Intussusception in children: evidence-based diagnosis and treatment

Recalcitrant intussusception: exploring potential associations with Helicobacter pylori infection - a case report and literature review

BACKGROUND

Intussusception, a common cause of abdominal pain in children, often lacks clear underlying causes and is mostly idiopathic. Recurrence, though rare, raises clinical concerns, with rates escalating after each episode. Factors like pathological lead points and Henoch-Schönlein purpura (HSP) are associated with recurrent cases. On the other hand, the prevalence of Helicobacter pylori (H. pylori), often asymptomatic, in children has been declining. Although its infection is reported to be linked with HSP, its role in recurrent intussusception remains unexplored. Further research is needed to understand the interplay among H. pylori (culprit pathogen), HSP (trigger), and intractable intussusception so as to develop effective management strategies.

CASE PRESENTATION

A two-year-old girl experienced four atypical episodes of intussusception at distinct locations, which later coincided with HSP. Despite treatment with steroids, recurrent intussusception persisted, suggesting that HSP itself was not a major cause for intractable presentations. Subsequent identification of H. pylori infection and treatment with triple therapy resulted in complete resolution of her recalcitrant intussusception.

CONCLUSION

This instructive case underscored a sequence wherein H. pylori infection triggered HSP, subsequently resulting in recurrent intussusception. While H. pylori infection is not common in young children, the coexistence of intractable intussusception and steroid-resistant recurrent HSP necessitates consideration of H. pylori infection as a potential underlying pathogen.

Applications of Artificial Intelligence in Acute Abdominal Imaging

Artificial intelligence (AI) is a rapidly growing field with significant implications for radiology. Acute abdominal pain is a common clinical presentation that can range from benign conditions to life-threatening emergencies. The critical nature of these situations renders emergent abdominal imaging an ideal candidate for AI applications. CT, radiographs, and ultrasound are the most common modalities for imaging evaluation of these patients. For each modality, numerous studies have assessed the performance of AI models for detecting common pathologies, such as appendicitis, bowel obstruction, and cholecystitis. The capabilities of these models range from simple classification to detailed severity assessment. This narrative review explores the evolution, trends, and challenges in AI applications for evaluating acute abdominal pathologies. We review implementations of AI for non-traumatic and traumatic abdominal pathologies, with discussion of potential clinical impact, challenges, and future directions for the technology.

Clinical presentation and management outcome of pediatric intussusception at Wolaita Sodo University Comprehensive Specialized Hospital: a retrospective cross-sectional study

OBJECTIVE

To assess the pattern of clinical presentations and factors associated with the management outcome of pediatric intussusception among children treated at Wolaita Sodo University Comprehensive Specialized Hospital, Ethiopia.

METHODS

This retrospective cross-sectional study included the medical records of 103 children treated for intussusception from 2018 to 2020. The data collected were analyzed using SPSS 25.0 (IBM Corp., Armonk, NY, USA).

RESULTS

In total, 84 (81.6%) patients were released with a favorable outcome. Ileocolic intussusception was a positive predictor, with a nine-fold higher likelihood of a favorable outcome than other types of intussusception [adjusted odds ratio (AOR), 9.16; 95% confidence interval (CI), 2.39-21.2]. Additionally, a favorable outcome was three times more likely in patients who did than did not undergo manual reduction (AOR, 3.08; 95% CI, 3.05-5.48). Patients aged <1 year were 96% less likely to have a positive outcome than those aged >4 years (AOR, 0.04; 95% CI, 0.03-0.57).

CONCLUSION

Most patients were discharged with favorable outcomes. Having ileocolic intussusception and undergoing manual reduction were associated with significantly more favorable outcomes of pediatric intussusception. Therefore, nonsurgical management such as hydrostatic enema and pneumatic reduction is recommended to reduce hospital discharge of patients with unfavorable outcomes.

Intussusception in Mosaic Trisomy 14

Mosaic trisomy 14 is exceptionally rare and was first described in the 1970s with fewer than 100 known liveborn individuals. Information about complications and the natural history of the disease is rare, especially in adult patients. This case illustrates an adult patient with severe functional limitations from mosaic trisomy 14 who presented with abdominal pain and failure to thrive and was subsequently found to have intussusception and severe chronic constipation, which was successfully treated conservatively.

Feasibility of a deep learning artificial intelligence model for the diagnosis of pediatric ileocolic intussusception with grayscale ultrasonography

PURPOSE

This study explored the feasibility of utilizing a deep learning artificial intelligence (AI) model to detect ileocolic intussusception on grayscale ultrasound images.

METHODS

This retrospective observational study incorporated ultrasound images of children who underwent emergency ultrasonography for suspected ileocolic intussusception. After excluding video clips, Doppler images, and annotated images, 40,765 images from two tertiary hospitals were included (positive-to-negative ratio: hospital A, 2,775:35,373; hospital B, 140:2,477). Images from hospital A were split into a training set, a tuning set, and an internal test set (ITS) at a ratio of 7:1.5:1.5. Images from hospital B comprised an external test set (ETS). For each image indicating intussusception, two radiologists provided a bounding box as the ground-truth label. If intussusception was suspected in the input image, the model generated a bounding box with a confidence score (0-1) at the estimated lesion location. Average precision (AP) was used to evaluate overall model performance. The performance of practical thresholds for the modelgenerated confidence score, as determined from the ITS, was verified using the ETS.

RESULTS

The AP values for the ITS and ETS were 0.952 and 0.936, respectively. Two confidence thresholds, CTopt and CTprecision, were set at 0.557 and 0.790, respectively. For the ETS, the perimage precision and recall were 95.7% and 80.0% with CTopt, and 98.4% and 44.3% with CTprecision. For per-patient diagnosis, the sensitivity and specificity were 100.0% and 97.1% with CTopt, and 100.0% and 99.0% with CTprecision. The average number of false positives per patient was 0.04 with CTopt and 0.01 for CTprecision.

CONCLUSION

The feasibility of using an AI model to diagnose ileocolic intussusception on ultrasonography was demonstrated. However, further study involving bias-free data is warranted for robust clinical validation.

Clinical characteristics and risk factors of IgA vasculitis with intussusception and intestinal perforation

AIM

Intussusception is the most common surgical complication of IgA vasculitis (IgAV), and intestinal perforation is usually associated with intussusception. If they are not recognised and treated in a timely manner, serious consequences may occur. The objective is to summarise the clinical features of IgAV complicated by intussusception and intestinal perforation and explore its risk factors.

