Incidence of recurrent intussusception following barium versus air enema

Scoring System to Evaluate Risk of Nonoperative Management Failure in Children With Intussusception

INTRODUCTION

Typical first-line management of children with intussusception is enema reduction; however, failure necessitates surgical intervention. The number of attempts varies by clinician, and predictors of failed nonoperative management are not routinely considered in practice. The purpose of this study is to create a scoring system that predicts risk of nonoperative failure and need for surgical intervention.

METHODS

Children diagnosed with intussusception upon presentation to the emergency department of a tertiary children's hospital between 2019 and 2022 were retrospectively identified. Univariable logistic regression identified predictors of nonoperative failure used as starting covariates for multivariable logistic regression with final model determined by backwards elimination. Regression coefficients for final predictors were used to create the scoring system and optimal cut-points were delineated.

RESULTS

We identified 143 instances of ultrasound-documented intussusception of which 28 (19.6%) required operative intervention. Predictors of failed nonoperative management included age ≥4 y (odds ratio [OR] 32.83, 95% confidence interval [CI]: 1.91-564.23), ≥1 failed enema reduction attempts (OR 189.53, 95% CI: 19.07-1884.11), presenting heart rate ≥128 (OR 3.38, 95% CI: 0.74-15.36), presenting systolic blood pressure ≥115 mmHg (OR 6.59, 95% CI: 0.93-46.66), and trapped fluid between intussuscepted loops on ultrasound (OR 17.54, 95% CI: 0.77-397.51). Employing these factors, a novel risk scoring system was developed (area under the curve 0.96, 95% CI: 0.93-0.99). Scores range from 0 to 8; ≤2 have low (1.1%), 3-4 moderate (50.0%), and ≥5 high (100%) failure risk.

CONCLUSIONS

Using known risk factors for enema failure, we produced a risk scoring system with outstanding discriminate ability for children with intussusception necessitating surgical intervention. Prospective validation is warranted prior to clinical integration.

Sonographic guided hydrostatic saline enema reduction of childhood intussusception: a prospective study

Background

The management of childhood intussusception in our sub-region is still via surgical intervention. Currently, the gold standard of treatment is non-operative reduction. We sought to assess the suitability of hydrostatic (saline) reduction of intussusception in children in our institution.

Materials and methods

A prospective study was conducted between January 2016 and June 2017 in all children with ultrasound confirmed intussusception at a tertiary teaching hospital in Nigeria. All children excluding those with signs of peritonitis, bowel gangrene and intestinal prolapse were selected for ultrasound-guided hydrostatic reduction (USGHR). We allowed a maximum of three attempts at reduction.

Results

The age range was 3 months to 48 months with a mean of 10.8 ± 9.1 months. Forty percent (N = 18) presented after 24 h of onset of symptoms. The success rate of hydrostatic reduction with saline enema was 84.4% (N = 38). Two (4.4%) perforations occurred during the procedure. Three (7.5%) patients had recurrent intussusception within six months. The duration of symptoms greater than 24 h, age and sex of patients did not influence successful reduction p > 0.05. The duration of admission between those who had successful non-operative reduction and those who subsequently had operative reduction and or resection attained statistical significant difference, p = 0.001. There was no mortality. We achieved a 68% decrease in the operative reduction of intussusception using USGHR as the primary modality of treatment.

Conclusion

Our study found out that USGHR is a suitable alternative for the treatment of childhood intussusception.

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

Background:

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

Objectives:

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

Patients and Methods:

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

Results:

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

Conclusions:

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

Operative indications in recurrent ileocolic intussusception

BACKGROUND

Air-contrast enema (ACE) is standard treatment for primary ileocolic intussusception. Management of recurrences is less clear. This study aimed to delineate appropriate therapy by quantifying the relationship between recurrence and need for bowel resection, pathologic lead points (PLP), and complication rates.

METHODS

After IRB approval, a single institution review of patients with ileocolic intussusception from 1997 to 2013 was performed, noting recurrences, outcomes, and complications. Fisher's exact and t-tests were used.

RESULTS

Of 716 intussusceptions, 666 were ileocecal. Forty-four underwent bowel resection, with 29 PLPs and 9 ischemia/perforation. Recurrence after ACE occurred in 96 (14%). Recurrence did not predict PLP (P=0.25). Recurrence (≥3) was associated with higher resection rate (P=0.03), but not ischemia/perforation (P=0.75). ACE-related complications occurred in 4 (0.5%) patients. Successful initial ACE had 98% negative predictive value for resection and PLP (e.g., after successful ACE, 2% had resections, 2% PLP). After failed initial ACE, 36% received resection, and 23% had PLP (P<0.001).

