59 days following the first 2 vaccine doses. Intussusception, Kawasaki disease, and convulsion were confirmed via medical record review. Outcome IRs were estimated. Incidence rate ratios (IRRs) were obtained from Poisson regression models. A post-hoc self-controlled case series (SCCS) analysis compared convulsion IRs in a 0–7 day post-vaccination period to a 15–30 day post-vaccination period. We identified 57,931 RV1, 173,384 cIPV, and 159,344 hIPV recipients. No increased risks for intussusception, LRTI, Kawasaki disease, or mortality were observed. The convulsion IRRs were elevated following RV1 Dose 1 (cIPV: 2.07, 95% confidence interval [CI]: 1.27 – 3.38; hIPV: 2.05, 95% CI: 1.24 – 3.38), a finding which is inconclusive as it was observed in only one of the claims databases. The IRR following RV1 Dose 1 in the SCCS analysis lacked precision (2.40, 95% CI: 0.73 – 7.86). No increased convulsion risk was observed following RV1 Dose 2. Overall, this study supports the favorable safety profile of RV1. Continued monitoring for safety signals through routine surveillance is needed to ensure vaccine safety.

A Case of Jejunal Intussusception caused by Burkitt Lymphoma in an Acquired Immunodeficiency Syndrome Patient

Non-Hodgkin's lymphoma of B-cell type is the second most common neoplasm after Kaposi's sarcoma among patients with human immunodeficiency virus infection. Most non-Hodgkin's lymphoma cases that are associated with acquired immunodeficiency syndrome (AIDS) involve extranodal sites, especially the digestive tract and the central nervous system. We report a case of multiple jejunal intussusception caused by Burkitt lymphoma in a 42-year-old AIDS patient. Upper gastrointestinal endoscopy and surgical biopsy were performed and a complete diagnostic study including histological and immunohistochemical analyses showed Burkitt lymphoma.

Intussusception-related Hospitalizations Among Infants Before and After Private Market Licensure of Rotavirus Vaccines in Taiwan, 2001-2013

INTRODUCTION

Rotavirus is a leading cause of acute gastroenteritis among Taiwanese children. Two globally licensed rotavirus vaccines recommended for inclusion in routine immunization programs that have been available for private market use in Taiwan since 2006 have been associated with a low risk of intussusception in postmarketing studies conducted in several countries. Our objective was to examine trends and characteristics of intussusception hospitalizations in Taiwan among children <12 months of age before and after rotavirus vaccine licensure to provide updated baseline and early postlicensure data.

METHODS

We extracted data on intussusception-related hospitalizations among children <12 months of age during 2001-2013 from the National Health Insurance Research Database. We examined patient demographics, clinical outcome and hospitalization trends, focusing on recommended ages for rotavirus vaccination (6-14, 15-24 and 25-34 weeks). We compared mean hospitalization rates for prevaccine licensure years 2001-2005 with those for postvaccine licensure years 2007-2013 using Poisson regression analysis.

RESULTS

During 2001-2013, 1998 intussusceptions hospitalizations were recorded. The mean age of hospitalization was 33 weeks. Almost all children recovered; 3 deaths occurred. The overall intussusception hospitalization rate was 75.1 per 100,000; seasonality was not evident. Hospitalization rates were greatest in children ≥25 weeks of age and occurred more frequently in boys. Prevaccine and postvaccine licensure trends in annual hospitalization rates did not significantly differ. However, mean hospitalization rates were lower during the postvaccine licensure period for children <12 months of age (rate ratio: 0.84, 95% confidence interval: 0.76-0.92) with the greatest decline among children 25-34 weeks of age (rate ratio: 0.66, 95% confidence interval: 0.55-0.78).

CONCLUSIONS

Infant intussusception in Taiwan occurs at a rate within the range of other Asian countries is rare among children <3 months of age, has a male predominance and does not have a clear seasonality pattern. We did not observe a postlicensure increase in intussusception hospitalization rates in children 6-14 weeks of age.