METHODS

The clinical data of 32 patients with IgAV complicated by surgical complications (25 cases of intussusception and 7 cases of intestinal perforation) were retrospectively analysed. A total of 160 IgAV children with gastrointestinal (GI) involvement but without surgical complications were randomly selected as a control group. Binary logistic regression analysis was performed to explore the risk factors for IgAV with intussusception and intestinal perforation.

RESULTS

Compared with the intussusception group, the intestinal perforation group had a significantly higher number of patients with GI symptoms prior to skin purpura and GI bleeding, a significantly higher number of days of abdominal pain, a significantly higher Wong-Baker score, and a significantly higher white blood cell count. Multivariate logistic regression analysis indicated that age ≤7 years, GI symptoms prior to skin purpura, abdominal pain intensity (Wong-Baker scale) and timing of glucocorticoid treatment were independent risk factors of IgAV with intussusception and intestinal perforation.

CONCLUSION

Age less than 7 years, severe abdominal pain, and GI symptoms prior to skin purpura were risk factors for IgAV with intussusception and intestinal perforation. Early use of glucocorticoids may prevent intussusception and intestinal perforation.

Lymphoma-related intussusception in children: diagnostic challenges and clinical characteristics

Intussusception is a common cause of acute abdominal pain in children and the most frequent cause of intestinal obstruction in infants. Although often idiopathic, it can stem from conditions like lymphoma. This study delves into lymphoma-related intussusception in children, aiming to enhance early detection and management. A retrospective review encompassed children admitted from 2012 to 2023 with intussusception due to intestinal lymphoma. Demographic, clinical, and imaging data were meticulously extracted and analyzed. The study included 31 children in the lymphoma-related intussusception group. Contrasted with non-lymphoma-related cases, the patients of lymphoma-related intussusception were notably older (median age: 87 months vs. 18.5 months), predominantly male, and demonstrated protracted abdominal pain. Ultrasound unveiled mesenteric lymph node enlargement and distinct intra-abdominal masses; enema reduction success rates were notably diminished. Detecting lymphoma-related intussusception remains intricate. Age, prolonged symptoms, and distinctive ultrasound findings can arouse suspicion. Timely surgical intervention, based on preoperative imaging, proves pivotal for accurate diagnosis.

CONCLUSION

 Swift identification of lymphoma-related intussusception, distinguished by unique clinical and ultrasound features, is imperative for timely intervention and treatment. Further research is warranted to refine diagnostic approaches.

WHAT IS KNOWN

• Intussusception in pediatric patients can be caused by a wide spectrum of underlying diseases including lymphoma. • Early Identifying the exact underlying cause of intussusception is crucial for tailored therapy, however often challenging and time-consuming.

WHAT IS NEW

• Lymphoma-related intussusception may present with increased abdominal fluid accumulation, intestinal obstruction, and a higher likelihood of failed reduction during enema procedures. • For high-risk children, repeated ultrasound examinations or further investigations may be necessary to confirm the diagnosis.

Intussusception Management in Children: A 15-Year Experience in a Referral Center

OBJECTIVE

To report a 15-y, single-center experience in the management and outcomes of ileocolic intussusception (ICI) episodes.

METHODS

A retrospective study was performed in patients with ICI episodes, who were treated at a single quaternary referral center from 2005 to 2019. Data evaluated included patient demographics, clinical presentation, treatment modalities, hospital stay, complications, and outcomes.

RESULTS

A total of 546 ICI episodes (66.1% males) were included, with a median age at diagnosis of 15 mo. Enema reduction was performed in 478 patients (87.6%), with an overall success rate of 85.8%. Hydrostatic saline enema was the most effective method (89.3%) when compared to pneumatic (80.6%) or barium enema (79.8%), this difference being statistically significant (p = 0.031). No associated complications were observed during nonoperative reduction. Surgical treatment was performed in 101 patients, in whom 36 bowel resections were performed. Postoperative complications were reported in 6 patients (5.9%). Hospital stay was significantly longer in patients with operative management (median 5 d vs. 1 d; p < 0.001).

CONCLUSIONS

Nonoperative management has a high overall success rate and low complication and recurrence rates. Saline enema reduction presents the highest effectiveness, and should be considered the first-line treatment.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A deep-learning pipeline to diagnose pediatric intussusception and assess severity during ultrasound scanning: a multicenter retrospective-prospective study

Ileocolic intussusception is one of the common acute abdomens in children and is first diagnosed urgently using ultrasound. Manual diagnosis requires extensive experience and skill, and identifying surgical indications in assessing the disease severity is more challenging. We aimed to develop a real-time lesion visualization deep-learning pipeline to solve this problem. This multicenter retrospective-prospective study used 14,085 images in 8736 consecutive patients (median age, eight months) with ileocolic intussusception who underwent ultrasound at six hospitals to train, validate, and test the deep-learning pipeline. Subsequently, the algorithm was validated in an internal image test set and an external video dataset. Furthermore, the performances of junior, intermediate, senior, and junior sonographers with AI-assistance were prospectively compared in 242 volunteers using the DeLong test. This tool recognized 1,086 images with three ileocolic intussusception signs with an average of the area under the receiver operating characteristic curve (average-AUC) of 0.972. It diagnosed 184 patients with no intussusception, nonsurgical intussusception, and surgical intussusception in 184 ultrasound videos with an average-AUC of 0.956. In the prospective pilot study using 242 volunteers, junior sonographers' performances were significantly improved with AI-assistance (average-AUC: 0.966 vs. 0.857, P < 0.001; median scanning-time: 9.46 min vs. 3.66 min, P < 0.001), which were comparable to those of senior sonographers (average-AUC: 0.966 vs. 0.973, P = 0.600). Thus, here, we report that the deep-learning pipeline that guides lesions in real-time and is interpretable during ultrasound scanning could assist sonographers in improving the accuracy and efficiency of diagnosing intussusception and identifying surgical indications.

Unexpected Etiology of Intussusception in an Adolescent Patient

Intussusception is a common cause of acute and subacute small bowel obstruction in children, young, and older patients; however, despite increasing awareness of the condition and the number of patients diagnosed with it across all ages, its clinical and diagnostic approach remains challenging. A 17-year-old girl attended our gastroenterology outpatient department complaining of a 6-month history of recurrent right iliac fossa pain associated with nausea and vomiting at times with no past medical history of note. Initial blood tests revealed a slightly raised CRP (9.1 mg/L) and a significantly elevated fecal calprotectin (>1000 µg/g). Computed axial tomography scan of the abdomen and pelvis revealed ileocecal intussusception with no evidence of small or large bowel obstruction. On subsequent colonoscopy a 5-cm mass protruding through the ileocecal valve was identified and multiple biopsies were taken for histological analysis, which confirmed a diagnosis of Burkitt's lymphoma. The lesion was surgically resected and plans for adjuvant chemotherapy were discussed. The learning lessons to take from this case are to widen the list of differential diagnoses of unexplained recurrent abdominal pain to include intussusception and to actively rule it out with an appropriate diagnostic approach that addresses its potential malignant etiology across all ages.

