Clinical and Ultrasonographic Features of Secondary Intussusception in Children

The Ileoileal intussusception due to a tubular duplication in a child: A case report

Intussusception is a surgical emergency that may result in the perforation of the intestinal wall if not immediately treated. Pathologic lead points, such as intestinal duplication, are present in 2.2%-15% of the cases.We describe a 4-year-old girl with a necrotic ileoileal intussusception diagnosed with a rare tubular ileal duplication.

Intestinal tumor lesions leading to intussusception in children: a report of four cases and literature review

Background

Intussusception is commonly idiopathic in children. Pathologic lead points (PLP) especially intestinal tumors (IT) are extremely rare. The diagnosis of intussusception secondary to pediatric IT is difficult due to the non-specific nature of symptoms. Its management remains a challenge. We report here four pediatric cases of intussusception secondary to IT lesions in order to analyze the clinical and therapeutic characteristics of this unusual condition.

Case presentations

Four children were diagnosed and operated in our center for intussusception secondary to IT during the period from February 2017 to February 2021. Patients’ demographics, clinical presentations, investigations, operative data, and postoperative outcome were recorded and analyzed. There were three girls and one boy. Ages ranged between 1 and 8 years (average of 5.5 years). Intermittent abdominal pain with acute exacerbation and vomiting were the main clinical signs. Radiologic investigations showed the intussusception in all cases but the tumor lead point was evident only during the surgical exploration in most cases. All patients underwent surgical treatment with intussusception reduction and mass removal. Pathological examination of these masses revealed: submucosal intestinal lipoma (1 case), hamartomatous polyposis (2 cases), and Burkitt’s lymphoma (1 case). For this last case, adjuvant chemotherapy was also needed. The postoperative period was uneventful in all cases.

Conclusion

Pediatric intussusception secondary to IT lesions is an unusual and challenging condition that requires high preoperative diagnostic suspicion, considerate intraoperative judgment, and appropriate postoperative follow-up for successful outcomes.

These tumors should be considered by the pediatric surgeons as possible PLP for recurrent intussusception, especially in older children. Surgeons should be familiar with the various treatment options, because the real cause of the intussusception is often accurately diagnosed by laparotomy.

A Technique to Reduce the Early Recurrence of Intussusception in Ultrasound-Guided Hydrostatic Reduction

OBJECTIVES

Ultrasound-guided saline enema is highly successful in treating pediatric intussusception; however, early recurrence-within 48 hours-is possible. This study aimed to explore effective methods of reducing early recurrence.

METHODS

This study included patients aged 0 to 14 years diagnosed with ileocolic intussusception with a symptom duration of <48 hours from January 2019 to March 2021. The patients were divided into control and intervention groups. All patients received successful treatment with ultrasound-guided saline enema; however, in patients treated before January 4, 2020 (control group), the intestinal fluid was drained immediately, and in patients treated after January 4, 2020 (intervention group), the intestinal fluid was drained after 15 minutes of intestinal pressure maintenance. Early recurrence rates of the groups were compared.

RESULTS

Ileocolic intussusception was treated successfully by ultrasound-guided saline enema in 231 patients (116, control group;115, intervention group). The early recurrence rate in the intervention group (10%; 95% CI: 4.9-16.5) was numerically lower than that in the control group (19%; 95% CI: 12.3-27.3). No significant difference was observed in the number of recurrences per person between the groups (P = .448). Patients without early recurrence were older (P = .004) and received enemas of a shorter duration (P < .001) and lower pressure (P < .001) than patients without early recurrence.

CONCLUSIONS

Maintaining reduction pressure for 15 minutes after a successful ultrasound-guided saline enema may reduce the early recurrence of intussusception. A randomized controlled trial is needed because the intervention and control cohorts were most probably incomparable (due to the COVID-19 pandemic).

Development and Validation of a Nomogram for Predicting Pathological Intussusceptions in Children Prior to Surgical Intervention

PURPOSE

Establish and validate a nomogram to help predict the preoperative risk of a pathological intussusception.