Intussusception: past, present and future

Intussusception is a common etiology of acute abdominal pain in children. Over the last 70 years, there have been significant changes in how we diagnose and treat intussusception, with a more recent focus on the role of ultrasound. In this article we discuss historical and current approaches to intussusception, with an emphasis on ultrasound as a diagnostic and therapeutic modality.

Risk factors associated with intestinal necrosis in children with failed non-surgical reduction for intussusception

BACKGROUND

Intestinal necrosis is the most serious complication of intussusception. The risk factors associated with intestinal necrosis in pediatric patients with intussusception have not been well characterized.

OBJECTIVE

This study aimed to investigate the risk factors associated with intestinal necrosis in pediatric patients with failed non-surgical reduction for intussusception.

METHODS

Hospitalized patients who failed the air-enema reduction for intussusception in the outpatient department and subsequently underwent surgery were retrospectively reviewed. All cases were categorized into two groups: intestinal necrosis group and non-intestinal necrosis group based on the surgical findings. Demographic and clinical features including the findings from the surgery were recorded and analyzed. Factors associated with intestinal necrosis were analyzed using univariate and multivariate unconditional logistic regression analyses.

RESULTS

A total of 728 cases were included. Among them, 171 had intestinal necrosis at the time of surgery. The group with intestinal necrosis had a longer duration of symptom or length of illness (P = 0.000), and younger (P = 0.000) than the non-intestinal necrosis group. Complex/compound type of intussusceptions is more likely to have intestinal necrosis. Multivariate analysis showed that the presence of grossly bloody stool (OR = 2.12; 95% CI 1.19-3.76, P = 0.010) and duration of symptom (OR = 1.07; 95% CI 1.06-1.08, P = 0.000) were independent risk factors for intestinal necrosis in patients hospitalized for surgical reduction for intussusceptions.

CONCLUSION

At time of admission, the presence of bloody stools and duration of symptom are the important risk factors for developing intestinal necrosis for those patients who failed non-surgical reduction. The length of illness has the highest sensitivity and specificity to correlate with intestinal necrosis. This finding may suggest that we should take the intussusception cases that have the longer duration of symptom directly to operation room for reduction.

Clinical and Ultrasonographic Features of Secondary Intussusception in Children

OBJECTIVES

The aim of this study was to review the ultrasonographic features of secondary intussusception (SI) in children and assess the value of ultrasound in the diagnosis of pediatric SI.

METHODS

The authors performed a retrospective analysis on the ultrasound findings of 1977 cases of primary intussusception (PI) and 37 cases of SI in children. The SI cases were diagnosed by ultrasonography and confirmed by laparotomy or histopathologic diagnosis. The clinical and ultrasonographic features were analyzed and compared between these two groups.

RESULTS

The age, no flatus or defecation, position, diameter and length of intussusception, the presence of free intraperitoneal liquid, and intestinal dialation at the proximal end present, all contributed to the differentiation between PI and SI (all P < 0.05). Ultrasound was able to demonstrate the pathological lead point (PLP) shadows in all of the 37 SI cases, either in the cervical part or intussusceptum of the intussusception. Among the 37 SI patients, 21 cases (56.8 %) were accurately categorized with lesions, including intestinal polyps, cystic intestinal duplication, intestinal wall lymphoma, and a small part of Meckel's diverticulum.

CONCLUSIONS

Ultrasound can be used as a feasible and effective method to discriminate PI from SI. Once the PLP is detected, a definite diagnosis can be made.

KEY POINTS

• The clinical and ultrasonographic features were compared between SI and PI. • The age, location, diameter and length of intussusception, and intestinal dilation were distinguishing features. • The causes of SI were found to be polyps, intestinal duplication, lymphoma, and Meckel's diverticulum. • Ultrasound can be used as an important method to diagnose SI. • Demonstration and confirmation of PLP are vital to diagnosing SI.