Cohort analysis of pediatric intussusception score to diagnose intussusception

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasound guided hydrostatic enema reduction of ileocolic intussusception: a safe and effective technique

BACKGROUND

Currently, the primary management of ileocolic intussusception in children is usually by non-operative image-guided enema reduction. In most centres around the world especially in Australasia the predominant technique is the pneumatic reduction under fluoroscopic guidance. At our institution, we have been performing ultrasound-guided hydrostatic reduction since 2012.This is an audit to determine the efficacy and safety of ultrasound-guided hydrostatic reduction for intussusception.

METHODS

Following ethics approval, a retrospective review of all patients presenting to our institution with intussusception and subsequently undergoing hydrostatic reduction over a period of 9 years (2012 to-2020) was performed. The parameters studied included (i) successful reduction, (ii) recurrence, (iii) need for surgery and (iv) lead point at surgery.

RESULTS

The mean age at presentation was 12 months. One hundred and eight children were diagnosed to have ileocolic intussusception. One hundred and six underwent ultrasound-guided hydrostatic reduction with successful reduction in 96 (90.5%) patients. Reduction was unsuccessful in 10 patients (9.5%). Of these eight were noted to have a pathological lead point (four-Meckel's diverticulum and four-Lymphoma) at the time of the surgery. The intussusception recurred in six patients (6.25%) within 24 h. No reduction related perforation occurred during the study period.

CONCLUSION

Ultrasound-guided hydrostatic reduction is a safe and effective technique for managing intussusception as it allows continuous monitoring of the reduction of the intussusception without exposing the children to ionizing radiation.

Role of artificial intelligence in oncologic emergencies: a narrative review

Oncologic emergencies are a wide spectrum of oncologic conditions caused directly by malignancies or their treatment. Oncologic emergencies may be classified according to the underlying physiopathology in metabolic, hematologic, and structural conditions. In the latter, radiologists have a pivotal role, through an accurate diagnosis useful to provide optimal patient care. Structural conditions may involve the central nervous system, thorax, or abdomen, and emergency radiologists have to know the characteristics imaging findings of each one of them. The number of oncologic emergencies is growing due to the increased incidence of malignancies in the general population and also to the improved survival of these patients thanks to the advances in cancer treatment. Artificial intelligence (AI) could be a solution to assist emergency radiologists with this rapidly increasing workload. To our knowledge, AI applications in the setting of the oncologic emergency are mostly underexplored, probably due to the relatively low number of oncologic emergencies and the difficulty in training algorithms. However, cancer emergencies are defined by the cause and not by a specific pattern of radiological symptoms and signs. Therefore, it can be expected that AI algorithms developed for the detection of these emergencies in the non-oncological field can be transferred to the clinical setting of oncologic emergency. In this review, a craniocaudal approach was followed and central nervous system, thoracic, and abdominal oncologic emergencies have been addressed regarding the AI applications reported in literature. Among the central nervous system emergencies, AI applications have been reported for brain herniation and spinal cord compression. In the thoracic district the addressed emergencies were pulmonary embolism, cardiac tamponade and pneumothorax. Pneumothorax was the most frequently described application for AI, to improve sensibility and to reduce the time-to-diagnosis. Finally, regarding abdominal emergencies, AI applications for abdominal hemorrhage, intestinal obstruction, intestinal perforation, and intestinal intussusception have been described.

Epidemiology, clinical characteristics, and treatment of children with acute intussusception: a case series

BACKGROUND

To summarize the clinical and epidemiological characteristics of acute intussusception.

METHODS

This retrospective study included pediatric patients with acute intussusception admitted to the Department of Pediatric Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, from January 2014 to December 2019.

RESULTS

A total of 402 infants/children were included (301 males and 101 females) with a mean age of 2.4 ± 1.5 years (2 months to 9 years). Thirty patients (7.5%) had a history of cold food intake, diarrhea, and upper respiratory infection before disease onset. Paroxysmal abdominal pain and crying occurred in 338 patients (84.1%). Eight patients (2.0%) had the typical triad, 167 (41.5%) had vomiting, 24 (6.0%) had bloody stools, and 273 (67.9%) had palpable abdominal mass. The average intussusception depth was 4.0 ± 1.4 cm. Air enema reduction was performed in 344 cases: 335 (97.3%) were successful. Fifty-eight patients were treated with intravenous phloroglucinol (2 mg/kg), and 53 (91.4%) were successful. Sixty-five patients suffered relapses, with a relapse rate of 16.8%.

CONCLUSIONS

Pediatric acute intussusception is common. There was no obvious etiology. The clinical manifestations are mostly atypical. Abdominal pain is the most common complaint. Air enema reduction is an effective treatment. The recurrence rate is high.

Current diagnosis and image-guided reduction for intussusception in children

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

Intussusception after injury to the small intestine during emergent cesarean delivery of a premature triplet pregnancy: A case report

Intussusception is a rare cause of intestinal obstruction in the postoperative setting. This report describes a rare case of intussusception in the early postoperative period following an emergent cesarean delivery of a premature triplet pregnancy, where the small intestine was fully transected. The intestine was repaired with a stapled primary side-to-side functional end-to-end anastomosis. Five days after being discharged, the patient was readmitted due to a small bowel obstruction due to intussusception. The anastomotic site was acting as the lead point, and it required resection. Bowel continuity was reestablished with a hand-sewn anastomosis in end-to-end fashion. The patient had an uneventful recovery and was discharged home. All three neonates were eventually discharged home and the patient was able to start breast feeding. This is believed to be the first case in the obstetric literature where intussusception occurred after intestinal repair of transected bowel during an obstetric emergency.

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Early bowel obstruction after a surgical procedure can be due to intussusception.

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Bowel anastomosis can be the lead point for intussusception requiring surgery.

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Both stapled and hand-sewn re-anastomosis techniques have benefits and drawbacks.

How Does the COVID-19 Pandemic Affect Pediatric Patients with Intussusception Treated by Ultrasound-Guided Hydrostatic Enema Reduction?