CONCLUSIONS

Recurrence is associated with a greater risk of resection but not PLP or ACE-complication. Failed ACE is associated with increased risk for harboring PLP and receiving resection. ACE should be the standard treatment in recurrent intussusception, regardless of number of recurrences.

Recurrent intussusception

Recurrent intussusception is defined as an occurrence of intussusception of a bowel loop in a patient with a prior resolution of intussusception, either spontaneously or with an intervention. It is not rare to develop a subsequent episode after a successful reduction of intussusception. We report the cases of 2 children who presented to the emergency department with recurrent intussusception and review the pertinent literature.

Management of recurrent intussusception: nonoperative or operative reduction?

PURPOSE

The aim of this study was to determine how to manage children with recurrence of intussusception.

METHODS

Medical records of patients treated for intussusception from 1976 to 2008 at the Queen Sirikit National Institute of Child Health were reviewed. Information on patients who developed recurrent intussusception was extracted to study patterns of recurrent attack and suitable management procedures. The statistical differences were analyzed by the χ² and the Student t test, with a P value < .05 considered significant.

RESULTS

During the study period, 1340 patients were treated for 1448 episodes of intussusceptions, with an average of 40 cases per year. There were 108 episodes of recurrent intussusception in 75 patients (45 males and 30 females). The overall recurrence rate was 8%. Patient age at the first episode ranged from 3 months to 12 years (average, 14.9 months). The time interval before each recurrence ranged from 1 day to 3.2 years (average, 7.8 months). The number of recurrences ranged from 1 to 5 attacks. Recurrent intussusception occurred in 35 (15.8%) of 222 children following successful hydrostatic barium enema (BE) reduction and in 55 (11.4%) of 482 after successful pneumatic or air enema (AE) reduction. There was no statistical difference between the recurrence rates after the 2 nonoperative procedures (P = .08). Recurrent intussusception developed in 14 (3.0%) of 457 patients after operative manual reduction. Recurrence was not observed after intestinal resection for initial irreducible intussusception in 175 patients. The remaining 4 recurrent episodes occurred after spontaneous reduction. Of the 108 episodes of recurrence, BE and AE reductions were successful in 25 (96.2%) of 26 attempts and in 57 (92%) of 62 attempts, respectively. Seven patients had their first episode of intussusception treated surgically. All 7 when they recurred were successfully treated with either BE or AE reduction. Operative intervention was needed in 23 episodes of recurrent intussusception; 18 were reduced manually, and 5 required intestinal resection. Overall, 7 (9.3%) of the 75 recurrences had a pathologic lead point: colonic polyps in 4 cases and Meckel diverticulum in 3 cases. There were no deaths among the 75 patients with recurrent intussusception.

CONCLUSIONS

Recurrent intussusception should be initially treated by nonoperative reduction. Laparotomy is needed in cases with failure of BE or AE reduction, in cases with suspicion of a pathologic lead point, and in selected cases with several episodes of recurrence. The treatment of recurrent intussusception, in general, should be similar to that of primary intussusception.

Enema-reduced intussusception management: is hospitalization necessary?

OBJECTIVES

To describe the demographic and clinical characteristics of hospitalized children with enema-reduced intussusception and to determine the necessity of hospitalization.

METHODS

Retrospective cross-sectional study of patients (0-17 years of age) with enema-reduced intussusception hospitalized at a 110-bed urban children's hospital. For this study, potential necessity of hospitalization was defined as the presence of associated dehydration, persistent symptoms and signs of intussusception requiring repeated radiographic studies, and/or enema-reduced serious complications (bowel perforation and/or sepsis).

RESULTS

For a 12-year period (January 1995 to December 2006), 45 patients who had enema-reduced intussusception were hospitalized. There were 32 males (71%). Three (6.7%) of the 45 patients had recurrent episodes of intussusception occurring at 2, 7, and 45 months after the initial episode. The initial episode for only 1 of these 3 was an enema-reduced hospitalization event. Thus, the following results include 46 episodes among 45 patientsThe mean (SD) age at the time of intussusception was 19.6 (25.4) months, and the median age was 10 months (range, 2-135 months). There were 27 episodes (59%) of patients 12 months or younger. The types of intussusception were ileocolic, 44 and ileoileum, 2. In 13 episodes (28%), patients were described as dehydrated and/or having an abnormal basic metabolic panel test result and meeting one of the study criteria for potential necessity of hospitalization. During the hospitalization, enema was repeated in 1 patient (2%) who had recurrent pain. The repeated enema was normal. No patient had a recurrent intussusception or developed signs of bowel perforation or sepsis while hospitalized. The mean (SD) hospital length of stay was 25.6 (9.9) hours, and the median time was 23 hours (range, 12-60 hours).