METHODS

A primary cohort of patients who underwent surgery for an intussusception were enrolled from one center, while a validation cohort consisted of patients from another center. Multivariate logistic regression analysis was used to identify the variables to build the nomogram. A calibration curve accompanied by the Hosmer-Lemeshow test was used to assess the calibration of the nomogram. To quantify the discrimination of the nomogram, Harrell's C-index was calculated. The performance of the validated nomogram was tested in the external validation cohort. The logistic regression formulae created during the analysis of the primary cohort was applied to all patients in the external validation cohort, and the total points for each patient were calculated.

RESULTS

The primary cohort consisted of 368 patients and the validation cohort included 74. The LASSO logistic algorithm identified three (recurrence episodes, mass size, and infection history) out of 11 potential clinical variables as significantly predictive of a pathologic intussusception. The C-index for the predictive nomogram was 0.922 (95% CI, 0.885-0.959) for the primary cohort and 0.886 (95% CI, 0.809-0.962) for the validation cohort. The decision curve showed that if the threshold probability of a patient in the validation cohort was > 7%, then the nomogram was more beneficial than either indiscriminately treating all or none of the patients.

CONCLUSION

We developed a nomogram based on clinical risk factors that could be used to individually predict pathological intussusceptions in children prior to surgical intervention.

Omphalomesenteric Duct Anomalies in Children: A Multimodality Overview

The omphalomesenteric duct is an embryologic structure that connects the yolk sac with the primitive midgut of the developing fetus. Omphalomesenteric duct anomalies include a group of entities that result from failed resorption of the omphalomesenteric duct. These anomalies include Meckel diverticulum, omphalomesenteric fistula, fibrous bands, cysts, and umbilical polyps. Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract and is usually asymptomatic. Symptoms develop when Meckel diverticulum involves complications such as hemorrhage, inflammation, and perforation, or when it causes intussusception or bowel obstruction. Hemorrhage is the most common complication of Meckel diverticulum, and technetium 99m-pertechnetate scintigraphy is the imaging modality of choice for detecting acute bleeding. US and CT are commonly used for the evaluation of patients with other complications such as obstruction and inflammation. Nevertheless, the diagnosis of these complications can be challenging, as their clinical manifestations are usually nonspecific and can masquerade as other acute intraabdominal entities such as appendicitis, inflammatory bowel disease, or other causes of bowel obstruction. There are other umbilical disorders, such as urachal remnants and umbilical granuloma, that may present with symptoms and imaging findings similar to those of omphalomesenteric duct anomalies. An accurate preoperative diagnosis of omphalomesenteric duct anomaly is crucial for appropriate management and a better outcome, particularly when these anomalies manifest as a life-threatening condition. The authors review the anatomy, clinical features, and complications of omphalomesenteric duct anomalies in children, describing the relevant differential diagnoses and associated imaging findings seen with different imaging modalities. ^©RSNA, 2021.

Sonographic imaging of appendiceal orifice polyps in children

Although gastrointestinal polyps are a common disease, appendiceal orifice polyps are rare and usually found incidentally during autopsy or surgery. Data on the sonographic features of appendiceal orifice polyps in children are limited. We describe the sonographic features of appendiceal orifice polyps in two children.

Accurately distinguishing pediatric ileocolic intussusception from small-bowel intussusception using ultrasonography

PURPOSE

The clinical treatment of ileocolic intussusception is different from that of small-bowel intussusception (SBI). This study aimed to analyze the differences between the two groups using ultrasonoscopy to avoid misdiagnosis.

METHODS

We conducted a retrospective study of intussusception in patients aged 0-18 years from September 2018 to March 2020. Clinical and ultrasonoscopy data were reviewed.

RESULTS

A total of 183 cases of intussusception were included in this study (123 cases of SBI and 60 of ileocolic intussusception). Ultrasonoscopy features that were significantly different between the two groups (p<0.05) included the lesion diameter, fat core thickness, outer wall thickness, lymph nodes inside intussusception, and lesion length. In the SBI group, 85% (104/123) of the normal ileocecal region was found in the right lower quadrant and 98% (120/123) of the normal ascending colon was found in the right side of the abdomen. In the ileocolic intussusception group, none of the normal ileocecal region was found and the ascending colon was found in only 5 cases (8%) (p<0.05).

CONCLUSIONS

The use of ultrasonography is the most practical method to distinguish SBI from ileocolic intussusception. In addition to comparing the differences between lesions, conventional probing of the ileocecal region and ascending colon will help to accurately differentiate between the types of intussusception and avoid misdiagnosis.