Background: The pandemic of COVID-19 has significantly influenced the epidemiology of intussusception. Nevertheless, the effects of the COVID-19 pandemic on the operation of ultrasound-guided hydrostatic enema reduction (USGHER) for intussusception have been largely unknown. Methods: The data of pediatric patients with intussusception who were treated by USGHER from January to March of 2019 (Control Group), 2020 (Study Group 1), and 2021 (Study Group 2) in a large Chinese medical institution were retrospectively collected and analyzed. Results: We enrolled 246 patients, including 90 cases in Control Group, 70 in Study Group 1, and 86 in Study Group 2 (p = 0.042). The time from the onset of symptoms to the hospital visit and the time from the hospital visit to performing the ultrasound in Study Group 1 was significantly longer than that in Control Group and Study Group 2 (p = 0.036, p = 0.031, respectively). The number of patients with bloody stool and the longest invaginated length of intussusception in Study Group 1 increased significantly compared with patients in the other two groups (p = 0.007, p = 0.042, respectively). Comparisons of neither the pressure of enema nor the time of duration when performing USGHER present statistical significance among the three groups (p = 0.091, p = 0.085, respectively). For all enrolled pediatric patients, there was no perforation case involved, and recurrence of intussusception occurred in few cases. Conclusions: Besides the negative impacts on the incidence of intussusception, the COVID-19 pandemic might have led to the diagnostic delay of intussusception and the deterioration of patients’ clinical manifestations, but it did not significantly affect the operation of USGHER and patients’ clinical outcome.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Pediatric case of colonic perivascular epithelioid cell tumor complicated with intussusception and anal incarceration: A case report

BACKGROUND

Perivascular epithelioid cell tumor (PEComa) represents a group of rare mesenchymal tumors. PEComa can occur in many organs but is rare in the colorectum, especially in children. Furthermore, PEComa is a rare cause of intussusception, the telescoping of a segment of the gastrointestinal tract into an adjacent one. We describe a rare case of pediatric PEComa complicated with intussusception and anal incarceration, and conduct a review of the current literature.

CASE SUMMARY

A 12-year-old girl presented with abdominal pain and abdominal ultrasound suggested intussusception. Endoscopic direct-vision intussusception treatment and colonoscopy was performed. A spherical tumor was discovered in the transverse colon and removed by surgery. Postoperative pathologic analyses revealed that the tumor volume was 5.0 cm × 4.5 cm × 3.0 cm and the tumor tissue was located in the submucosa of the colon, arranged in an alveolar pattern. The cell morphology was regular, no neoplastic necrosis was observed, and nuclear fission was rare. The immunohistochemical staining results were as follows: Human melanoma black 45 (HMB 45) (+), cluster of differentiation 31 (CD31) (+), cytokeratin (-), melanoma-associated antigen recognized by T cells (-), smooth muscle actin (-), molleya (-), desmin (-), S-100 (-), CD117 (-), and Ki67 (positive rate in hot spot < 5%). Combined with the results of pathology and immunohistochemistry, we diagnosed the tumor as PEComa. Postoperative recovery was good at the 4 mo follow-up.

CONCLUSION

The diagnosis of PEComa mainly depends on pathology and immunohistochemistry. Radical resection is the preferred treatment method.

Colocolic Intussusception in Children: A Case Series and Review of the Literature

Background

Colocolic intussusception is a rare subtype of intussusception mostly caused by juvenile polyps. The treatment of colocolic intussusception caused by other pathologic lead points in children remains poorly understood.

Method

A systematic literature review was performed between January 2000 and June 2021 to characterize the comprehensive treatment of colocolic intussusception in children. This report also included patients admitted to our center between January 2010 and June 2021 who were not previously reported in the literature.

Results

We identified 27 patients in 20 studies in addition to 17 patients from our center for a total of 44 patients (median age, 4.4 years; 52.3% male). The lead point was identified in 40 patients (40/44, 90.9%). The most common lead point was juvenile polyps (19/44, 43.2%). A therapeutic enema was performed in 15 patients with colocolic intussusception caused by juvenile polyps and was successful in 9 patients (9/15, 60.0%). Colonoscopic polypectomy was subsequently performed in 8 patients and was successful in 7 patients (7/8, 87.5%). The other patient had undergone laparoscopic exploration, and no abnormality was found. Subsequently, the patient underwent open surgery. The patients with colocolic intussusception caused by other pathologic lead points almost underwent surgical treatment (15/21, 71.4%), including 13 open surgeries and 2 laparoscopic surgeries.

Conclusion

A therapeutic enema followed by colonoscopic polypectomy is feasible to treat colocolic intussusception caused by juvenile polyps unless the patient has bowel perforation; however, surgery is sometimes needed. For patients with colocolic intussusception caused by other pathologic lead points, open surgery remains the primary treatment.

Reduction of ileocolic intussusception under sedation or anaesthesia: a systematic review of complications

BACKGROUND

Despite the increased use of sedation in children undergoing stressful procedures, reduction of ileocolic intussusception (RII) is usually performed on awake children without any form of sedation.

OBJECTIVE

To evaluate the incidence of severe complications of RII under sedation or anaesthesia.

DESIGN

A systematic review including English language original articles of any date.

PATIENTS

Children undergoing RII (pneumatic or hydrostatic) under sedation or anaesthesia.

DATA SOURCES

Ovid Embase, Scopus, PubMed, the Cochrane Database of Systematic Reviews and the internet search engine Google Scholar.

DATA EXTRACTION

Three authors independently reviewed each article for eligibility. The Newcastle-Ottawa Scale was used to assess the quality of included studies.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of intestinal perforation during RII. The secondary outcomes were the incidence of sentinel adverse events defined as death, cardiopulmonary resuscitation, permanent neurological deficit and pulmonary aspiration syndrome.

RESULTS

The search yielded 368 articles. Nine studies with 1391 cases were included in the analysis. Of the nine studies, six had a score of ≤6 stars in the Newcastle-Ottawa Scale assessment, indicating low-to-moderate quality. Propofol-based sedation was used in 849 (59.2%) cases; 5 (0.6%) had intestinal perforation. Intestinal perforation was not reported in patients who were sedated with other sedatives. One patient had pulmonary aspiration syndrome.

CONCLUSIONS

Although caution remains warranted, current data suggest that the incidence of severe complications due to RII under sedation or anaesthesia is low. Due to the lack of prospective data, it is difficult to ascertain the exact incidence of severe complications.