Rotavirus vaccination and intussusception - Science, surveillance, and safety: A review of evidence and recommendations for future research priorities in low and middle income countries

As of January 2016, 80 countries have introduced rotavirus vaccines into their national immunization programs. Many have documented significant declines in rotavirus-specific and all-cause diarrheal illnesses following vaccine introduction. Two globally licensed rotavirus vaccines have been associated with a low risk of intussusception in several studies. In July 2014, the Rotavirus Organization of Technical Allies Council convened a meeting of research and advocacy organizations, public health experts, funders, and vaccine manufacturers to discuss post-marketing intussusception surveillance and rotavirus vaccine impact data. Meeting objectives were to evaluate updated data, identify and prioritize research gaps, discuss best practices for intussusception monitoring in lower-income settings and risk communication, and provide insight to country-level stakeholders on best practices for intussusception monitoring and communication. Meeting participants agreed with statements from expert bodies that the benefits of vaccination with currently available rotavirus vaccines outweigh the low risk of vaccination-associated intussusception. However, further research is needed to better understand the relationship of intussusception to wild-type rotavirus and rotavirus vaccines and delineate potential etiologies and mechanisms of intussusception. Additionally, evidence from research and post-licensure evaluations should be presented with evidence of the benefits of vaccination to best inform policymakers deciding on vaccine introduction or vaccination program sustainability.

Intussusception in Children Aged Less than Five years

OBJECTIVE

To enumerate the cases of intussusception in Chennai during 2012-2013, describe the clinical profile, outcomes of case management and highlight the importance of systematically collecting this data in lieu of rotavirus vaccine introduction in India.

METHODS

Medical records of pediatric intussusception cases admitted in eight large hospitals in Chennai from July 2012 through June 2013 were retrospectively reviewed. Demographic and clinical data including diagnostic and treatment practices were obtained. Cases were categorized based on the diagnostic certainty criteria stipulated by the Brighton collaboration on intussusception.

RESULTS

During the one year of study period, 205 cases of intussusception were diagnosed in 8 hospitals in Chennai city of India. The median age at presentation was 9 mo (Inter Quartile Range, IQR 6-14) with a male to female ratio of 1.8:1. The commonest site of intussusception was ileocolic (80.4 %). Most of the cases (59.8 %) were managed non-surgically. Direct surgical intervention was carried out in 26.5 % cases whereas in 11.8% of cases, surgery was required after failure of non-surgical measures. Median duration of hospital stay was 3 d (IQR 1-5).

CONCLUSIONS

This study documents the case burden of intussusception among children in Chennai in a calendar year. Data on receipt of rotavirus vaccine was not available. The authors recommend collection of rotavirus vaccine data among all cases of intussusception in the country, and do retrospective analysis in other parts of the country and prospective surveillance in pediatric / immunization clinics to assess impact of rotavirus vaccine on intussusception rates in the post rotavirus vaccine introduction scenario.

Intussusception:

Intussusception, the invagination of one portion of the intestine into another, is considered a true emergency, which most commonly affects pediatric patients. It occurs when bowel (small or large) telescopes within itself, creating an obstructive mass. Peristalsis exacerbates the more proximal bowel into the lesion, causing the intussusception to have a “sleeve”-like shape. The lesion propagates distally, with obstructive ischemia and possible necrosis occurring over time. With the improvement of technology in diagnostic imaging, sonography has become the initial imaging modality of choice. The authors present a case study and current review of the literature regarding intussusception from a sonographer's viewpoint.

Pediatric Intussusception in Northern Iran: Comparison of Recurrent With Non-Recurrent Cases

Background:

Intussusception represents as the invagination of a part of the intestine into itself and is the most common cause of intestinal obstruction in infants and children between 6 months to 3-years-old.

Objectives:

The objective of this study was to determine the recurrence rate and predisposing factors of recurrent intussusception.

