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

Comparison of Clinical Features of Intussusception in Terms of Age and Duration of Symptoms

OBJECTIVES

Intussusception is one of the most common surgical emergencies in children. We aimed to analyze the current clinical characteristics of intussusception.

METHODS

We retrospectively reviewed 209 children diagnosed with intussusception, who were admitted to our hospital between January 2009 and August 2022. We grouped the patients according to symptom duration (before and after 12 hours and before and after 24 hours) and age (younger and older than 1 year, and younger and older than 2 years).

RESULTS

The median age at admission was 31 months (2-204 months). The median symptom duration was 12 hours (1-420 hours). Most patients (91.4%) were admitted due to abdominal pain, irritability, and/or vomiting. The most common symptoms were vomiting (70.8%) and abdominal pain (60.6%). The classical triad of symptoms was seen in 9 cases (4.3%). In patients aged younger than 1 year, bloody stool, abnormal abdominal radiography findings, and a longer intussusceptum segment were more frequent. In patients aged younger than 2 years, abdominal pain, fever, and defense on physical examination were less frequent, and irritability, bloody stool, and recurrence were more frequent. Patients aged younger than 2 years had a longer intussusceptum segment and less lymphadenopathy based on ultrasonography (USG). The patients admitted more than 12 hours after symptom onset had more diarrhea, fever, abnormal x-ray, peritoneal fluid on USG, and recurrences, and less vomiting. After the symptoms had lasted for 24 hours, fever, mass palpation, and abnormal abdominal radiography findings were more frequent.

CONCLUSIONS

We recommend performing abdominal USG, especially in young children admitted to the emergency department with complaints of abdominal pain and/or vomiting, to rule out intussusception. In countries that have reported a high mortality rate from intussusception, we advise precautions such as increasing the availability of USG in emergency departments and educating the population to seek early medical assistance.

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.

Meckel's Diverticulum Mimicking Inflammatory Bowel Disease

Intermittent abdominal pain is the most common gastrointestinal (GI) complaint in the pediatric age group. When basic investigations and sonograms do not give etiological basis, functional GI disorders are diagnosed. Meckel's diverticulum (MD), being the common GI surgical condition, can be missed in absence of classical symptoms. Clinical presentation varies based on the size, location, and presence of ectopic gastric mucosa. We report a case of an adolescent female with MD presenting as chronic abdominal pain. Abdominal ultrasonogram was normal. Abnormal fecal calprotectin level and colonoscopy directed for a suspicion of inflammatory bowel disease. Persistence of symptoms with increasing severity prompted a relook into the diagnosis. The presence of intussusception on abdominal scan during one of the painful episodes warranted emergency exploratory laparotomy. Intraoperatively, the lead point for intussusception was identified as MD, which was resected. Postoperative period was uneventful. There are no abdominal symptoms since a year during the follow-up period.

Clinical characteristics of pediatric intussusception and predictors of bowel resection in affected patients

Background

Surgery is required for the treatment of intussusception when enema reduction is unsuccessful, or when the patient develops peritonitis, bowel perforation, or intestinal damage. We aimed to evaluate the clinical and laboratory parameters that may be used to predict the need for bowel resection in children with intussusception.

Methods

This observational retrospective study included children who were admitted to the pediatric emergency department with intussusception. Univariate and multivariate logistic regression models were used to evaluate factors associated with bowel resection.

Results

In total, 584 children with intussusception were admitted to the pediatric emergency department; 129 of these children underwent surgery. Multivariate analysis revealed the following independent predictors of bowel resection for intussusception: symptoms for at least 2 days before surgery (OR = 6.863; p = 0.009), long intussusception (OR = 5.088; p = 0.014), pathological lead point (OR = 6.926; p = 0.003), and intensive care unit admission (OR = 11.777; p = 0.001) were factors independently associated with bowel resection.

Conclusion

Symptoms for at least 2 days before surgery, long intussusception, pathological lead, and intensive care unit admission were predictors of bowel resection in children with intussusception. These findings can be used to identify patients at high risk of needing surgery and bowel resection.

COVID-19-Related Intussusception: A Case Series and Review of the Literature

Background: Ileocolic intussusception is a common gastrointestinal emergency that occurs in infancy. Many cases are caused by anatomic lead points, such as hypertrophied Peyer's patches. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, which causes coronavirus disease 2019 (COVID-19), commonly presents with respiratory symptoms, however, its relation to intussusception remains unknown. Methods: Two cases are reported as well as a review of pertinent English-language literature on the topic. Results: We present two cases of intussusception in COVID-19-positive patients, including the first known case of a lead point with tissue polymerase chain reaction (PCR) confirming COVID-19 positivity, and compare these findings to a review of the recent literature. Intussusception in COVID-19-positive patients is becoming more prevalent and more often requires operative treatment. Discussion: We offer evidence that intussusception can be the presenting symptom in the absence of COVID-19-related respiratory symptoms. There also seems to be a trend toward the need for operative intervention compared with COVID-19-negative intussusception. The presence of SARS-CoV-2 can be confirmed via PCR in specific lead points (lymph nodes), directly causing the intussusception. Conclusions: Providers should have a low threshold to suspect and diagnose intussusception as operative treatment is more readily used in COVID-19-positive pediatric patients with gastrointestinal symptoms.

Clinical characteristics of recurrent intussusception: A single-center retrospective study

PURPOSE

we attempted to summarize the clinical characteristics of recurrent intussusception through a large sample size retrospective study.

METHODS

5778 patients who were diagnosed with intussusception and treated in our hospital between January 2014 and December 2018 were reviewed.