Impact of the COVID-19 Pandemic on Emergency Care Utilization and Outcomes in Pediatric Patients with Intussusception

Background: We determined whether a decrease in healthcare utilization patterns during the COVID-19 pandemic affected the treatment process of pediatric patients with intussusception. Methods: Patients with suspected intussusception who had ICD-10 code K561 as their discharge diagnosis from the national database were selected, and those who underwent either radiologic and/or surgical reduction were defined as true intussusception patients. We compared the time periods from patients visiting the ED to ultrasound, radiologic reduction and/or surgical reduction between the study group (first half of 2020, COVID-19 period) and the control groups (control group 1: first half of 2019, control group 2: second half of 2019). Results: The number of suspected intussusception patients in each group was 1223, 1576, and 624, and the incidence rates were 7.85, 11.30, and 4.19 per 100,000 person-half-years (control group 1, control group 2, study group, respectively, p < 0.05). No differences in terms of the time from the ED visit to ultrasound, radiological reduction and/or surgical reduction were noted between the study group and the control groups. Conclusions: In Korea, the COVID-19 pandemic did not significantly affect the ED treatment process or the results of patients with intussusception.

Laparoscopic approach for managing intussusception in children: Analysis of 65 cases

BACKGROUND

Intussusception can be managed by pneumatic reduction, ultrasound-guided hydrostatic reduction, open or laparoscopic surgery, but laparoscopy in such cases remains controversial.

AIM

To explore the clinical characteristics, effectiveness, and complications of surgical reduction for intussusception using laparoscopy in children.

METHODS

This study was a retrospective case series of pediatric patients with intussusception who underwent surgical reduction by laparoscopy from May 2011 to April 2016 at Taizhou Hospital of Zhejiang Province. Clinical characteristics (operation time, intraoperative blood loss, conversion rate of laparotomy, reasons for conversion, postoperative hospital stay, and adverse events) were described.

RESULTS

The 65 patients included 45 boys and 20 girls. The average age was 2.3 years (27.5 ± 24.5 mo). Of the 65 patients, 61 underwent surgical reduction by laparoscopy after a failed enema reduction of intussusception, and four underwent the procedure directly. All patients were treated successfully and 57 (87.7%) patients underwent successful laparoscopic surgery, two of which had a spontaneous reduction. Among the remaining cases, one was converted to open surgery via right upper quadrant incision, and seven required enlarged umbilical incisions. Intestinal resection was performed in 5 patients because of abnormal bowel lesions. There were no complications (intestinal perforations, wound infections, or intestinal adhesions) during the follow-up of 3 years to 8 years. Two patients experienced a recurrence of intussusception; one was resolved with pneumatic reduction, and the other underwent a second laparoscopic surgery.

CONCLUSION

Laparoscopic approach for pediatric intussusception is feasible and safe. Bowel resection if required can be performed by extending umbilical incision without the conventional laparotomy.

Early discharge after nonoperative management of intussusception is both safe and cost-effective

BACKGROUND/PURPOSE

We implemented a quality improvement (QI) initiative to safely reduce post-reduction monitoring for pediatric patients with ileocolic intussusception. We hypothesized that there would be decreased length of stay (LOS) and hospital costs, with no change in intussusception recurrence rates.

METHODS

A retrospective cohort study was conducted of pediatric ileocolic intussusception patients who underwent successful enema reduction at a tertiary-care pediatric hospital from January 2015 through June 2020. In September 2017, an intussusception management protocol was implemented, which allowed discharge within four hours of reduction. Pre- and post-QI outcomes were compared for index encounters and any additional encounter beginning within 24 h of discharge. An economic evaluation was performed with hospital costs inflation-adjusted to 2020 United States Dollars ($). Cost differences between groups were assessed using multivariable regression, adjusting for Medicaid and transfer status, P < 0.05 significant.

RESULTS

Of 90 patients, 37(41%) were pre-QI and 53(59%) were post-QI. Patients were similar by age, sex, race, insurance status, and transfer status. Pre-QI patients had a median LOS of 23.4 h (IQR: 16.1-34.6) versus 9.3 h (IQR 7.4-14.2) for post-QI patients, P < 0.001. Mean total costs per patient in the pre-QI group were $3,231 (95% CI, $2,442-$4,020) versus $1,861 (95% CI, $1,481-$2,240) in the post-QI group. The mean absolute cost difference was $1,370 less per patient in the post-QI group (95% CI, [-$2,251]-[-$490]). Five patients had an additional encounter within 24 h of discharge [pre-QI: 1 (3%) versus post-QI: 4 (8%), p = 0.7] with four having intussusception recurrence [pre-QI: 1 (3%) versus post-QI: 3 (6%), p = 0.6].

CONCLUSIONS

Implementation of a quality improvement initiative for the treatment of pediatric intussusception reduced hospital length of stay and costs without negatively affecting post-discharge encounters or recurrence rates. Similar protocols can easily be adopted at other institutions.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective comparative treatment study.

Neonatal and Pediatric Bowel Obstruction: Imaging Guidelines and Recommendations

Pediatric bowel obstructions are one of the most common surgical emergencies in children, and imaging plays a vital role in the evaluation and diagnosis. An evidence-based and practical imaging approach to diagnosing and localizing pediatric bowel obstructions is essential for optimal pediatric patient care. This article discusses an up-to-date practical diagnostic imaging algorithm for pediatric bowel obstructions and presents the imaging spectrum of pediatric bowel obstructions and their underlying causes.

Decreased Incidence of Pediatric Intussusception during COVID-19

Coronavirus disease 2019 (COVID-19) changed the epidemiology of various diseases. The present study retrospectively investigates the epidemiologic and clinical changes in pediatric intussusception for ages ≤ 7 years before (February 2019–January 2020) and after (February 2020–January 2021) the COVID-19 outbreak in a single pediatric emergency department of a university-affiliated tertiary hospital. The incidence of communicable diseases—defined as infectious diseases with the potential for human-to-human transmission via all methods, non-communicable diseases, and intussusception were decreased following the COVID-19 outbreak (15,932 to 3880 (24.4%), 12,994 to 8050 (62.0%), and 87 to 27 (31.0%), respectively). The incidence of intussusception correlated significantly with the change in incidence of communicable diseases (Poisson log-linear regression, odds ratio = 2.15, 95% CI = 1.08–4.26, and p = 0.029). Compared with the pre-pandemic period, patients of the pandemic period showed higher proportions of pathologic leading point (PLP) and hospitalization (14.8% vs. 2.3% and 18.5% vs. 4.6%, respectively), lower base excesses (−4.8 mmol/L vs. −3.6 mmol/L), and higher lactate concentrations (1.7 mmol/L vs. 1.5 mmol/L). The incidence of pediatric intussusception decreased after the COVID-19 pandemic. This reduced incidence may be related to the reduced incidence of communicable diseases. However, the proportions of more severe diseases and PLPs were higher after the COVID-19 pandemic.