LEVELS OF EVIDENCE

Diagnostic.

Management of Intussusceptions Secondary to Pathological Lead Points in Infants and Children

Objectives This study was undertaken to investigate and review the age, sex, clinical presentation, surgical procedures done, major postoperative complications, and the final outcome of infants and children operated for intussusceptions secondary to pathological lead points (PLPs).

Materials and Methods This is a single-institution, retrospective study and included infants and children below the age of 12 years who were operated for the secondary intussusceptions. This study was conducted at author’s Department of Paediatric Surgery during the last 20 years; from January 1, 2000 to December 31, 2019.

Results During the study period, 200 infants and children were operated for the intussusceptions, and 23 (11.5%) of them were operated for the intussusceptions secondary to PLPs. This review comprised 18 (78.26%) boys and 5 (21.73%) girls, and consisted of infants (n = 9, 39.13%) and children of 1 to 5 years of age (n = 7, 30.43%) and 6 to 12 years of age (n = 7, 30.43%). The age at presentation ranged from 3 months to 10 years, with the mean age of 41.47 ± 40.06 months. Clinically, all the children presented with features of acute intestinal obstruction. Ultrasonography (USG) examination of the abdomen revealed the diagnosis of intussusception in all of them but not able to document the PLPs as a cause for it. During the exploratory laparotomies, gangrenous bowel was detected in 15 (65.21%) cases. PLPs causing intussusceptions were Meckel’s diverticulum (n = 17, 73.91%), begin ileal growth (n = 4, 17.39%), benign ileal polyp (n = 1, 4.34%), and caecal lymphoma (n = 1, 4.34%). Surgical procedures were executed in the following order of frequency: (1) resection of segment of ileum including PLP, and ileoileal anastomosis (n = 13, 56.52%); (2) resection of segment of ileum including PLP, caecum and part of ascending colon, and ileoascending anastomosis (n = 5, 21.73%); (3) Meckel’s diverticulectomy (n = 3, 13.04%); and (4) resection of segment of ileum including PLP and terminal ileostomy (n = 2, 8.69%). This study documented two (8.69%) deaths in postoperative period.

Conclusion Meckel’s’ diverticulum was the commonest pathology for the secondary intussusceptions in infants and children and documented most frequently during infancy. Half of the secondary intussusceptions occurred within 24 months of age. Bowel resection was required in more than 85% of the cases during the surgical procedures.

Management of recurrent ileocolic intussusception

PURPOSE

The aims of this study were to evaluate the need for surgical intervention for patients with recurrent ileocolic intussusception (RICI), especially for multiple recurrences, and to investigate whether early and late recurrence patterns were associated with surgery.

METHODS

Patients with ileocolic intussusception (ICI) during the years 2007-2019 were included. Demographic data, recurrences, and outcomes were analyzed. Early RICI was defined as recurrence within 48 h.

RESULTS

Overall, 604 episodes of ICI were confirmed in 491 patients. The recurrence rate was 13.8%, with 113 episodes in 68 patients. There were no statistically significant differences in age, reduction success rate, operation, or pathological lead points (PLPs) between the recurrence and non-recurrence groups. There was no significant association between the number of recurrences and the presence of a PLP or between the number of recurrences and whether the recurrences were early or late. The presence of PLPs was not significantly associated with age or recurrence, but the reduction success rate was significantly lower (P < 0.001).

CONCLUSIONS

Each recurrence should be managed as a first episode, regardless of early or late recurrence. Operative reduction should be considered when nonoperative reduction fails, a PLP is suspected, or there are signs of peritonitis.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level 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.

Clinical Characteristics of Intussusception with Surgical Reduction: a Single-Center Experience with 568 Cases

BACKGROUND

Intussusception is among the most common acute abdominal emergencies in infancy, but only some cases need surgical reduction. This study assessed the clinical characteristics of patients undergoing surgical reduction of intussusception.

METHODS

This retrospective study reviewed 568 pediatric patients who failed air-enema reduction and underwent surgical reduction for intussusception in our department between 2008 and 2017.