RESULTS

the overall recurrence rate was 20.0%, with the recurrence frequency ranged from 1 to 17 episodes and the recurrence interval ranged from 0 to 5 years. 80.0% (926/1158) patients had only 1 to 2 episodes of recurrence. Most of the patients (88.3%) relapsed within 1 year after successful reduction, among which 616 patients (53.2%) relapsed within 3 days. The recurrence rate of intussusception was the lowest when the age was less than 1 year, increased and kept high level in patients aged from 1 to 5 years old, then decreased after 5 years. The pathologic lead point (PLP) proportion of recurrence group was higher than that of non-recurrence group (2.2% VS 1.2%, P = 0.005).

CONCLUSIONS

the overall recurrence rate was 20.0%. Most of the patients had only 1 to 2 episodes of recurrence and relapsed within 1 year after successful reduction. Age and PLP were risk factors for intussusception recurrence.

A case of iatrogenic intussusception in adults: a rare case report

Background

Intussusception has a low incidence rate in adults. Many cases in adults are caused by tumors. Intussusception results from conditions other than tumors are uncommon. This is the first case report about intussusception that occurred after removing a long intestinal tube (LT).

Case presentation

A 69-year-old female complained of “recurrent abdominal pain with reduced flatus passage and frequency of bowel movement for 10 days” was admitted to the hospital. Plain abdominal radiography and abdominal CT upon admission showed intestinal obstruction. The patient’s abdominal pain was not relieved after symptomatic treatments, which involved fluid and electrolyte replacement, LT placement, spasmolytic agents, and analgesics. Hence, surgical exploration was carried out. The patient had a good recovery postoperatively. No abdominal pain or bloating developed after food intake. The patient passed flatus and had bowel movements later. On postoperative day 9, the LT was removed. On the 10th day, the patient suddenly developed abdominal distension and acute abdominal pain. Emergency abdominal CT showed small bowel intussusception. Surgical exploration was then performed. Severe small bowel dilatation located at 1.5 m from the ligament of Treitz was found during the procedure. Intussusception at the site was observed. No color change of the intestinal wall was detected, suggesting that no necrosis was present. So, a manual reduction was done. The patient was discharged on postoperative day 6.

Conclusions

This case serves as a warning that the simple action of pulling out the LT might also cause serious complications, which should be given more attention.

Hydrostatic reduction of intussusception with intermittent radiography: an alternative to fluoroscopy or ultrasound-guided reduction in low-income and middle-income countries

Background

Although hydrostatic reduction of intussusception with ultrasound (US) or fluoroscopy guidance is well known, it is not yet well established in many low-income and middle-income countries. The aim of the study is to report our results of hydrostatic reduction with intermittent radiography, which has the potential to be practiced in resource-limited settings.

Methods

We retrospectively analyzed our patients with intussusception from 2009 to 2019 (11 years). Hydrostatic reduction was performed using water-soluble contrast medium (iopamidol), and reduction was followed with intermittent X-rays taken after every 50 mL of diluted contrast injection. The procedure was not continuously monitored by US or fluoroscopy. Differences in outcome based on age and gender, and yearly trends of admission for intussusception, types of treatment and mortality were analyzed.

Results

Among 672 patients, the ratio of boys to girls was 2.46:1.0, and their ages ranged from 1 month to 15 years (median 8 months). Hydrostatic reduction was performed successfully in 351 (52.23%) patients; 308 (45.83%) patients underwent surgery; and 13 (1.93%) patients died before any intervention. There were significant differences in age between patients with successful hydrostatic reduction (median 7 months) and patients needing surgery (median 9 months) (p<0.001). The number of successful hydrostatic reductions increased during the 11 years of the study (R2=0.88). One patient (0.15%) died after hydrostatic reduction, and 10 (1.49%) died after surgery.

Conclusion

Hydrostatic reduction with intermittent radiography was performed successfully in more than half of the patients with acceptable complication rates.

Clinical Characteristics According to Age and Duration of Symptoms to Be Considered for Rapid Diagnosis of Pediatric Intussusception

Purpose: The purpose of this study was to evaluate whether clinical findings in children with ileocolic intussusception differ based on age and duration of symptoms and to assess the clinical characteristics of diagnosed and undiagnosed patients to determine which symptoms make diagnosis more difficult. Methods: We reviewed 536 medical records of <15-year-old children diagnosed with ileocolic intussusception between 2008 and 2019. We divided the children into three categories according to age (<1 year, 1-2 years, and ≥2 years). The children were also divided into two groups based on whether symptoms lasted for more or <6 h. Diagnosed and undiagnosed children were assessed separately during for the initial evaluation. Results: Following analysis of the three age groups, bloody stool, post-enema bloody stool, diarrhea, vomiting, poor oral intake, and lethargy were more frequent in children aged <1 year. In children aged ≥2 years, non-specific abdominal pain was more frequent and the undiagnosed rate was higher. Following analysis of the duration of symptoms, paroxysmal pain was significantly more frequent in the early group (<6 h), and bloody stool and fever were significantly more frequent in the late group (≥6 h). Nonspecific abdominal pain was more frequent and the door-to-diagnosis time was significantly longer in the undiagnosed group than in the diagnosed group. Conclusions: Clinical findings of ileocolic intussusception vary depending on the age and duration of symptoms. Younger children with paroxysmal pain, vomiting, bloody stool, poor oral intake, or lethargy should be suspected of having intussusception. In older children, non-specific abdominal pain without bloody stool may be a symptom of intussusception. Glycerin enema is helpful in diagnosing intussusception in children with no typical symptoms.