Ileocolic intussusception: Ultrasound-guided hydrostatic reduction with sedation and analgesia

INTRODUCTION

The first-choice treatment for ileocolic intussusception is imaging-guided reduction with water, air, or barium. The objectives of the current study were to evaluate the efficacy and safety of ultrasound-guided reduction of intussusception using water in patients under sedation and analgesia. We compare this approach with our previous experience in reduction using barium under fluoroscopic guidance without sedation and analgesia and investigate what factors predispose to surgical correction.

MATERIAL AND METHODS

We retrospectively reviewed cases of children with ileocolic intussusception treated in a third-level pediatric hospital during a 52-month period: during the first 24 months, reduction was done using barium and fluoroscopy without sedoanalgesia, and during the following 28 months, reduction was done using water and ultrasound with sedoanalgesia. A pediatric radiologist and a pediatrician reviewed the clinical history, surgical records, and imaging studies.

RESULTS

In the 52-month period, 59 children (41 boys and 18 girls; mean age, 16.0 months) were diagnosed with ileocolic intussusception at our hospital. A total of 33 reductions (28 patients and 5 recurrences) were done using barium under fluoroscopic guidance, achieving a 61% success rate. A total of 38 reductions (31 patients and 7 recurrences) were done using water under ultrasound guidance with patients sedated, achieving a success rate of 76%. No significant adverse effects were observed in patients undergoing ultrasound-guided hydrostatic reduction under sedation, and the success rate in this group was higher (p = 0.20). The factors that predisposed to surgical reduction were greater length of the intussusception (p = 0.03), location in areas other than the right colon (p = 0.002), and a greater length of time between symptom onset and imaging tests (p = 0.08).

CONCLUSION

Ultrasound-guided hydrostatic reduction of ileocolic intussusception under sedoanalgesia is efficacious and safe.

Clinical presentation and management of childhood intussusception in South Africa

PURPOSE

We assessed management and outcomes for intussusception at nine academic hospitals in South Africa.

METHODS

Patients ≤ 3 years presenting with intussusception between September 2013 and December 2017 were prospectively enrolled at all sites. Additionally, patients presenting between July 2012 and August 2013 were retrospectively enrolled at one site. Demographics, clinical information, diagnostic modality, reduction methods, surgical intervention and outcomes were reviewed.

RESULTS

Four hundred seventy-six patients were enrolled, [54% males, median age 6.5 months (IQR 2.6-32.6)]. Vomiting (92%), bloody stool (91%), abdominal mass (57%), fever (32%) and a rectal mass (29%) represented advanced disease: median symptom duration was 3 days (IQR 1-4). Initial reduction attempts included pneumatic reduction (66%) and upfront surgery (32%). The overall non-surgical reduction rate was 28% and enema perforation rate was 4%. Surgery occurred in 334 (70%), 68 (20%) patients had perforated bowel, bowel resection was required in 61%. Complications included recurrence (2%) and nosocomial sepsis (4%). Length of stay (LOS) was significantly longer in patients who developed complications. Six patients died-a mortality rate of 1%. There was a significant difference in reduction rates, upfront surgery, bowel resection, LOS and mortality between centres with shorter symptom duration compared longer symptom duration.

CONCLUSION

Delayed presentation was common and associated with low success for enema reduction, higher operative rates, higher rates of bowel resection and increased LOS. Improved primary health-care worker education and streamlining referral pathways might facilitate timely management.

Risk factors for intussusception in children with Henoch-Schönlein purpura: A case-control study

BACKGROUND

The etiology of Henoch-Schönlein purpura (HSP) with intussusception remains undefined.

AIM

To investigate the risk factors for intussusception in children with HSP and gastrointestinal (GI) involvement.

METHODS

Sixty children with HSP and concomitant intussusception admitted to the Beijing Children’s Hospital of Capital Medical University between January 2006 and December 2018 were enrolled in this study. One hundred pediatric patients with HSP and GI involvement but without intussusception, admitted to the same hospital during the same period, were randomly selected as a control group. The baseline clinical characteristics of all patients, including sex, age of onset, duration of disease, clinical manifestations, laboratory test results, and treatments provided, were assessed. Univariate and multiple logistic regression analyses were performed to identify possible risk factors.

RESULTS

The 60 children in the intussusception group comprised 27 girls (45%) and 33 boys (55%) and the 100 children in the non-intussusception group comprised 62 girls (62%) and 38 boys (38%). The median age of all patients were 6 years and 5 mo. Univariate and multiple regression analyses revealed age at onset, not receiving glucocorticoid therapy within 72 h of emergence of GI symptoms, hematochezia, and D-dimer levels as independent risk factors for intussusception in children with HSP (P < 0.05).

CONCLUSION

The four independent risk factors for intussusception in pediatric HSP with GI involvement would be a reference for early prevention and treatment of this potentially fatal disease.

The radiological characteristics of childhood intussusception including unusual features and rare pathological lead points

PURPOSE

To describe the radiological characteristics for childhood intussusceptions including unusual radiological features and rare pathological lead points (PLP).

MATERIAL AND METHODS

The medical records of all childhood intussusceptions between 1/1/2010 -1/10/2020 were retrospectively reviewed. 95 cases were identified in 82 patients. The demographic data, presenting symptoms, diagnostic and treatment methods, radiological features, and PLPs among the different types of intussusception were analyzed.

RESULTS

Ileocolic intussusception (ICI) represented 53.7% (51/95). The average age for ICI was 1.87 years. Males constituted 72.1% (31/43). 29.4% (15/51) were treated primarily surgically due to peritonitis. Small bowel intussusception (SBI) represented 40% (38/95) in which females constituted 51.5% (17/33). Ileo-ileal represented 63.2% (24/38). 81.8% (27/33) were transient. On ultrasound; There was a statistically significant difference in the size of the outer diameter of ICI compared to SBI (P-value 0.00012). Ileo-ileocolic and colo-colic intussusceptions constituted 3.2% (3/95); each and were more common in females. Vomiting was the most common symptom for intussusception and ultrasound was diagnostic in the majority of cases. PLPs were seen in 36.6% (30/82) of the patients of which the average age was 7 years. PLPs/risk factors were benign in 80% (24/30). A case of colo-colic intussusception was seen in a 16-year-old female due to clear cell sarcoma which was not reported before. 12.2% patients (10/82) had recurrent intussusception.