RESULTS

The series comprised 376 boys and 192 girls (2.0:1, male:female ratio) and most of the intussusceptions were primary, which is typical before the age of 1 year. The success rate of air-enema reduction in our hospital was 94.2%. Patients over 3 years old had the highest rate of surgical reduction (ca. 11.8%). The probabilities of primary and secondary intussusception were equal above 2 years old. Intussusception caused by intestinal malignant lymphoma was diagnosed above 2 years of age with atypical symptoms. Gender was irrelevant regarding the presence of bloody stools (P = 0.594), but the younger patients and children with complex/compound intussusception had a higher proportion of bloody stools (n = 148, 40.0%, P = 0.000) and intestinal necrosis (n = 44, 42.3%, P = 0.024). The occurrence time of bloody stools (OTBS) in complex/compound intussusception was shorter than for other types.

CONCLUSIONS

This retrospective study analyzed the clinical features of patients undergoing surgical reduction for intussusception and summarized the characteristics and management of complex/compound intussusception.

Small bowel-small bowel intussusception with high grade obstruction due to intramural submucosal ileal hamartoma in a 5-year-old child: A case report

•

Intussusception in children can present with evidence of small bowel obstruction.

•

Ultrasound can show a pathologic lead point which requires surgical intervention.

•

Surgery should begin with a laparoscopic approach and converted to open procedure if needed.

Introduction

Intussusception is a common cause of emergency in children. We report a unusual case of intestinal obstruction due to small bowel-small bowel intussusception with an intestinal hamartoma as the lead point.

Presentation of the case

A 5 year old boy presented to the ED with worsening abdominal pain, emesis and bloody diarrhea. An abdominal radiograph showed evidence of small bowel obstruction and US confirmed a small bowel-small bowel intussusception with a likely cystic mass as the lead point. Given these findings, surgery was performed and revealed an intestinal hamartoma as a lead point.

Discussion

Intussusception in children is mostly idiopathic and usually amenable to reduction by air enema. The presence of a lead point is unusual and usually requires surgical intervention.

Conclusion

We report an unusual case of intussusception with small bowel obstruction due to intestinal hamartoma, a rare pathologic finding as a lead point for intussusception. Ultrasound was useful for diagnosing the intussusception and confirming the presence of a lead point.

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 characteristics of intussusception secondary to pathologic lead points in children: a single-center experience with 65 cases

OBJECTIVE

Intussusception secondary to pathologic lead points (PLPs) is a challenging condition for pediatric surgeons, and few studies have been published on this subject. The aim of this study was to review and analyze clinical data on the diagnosis and management of intussusception secondary to PLPs in children.

METHODS

Between 2002 and 2016, a total of 65 pediatric patients with a diagnosis of intussusception secondary to PLPs were retrospectively reviewed.

RESULTS

The series comprised 47 males and 18 females. The average age of the patients was 4.9 years old. All patients had typical clinical manifestations, and intussusception was proven by ultrasound. Fifty-one patients had recurrent intussusception, of whom 21 had one, 14 had two, 10 had three, and 6 had more than three. There were 20 episodes of recurrence within 24 h (39.2%), 15 episodes were found between 24 and 72 h (29.4%), and the remaining 31.4% (16/51) of recurrences occurred after 72 h. All patients received surgical intussusception reduction. Meanwhile, enterectomy was the procedure of choice in 55 patients, polypectomy in 5 patients, and cystectomy in 3 patients. The types of intussusception secondary to PLPs included small intestinal (n = 25), ileocolic (n = 19), ileocecal (n = 11), ileo-ileocolic (n = 9) and cecalcolic (n = 1). The types of PLPs included Meckel diverticulum (n = 32), intestinal duplication (n = 14), benign polyps (n = 5), malignant lymphoma (n = 4), Peutz-Jeghers syndrome (n = 3), mesenteric cyst (n = 3), intestinal wall hematoma of hemophilia (n = 2), allergic purpura (n = 1), and hamartoma (n = 1). All patients recovered well with no relapse during follow-up, except for one patient who had an intestinal obstruction from adhesions that occurred approximately 3 months after discharge and who was curable after conservative treatment.

CONCLUSIONS

Intussusception secondary to PLPs tends to exhibit recurrence. There are various types of intussusception secondary to PLPs. It is necessary to improve auxiliary examinations to identify the etiology and avoid intraoperative omission. Surgical reduction of intussusception secondary to PLPs is the preferred clinical management.