CONCLUSIONS

Hospitalized children with enema-reduced intussusception required minimal interventions, had a low rate of signs and symptoms requiring further radiographic studies, and had no enema-reduced serious complications during hospitalization. These results support outpatient management as an acceptable alternative.

Current radiological management of intussusception in children

Intussusception is the most common abdominal emergency situation in infants and small children. There has been great progress in diagnostic and therapeutic management of intussusception. Ultrasound (US) has been shown to be the first-choice imaging technique in diagnosing intussusception for reasons of high accuracy, simultaneous exclusion of differential diagnoses, and disclosure of additional pathologies. Controversial opinions exist worldwide concerning the nonoperative treatment of intussusception in infants and children. Pneumatic reduction under fluoroscopic guidance and hydrostatic reduction under US monitoring are the preferred techniques. The aim should be a success rate of at least 90% in idiopathic intussusception. This review summarizes different types of intussusception and outlines diagnostic aspects as well as several treatment concepts.

Utility of hospital admission after successful enema reduction of ileocolic intussusception

BACKGROUND

In-hospital observation of 24 to 48 hours has been the standard practice after successful enema reduction (ER) of ileocolic intussusceptions, but this practice has not been validated. We evaluated retrospectively the safety of short-term emergency department observation.

METHODS

Between April 2000 and October 2004, 121 patients presented to the emergency department with ileocolic intussusception, and all had ER attempts.

RESULTS

Ninety-six patients had successful reduction, 25 were excluded for failed reduction or unconfirmed diagnosis, and another 16 needed observation anyway for high white blood count or persistent postreduction pain. Of the remaining 80 patients, the mean time from symptoms to reduction was 45.9 hours (4 hours to 10 days). All patients, except one, were admitted for observation for a mean period of 1.6 days (8 hours to 6.5 days). No complications were associated with air ER; however, 6 (7.5%) patients had reintussusception during the observation period and 5 (6.3%) recurred after discharge. The mean intervals for recurrence postreduction were 17.8 hours and 14.5 months with no mortality or morbidity in either.

CONCLUSIONS

Short-term emergency department observation could be a safe practice in more than 90% of the selected cases, recurrence of intussusception outside the hospital is not associated with unfavorable outcome, and routine admission is not warranted.

Postreduction management of intussusception in a children's hospital emergency department

OBJECTIVE

To evaluate the current management of patients with intussusception who have undergone successful reduction by contrast enema in a tertiary care children's hospital. To compare differences in the incidence of recurrence and adverse events between those patients who were hospitalized after enema reduction and those who were observed in the emergency department (ED).

METHODS

This was a retrospective cohort study of children 0 to 18 years of age who underwent uncomplicated enema reduction for intussusception. Hospitalization versus ED observation management were compared for length of stay, incidence of recurrence, and adverse events.

RESULTS

One hundred twenty-three children were identified with an International Classification of Diseases, Ninth Revision code for intussusception. Of those, 106 patients (86%) had an enema reduction attempted. Three had a normal enema and were given the diagnosis of "resolved intussusception." Eighty-three (80%) of the patients had a successful reduction. Seventy-eight (94%) of those patients had no preexisting condition and had complete medical records. Of those 78 patients, 27 (35%) were hospitalized and 51 (65%) were observed in the ED. The mean length of hospitalization was 22.7 hours (range: 10-50 hours), and the mean length of ED observation was 7.2 hours (range: 0-21 hours). Eleven recurrences were observed in 8 of these 78 patients (10% recurrence rate). Four patients in the hospitalized group and 4 patients in the ED observation group had recurrences (5 hours-10.9 months). Four of the 8 patients had a recurrence within the first 48 hours. All first recurrences occurred after the patient had been discharged from the hospital or ED observation unit. No adverse events occurred in any of the patients who had a successful initial reduction (95% confidence interval [0%-4.6%]).

CONCLUSIONS

The postreduction management of intussusception is variable at our institution. Previously healthy patients who have undergone successful enema reductions are unlikely to have adverse outcomes. Postreduction observation in the ED or the hospital does not seem to affect outcomes in this clinical setting.

The approach to common abdominal diagnosis in infants and children

This article focuses on salient points in the evaluation of abdominal pain in infants and children. Specifically, the authors address appendicitis and abdominal pain associated with either vomiting, constipation, or gastrointestinal bleeding. A discussion of common abdominal masses, urologic, and gynecologic problems, and considerations in the evaluation of immunologically suppressed or neurologically impaired children, and children with recurrent abdominal pain is also presented. The authors establish logical, focused approaches to the initial evaluation and management of abdominal pain and suggest criteria for timely surgical referral.