CONCLUSION

Our study showed that ICI is the most commonly encountered type. SBIs are mostly transient. It is important to radiologically determine the type of intussusception and to identify PLPs or unusual radiological features to avoid unnecessary intervention and significant patient morbidity.

Predictors of failed enema reduction in children with intussusception: a systematic review and meta-analysis

OBJECTIVE

To identify predictors of failed enema reduction in children with intussusception.

METHODS

PubMed and EMBASE were searched for all studies published over a 20-year time frame, prior to March 25, 2020. Original articles that reported predictors of failed enema reduction were included. The pooled odds ratio (OR) for successful enema reduction according to various features was calculated. The combined estimates were meta-analytically pooled by random-effects modeling. The risk of bias was assessed using the National Institute of Health Quality Assessment Tool. This review was registered to the PROSPERO (CRD42020190178).

RESULTS

A total of 38 studies, comprising 40,133 cases, were included. The shorter duration of symptoms (< 24 h; combined OR, 3.812; 95% CI, 2.150-6.759) and abdominal pain (combined OR, 2.098; 95% CI, 1.405-3.133) were associated with the success (all p < 0.001). Age < 1 year (combined OR, 0.385; 95% CI, 0.166-0.893; p = 0.026), fever (combined OR, 0.519; 95% CI, 0.371-0.725; p < 0.001), rectal bleeding (combined OR, 0.252; 95% CI, 0.165-0.387; p < 0.001), and vomiting (combined OR, 0.497; 95% CI, 0.372-0.664; p < 0.001) were associated with the failed reduction. The ascites (combined OR, 0.127; 95% CI, 0.044-0.368; p = 0.001), left-sided intussusception (combined OR, 0.121; 95% CI, 0.058-0.252; p < 0.001), and trapped fluid (combined OR, 0.179; 95% CI, 0.061-0.525; p = 0.017) on US were associated with the failed reduction.

CONCLUSIONS

Successful predictors for intussusception reduction have been summarized. This evidence can help identify patients who are more likely to fail non-operative reduction and could be potential surgical candidates.

KEY POINTS

• A shorter duration of symptoms and presence of abdominal pain were associated with increased probability of success. • Age (less than 1 year), presence of fever, rectal bleeding, vomiting, and presence of ascites, left-sided intussusception, or trapped fluid on ultrasonography were associated with decreased probability of success. • This study suggests that various clinical and ultrasonography predictors would help identify patients who are more likely to fail nonoperative reduction and identify potential preoperative candidates.

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

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

Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A, Smith CA, Miniati D, Sola JE, Valusek P, Berman L, Raval MV, Gosain A, Dellinger MB, Sømme S, Downard CD, McAteer JP, Kawaguchi A. Management of intussusception in children: A systematic review

OBJECTIVE

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children.

METHODS

The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence.

RESULTS

A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful.

CONCLUSIONS

Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy.

LEVEL OF EVIDENCE

Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.

A Hospital-Based Multi-Centric Study to Determine the Clinico-Epidemiological Profile of Intussusception in Children < 2 Years in Rajasthan, India

OBJECTIVE

To determine the clinical and epidemiological profile of Intussusception in children aged <2 y after introduction of rotavirus vaccine in Universal Immunization Programme of Rajasthan.

METHOD

This was a hospital-based multi-centric surveillance study conducted at three tertiary care sentinel sites in Rajasthan over a period of 2 y. Children <2 y of age admitted with intussusception as per Brighton's criteria 1 were enrolled. Demographic details including age, sex, clinical presentation, diagnostic methods, duration of symptoms, mode of treatment, and complications were recorded and analyzed.

RESULTS

During the study period of 2 y, the authors identified 164 cases of intussusception based on level-1 Brighton's criteria. Median age at presentation was 7 mo [Interquartile range (IQR) 5-10 mo] with a male to female ratio of 2:1. Pain abdomen and blood stained stool were the commonest presenting complaints (88.4% and 81.7%, respectively). Commonest site of intussusception was Ileocolic (82.32%). Pathological lead point was identified in 18.9% cases. Distinct seasonality was observed as maximum cases of intussusception were detected in the months of Jan-March (34.1%). Surgical intervention was required in the 89.63% cases. The median time duration between onset of symptoms and admission at sentinel site was 2 d (IQR 1-3 d). Proportion of cases that required surgery increased as the time interval between onset of symptoms and admission increases.

CONCLUSION

Intussusception is a common surgical condition among children under-two years of age with majority of cases occurring during infancy. Case management is dependent primarily on time duration elapsed between symptoms onset and admission to tertiary care centre. Early case detection and timely referral may provide an opportunity to avoid surgical interventions.

Routine Ultrasound Control after Successful Intussusception Reduction in Children: Is It Really Necessary?

INTRODUCTION

 Recurrence of ileocolic intussusception (ICI) has been related to residual bowel wall edema after enema reduction. Early oral tolerance has been associated with a higher risk of re-intussusception, so an imaging test (ultrasound) has traditionally been performed before restarting oral tolerance. Our aim is to analyze the cost-effectiveness of performing a routine ultrasound in patients who remain asymptomatic after successful enema reduction.

MATERIALS AND METHODS

 A retrospective observational study was performed in patients with ICI who underwent a successful enema reduction between 2005 and 2019 and distributed in two groups according to whether or not a routine ultrasound was performed before restarting oral tolerance: group A (ultrasound) or B (no ultrasound). We analyzed demographic, clinical and laboratory variables, length of hospital stay, and recurrence rate.

RESULTS

 We included 366 patients who presented 373 ICI episodes (165 in group A and 208 in group B), without significant differences in gender and age. Group A patients presented a higher percentage of vomiting and bloody stools than those in group B without differences in the other clinical features studied, time of evolution, or laboratory variables. Group A presented a higher length of hospital stay than group B (36 vs. 24 hours), although it was not statistically significant (p = 0.30). No statistically significant differences were observed in the recurrence rate between both groups (10.3% A vs. 10.8% B; p = 0.83).

CONCLUSION

 Performing routine ultrasound before restarting oral tolerance in asymptomatic patients after successful ICI reduction does not decrease the risk of re-intussusception and should not be routinely encouraged.

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.