Patients and Methods:

The medical records of children aged less than 13-years-old with confirmed intussusception who underwent reduction at a tertiary academic care in northern Iran (Mazandran), from 2001 to 2013 were reviewed. Data were extracted and recurrence rate was determined. The two groups were compared by chi square, Fisher, Mann-Whitney and t-test. Diagnosed cases of intussusception consisted of 237 children.

Results:

Average age of the patients was 19.57 ± 19.43 months with a peak of 3 to 30 months. Male to female ratio was 1.65 and this increased by aging. Recurrence rate was 16% (38 cases). 87 (36.7%) underwent surgery. These were mainly children under one year old. In 71% (40) of episodes recurrence occurred 1 to 7 times within 6 months. The recurrence occurred in 29 (23.5%) children in whom a first reduction was achieved with barium enema (BE) and 5 (5.7%) children who had an operative reduction (P < 0.001) in the first episode. Pathological leading points (PLPs) were observed in 5 cases; 2.6% in recurrence group versus 2% in non-recurrence group (P = 0.91). Three patients had intestinal polyp, 2 patient’s lymphoma and Mackle’s diverticulum. Age (P = 0.77) and sex (P = 0.38) showed no difference between the two groups. PLPs were observed in 1.4% of children aged 3 months to 5 years. This was 13.3%, in older children (P = 0.02).

Conclusions:

The recurrence of intussusception was related to the method of treatment in the first episode and it was 5-fold higher in children with BE than in operative reduction. Recurrent intussusceptions were not associated with PLPs, they were more idiopathic.

Abdominal radiography is not necessary in children with intussusception

BACKGROUND

Children with intussusception require rapid and accurate diagnosis to enable timely intervention for satisfactory outcome. Ultrasonography is the recommended standard diagnostic modality; however, abdominal radiography (AR) is still used as an initial investigation. The aim of this study was to investigate the benefit of AR in intussusception by determining diagnostic accuracy and analysing correlation of AR findings with outcome.

METHODS

Index cases of intussusception presenting over 15 years (1998-2013) were analysed. Those who had AR performed were allocated into groups with positive or normal findings. Outcome of pneumatic reduction of intussusception (PRI) between these groups was compared.

RESULTS

Six hundred and forty-four cases of intussusception treated with PRI were identified, 412 (64 %) had AR performed and 232 (36 %) did not. 303 (74 %) radiographs had positive findings and 109 (26 %) were normal. The success rate of PRI did not differ between AR positive (82 %) and AR normal (84 %). Occult pneumoperitoneum was not detected in any patient by AR in our cohort.

CONCLUSION

AR is not recommended for the diagnosis of intussusception in children, for the prediction of the outcome of PRI or for the detection of occult pneumoperitoneum. AR should always be performed when clinical peritonism is present but is not otherwise necessary in children with suspected or confirmed intussusception.

Pathologic leadpoint is uncommon in ileo-colic intussusception regardless of age

PURPOSE

Historically, the rate of pathologic leadpoints in older children with intussusception is quoted as 20%-25%. Our anecdotal experience suggested a lower rate. We therefore compiled a case series to examine the actual incidence of pathologic leadpoint, and treatment success, by age.

METHODS

A retrospective review was performed of all patients admitted with intussusception between 1998 and 2012 and tested for differences in anatomic location, presence of pathologic leadpoint, and need for operative intervention, on the basis of age.

RESULTS

In total, 154 cases of intussusception were diagnosed in 141 patients (136 ileo-colic), 38 of which were in children older than 3 (29 ileo-colic). Considering all anatomic locations, older children were more likely to have a pathologic leadpoint (p-value 0.01); however subgroup analysis of ileo-colic intussusception demonstrated no difference (p-value 0.38). Additionally, there was no difference in the success of pneumatic or barium enema reduction on the basis of age (p-value 0.56).

CONCLUSION

Despite historical reports of increased pathologic leadpoints in ileo-colic intussusception in older children, in this series the majority were idiopathic. Non-operative management was successful approximately 75% of the time, irrespective of age. In older age groups, there was an increased frequency of pathologic leadpoints in small bowel-small bowel intussusception.