Point-of-Care Ultrasound May Reduce Misdiagnosis of Pediatric Intussusception

Aim: Intussusception, the most common abdominal emergency in early childhood, is frequently misdiagnosed at initial presentation. The effect of using point-of-care ultrasonography (POCUS) by emergency medicine physicians on pediatric intussusception misdiagnosis rate remains unclear. Here, we summarize outcomes and misdiagnoses before and after training junior and senior physicians on using POCUS for diagnosing intussusception and compared their performance levels. Materials and Methods: This observational cohort analysis included patients with suspected intussusception who visited a pediatric emergency department (ED) between January 2017 and December 2019. All enrolled patients were evaluated by junior (<10-year experience) or senior attending physicians. Misdiagnosis was defined as a finding of negative air reduction or confirmation of diagnosis on ED revisit or admission. The misdiagnosis rates and outcomes before and after POCUS training for intussusception diagnosis were evaluated and performance of the junior and senior physicians was compared. Results: Of the 167 enrolled patients, 130 were confirmed to have intussusception by air reduction. Misdiagnosis rate was significantly lower in the post-training patient group after training than in the pre-training patient group (43.7 vs. 12.7%, P < 0.001). After training, fewer misdiagnoses were made by the junior (59.1 vs. 25.9%, P = 0.003) and senior (31.7 vs. 0%, P < 0.001) physicians. In the post-training patient group, the door-to-reduction time and rate of ultrasonography consultation with an expert also decreased significantly (118.2 ± 124.5 vs. 198 ± 250.2 min, P = 0.006). Abdominal pain (80.9%) was the most common symptom of intussusception, followed by vomiting (58.3%), fever (17.8%), bloody stool (15.4%), and diarrhea (14.2%). Even after training, the presenting symptoms of intussusception often leading junior physicians to misdiagnosis were diarrhea and fever. Conclusions: A brief POCUS training leads to decreased misdiagnosis rates in both the senior and junior physicians. Junior physicians should increase their awareness regarding diarrhea and fever being the presenting symptoms of intussusception, particularly in early childhood. Combining clinical judgment and POCUS results forms the core principle of the evaluation of children with intussusception.

Practical Imaging Strategies for Intussusception in Children

OBJECTIVE. Intussusception is the most common cause of intestinal obstruction in young children. Radiology has a key role in its diagnosis and treatment. This systematic review summarizes the currently available evidence for best practices in radiologic management of pediatric intussusception. CONCLUSION. High diagnostic accuracy and lack of ionizing radiation make ultrasound (US) the preferred imaging modality for diagnosing intussusception. For intussusception reduction, fluoroscopy-guided pneumatic enema and US-guided hydrostatic enema are equally dependable and safe techniques. The areas that warrant further research in this field include the efficacy and safety of the US-guided pneumatic enema, potential benefits of sedation and general anesthesia for the reduction procedure, and the optimal management of intussusceptions potentially involving pathologic lead points.

Ultrasonography for the Diagnosis of Intussusception in Children: An Experience From Pakistan

INTRODUCTION

Intussusception can lead to small bowel obstruction in children, hence the early diagnosis of this condition is very important. The purpose of this study is to evaluate the accuracy of sonography in the diagnostic work-up of children with suspected intussusceptions in the emergency setting, keeping surgical findings as the gold standard.

METHODS AND DESIGN

Two hundred patients with classical presentation of intussusceptions, who were diagnosed either by barium enema or CT scan, were included in this study. Patients with irreducible intussusceptions on color Doppler were followed after surgery.

RESULTS

The average age of the patients was 6.7 ± 2.8 years, and the study population consisted of 115 (57.5%) boys and 85 (42.5%) girls. One hundred forty-three patients were confirmed to have intussusception on ultrasonography, of whom 117 (81.8%) were confirmed to have intussusception after surgery while 26 (18%) were not diagnosed with intussusception during surgery. Despite the clinical presentation of intussusceptions, ultrasonography was not diagnostic in 57 patients, of whom 28 were confirmed to have intussusception after surgery and 29 were not found to have the disease.

CONCLUSION

Use of ultrasonography in cases with intussusception has proven to be a reliable and accurate method for diagnosing intussusception and provides an advantage over unnecessary radiological or surgical procedures being performed.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Use of Ultrasound in the Diagnostic Work-Up of Adult Intussusception - A Multicenter Retrospective Analysis

PURPOSE

 To evaluate the use of ultrasound (US) in the diagnostic work-up of adult intussusception (AI).

METHODS

 This multicenter study includes 26 consecutive patients diagnosed with AI between January 2010 and November 2017. A retrospective chart analysis was conducted with a focus on abdominal US findings and diagnostic accuracy of different imaging modalities (ultrasound, computed tomography (CT), magnetic resonance imaging). If available, surgical and pathological findings served as the gold standard (76.9 %). US examiners certified according to DEGUM grade 2 or 3 were classified as experts. Otherwise, they were regarded to have basic skills.

RESULTS

 During diagnostic work-up, 92.3 % underwent abdominal US. US was the first-line imaging modality in 88.5 % of cases. The accuracy regarding the detection of AI (85 %), correct localization (95 %) and detection of complications (100 %) was excellent and comparable with CT (81 %, 90.5 %, and 91.7 %) when performed by experts. 72.7 % of tumorous lead points were detected by experienced examiners. In contrast, AI was detected in only 45.5 % of cases by examiners with basic skills. AI was diagnosed prior to surgery in all patients.

CONCLUSION

 US is reliable in the diagnostic work-up of AI when performed by experienced examiners with high-quality equipment. US, CT and MRI should be used in a complementary fashion since combination provides excellent sensitivity regarding the detection and correct localization of AI as well as the detection of complications. The impact of real-time imaging is illustrated by supplementary videos.

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.

Pediatric intussusception in Uganda: differences in management and outcomes with high-income countries

PURPOSE

In high-income countries the presentation and treatment of intussusception is relatively rapid, and most cases are correctable with radiographically-guided reduction. In low-income countries, many delays affect outcomes and surgical intervention is required. This study characterizes the burden and outcome of pediatric intussusception in Uganda.

METHODS

Prospective case series of intussusception cases from May 2015 to July 2016 at a tertiary referral hospital in Uganda.

RESULTS

Forty patients were included in the study. Male to female ratio was 3:2. Average duration of symptoms before presentation was 4.5 days. Median duration of symptoms in referred patients was 4 days and 2 days in non-referred patients (P value 0.0009). All 40 patients underwent surgical treatment: 25% had resection and enterostomy, 15% had resection and primary anastomosis, 2.5% had resection, primary anastomosis and enterostomy and 57.5% underwent manual reduction. Mortality was 32% and febrile patients on admission were 20 times more likely to die (P value 0.040).

CONCLUSION

Intussusception carries a high operative and mortality rate in Uganda. Referred patients presented later than non-referred patients to health facilities. Fever on examination at admission was positively associated with mortality. This disease remains a target for quality metrics in global pediatric surgery.

TYPE OF STUDY

Diagnostic study.

LEVEL OF EVIDENCE

III.