Intussusception presenting to a paediatric accident and emergency department

Impact of vaccination with different types of rotavirus vaccines on the incidence of intussusception: a randomized controlled meta-analysis

Background

Intussusception is a prevalent pediatric issue causing acute abdominal pain, with potential links to rotavirus vaccines. The variety of these vaccines has grown in recent years. This meta-analysis study aims to evaluate the impact of various rotavirus vaccines on intussusception incidence.

Methods

We executed a thorough search across databases like PubMed, Cochrane Library, Embase, and Web of Science, leading to the selection of 15 credible randomized controlled trials (RCTs) that encompass various types of rotavirus vaccines. From each study, we extracted essential details such as vaccine types and intussusception occurrences. We assessed the risk of bias using the Cochrane Collaboration's tool, conducted statistical analysis with R (version 4.2.3), determined relative risk (RR) using a random effects model, and performed a subgroup analysis for vaccines of differing brands and types.

Results

We included 15 randomized controlled studies from various countries. While intussusception incidence differed between vaccinated and control groups, this difference was not statistically significant. The overall risk ratio (RR), calculated using a random effects model, was 0.81, with a 95% confidence interval of [0.53, 1.23]. This crossing 1 shows that vaccination didn't notably change disease risk. Additionally, the 0% group heterogeneity suggests consistency across studies, strengthening our conclusions. Subgroup analysis for different vaccine brands and types (RV1 (Rotarix, Rotavac, RV3-BB), RV3 (LLR3), RV5 (RotasiiL, RotaTeq), and RV6) showed no significant variation in intussusception incidence. Despite variations in RR among subgroups, these differences were not statistically significant (P > 0.05).

Conclusions

Our study indicates that rotavirus vaccination does not significantly increase the incidence of intussusception. Despite varying impacts across different vaccine brands and types, these variations are insignificant. Given the substantial benefits outweighing the risks, promoting the use of newly developed rotavirus vaccines remains highly valuable.

Systematic Review Registration

www.crd.york.ac.uk/prospero/, Identifier CRD42023425279.

Inflammatory Myofibroblastic Tumor Presenting as a Partial Bowel Obstruction: A Case Report

Intussusception, or telescoping of the bowel, is a rare condition in the adult population that can lead to serious complications, such as obstruction or ischemia. Most cases of intussusception are idiopathic and present with a pathognomonic "target sign" on imaging. Rarely, in adults, intussusceptions can be found with lead points, some of which may be neoplastic. Treatments for intussusception include air enemas or surgical intervention if enemas are unsuccessful in resolving the telescoped bowel. This case report discusses an atypical presentation of intussusception in an adult female with a "whirlpool sign" on imaging rather than the typical "target sign." She was found to have incorporation of mesenteric fat into telescoping bowel causing edema and partial bowel obstruction. The affected bowel was removed laparoscopically, and an end-to-end anastomosis was formed. Pathology of the resected bowel revealed a non-immunoreactive inflammatory myofibroblastic neoplasm as the lead point. Most inflammatory myofibroblastic tumors stain positive for desmin, smooth muscle actin, and anaplastic lymphoma kinase (ALK), whereas this patient was non-immunoreactive. The patient tolerated surgery well and is now pain-free with normal gastrointestinal function. This case report hopes to heighten awareness of atypical presentations of intussusceptions, the use of imaging to help aid in uncertain diagnoses, and the appropriate surgical treatment for symptomatic patients.

Temporal Validation of Chiang Mai University Intussusception Failed Reduction Score (CMUI)

This study aimed to validate the “Chiang Mai University Intussusception Failed Score (CMUI)” for intussusception non-operative reduction. Both a 2-year retrospective and a 5-year prospective consecutive review of patients with intussusception were conducted. Data were collected from January 2013 to December 2020. Related retrospective data of a developmental set from two centers from January 2006 to December 2012 were used. Ten prespecified prognostic factors for failed reduction were collected and from these a predictive score was calculated. The actual results of non-operative reduction were collected and set as a reference standard. Altogether, 195 episodes of intussusception were found. Twenty-two patients were excluded due to contraindications; therefore, a total of 173 episodes were included in the validation dataset. The development data set comprised 170 episodes. We found that no statistical significance was found from comparing the areas under the ROC of two datasets (p-value = 0.31), while specificity of the validation set was 93.8% (88.1–97.3). This temporal validation showed a high specificity and a high affinity for prediction of failed reduction as the development dataset despite being in an era of a higher successful reduction rate. The intensive reduction protocols might be introduced among patients with high-risk scores.

The epidemiology of childhood intussusception in South Korea: An observational study

Intussusception is one of the most common causes of intestinal obstruction in young children. We report a retrospective, observational study of the epidemiology of intussusception in South Korea using the National Health Insurance Service-National Sample Cohort (NHIS-NSC). A cohort of newborns born between 2002 and 2008 was selected. The primary objective was to assess the incidence of intussusception in the pediatric population of Korea. The secondary objectives were to describe the basic epidemiological characteristics of intussusception and to identify risk factors. A total of 362 children were identified. The highest incidence of intussusception (2.6 per 1,000) was observed in children aged 1-2 years. A total of 58.8% of the children were male, and there was no significant difference in incidence according to the birth year (P = 0.804). Most of the children diagnosed with intussusception underwent air reduction, while only 0.6% had surgery. In all, 82.3% of the children were admitted to the hospital, 0.8% of them had to be admitted to the ICU, and the 6-month mortality was only 0.3%. In this retrospective, observational study, the incidence of intussusception was highest among children between 1 and 2 years of age. Most of the children underwent air reduction.

Risk factors for pediatric intussusception complicated by loss of intestine viability in China from June 2009 to May 2014: a retrospective study

PURPOSE

Intussusception is one of the most common causes of acute abdominal emergencies in infants and preschool children. Loss of intestine viability is the most serious complication of intussusception. This study aimed to investigate the risk factors for loss of intestine viability in pediatric intussusception cases among children.

METHODS

Data were collected for operative pediatric intussusception cases (N = 316) from medical records of 5,537 hospitalized children due to intussusception between June 2009 and May 2014 in a pediatric surgery department of an academic teaching hospital in China. Seventy-six patients (24.1 %) of the operated intussusception cases had complication of loss intestine viability.

RESULTS

Pediatric intussusception cases with loss of intestine viability and without loss of intestine viability were similar in terms of their age, malformation and season of admission. The median time of the duration from onset of symptoms to operative treatment was 23 h (range 3-90 h). The loss of intestine viability group of the intussusception cases was significantly associated with longer length of history (P = 0.000). Receiver operating characteristic curve analysis for length of history showed that the optimal ratio of sensitivity (0.70) and specificity (0.73) was calculated for the length of history longer than 27.5 h regarding loss of intestine viability of intussusception. In addition, the risk of loss of intestine viability was higher for female (31 %) than for male (20.8 %) (P = 0.049). The loss of intestine viability rate was also significantly higher in ileo-ileal intussusception cases than that of the other types (P = 0.033). However, there is no difference among the other groups.

CONCLUSION

The result of our risk factor analysis for loss of intestine viability in pediatric intussusception cases may help develop a predictability index to prevent the complication to happen. Further prospective studies are required to confirm our findings.

A High Incidence of Intussusception Revealed by a Retrospective Hospital-Based Study in Nha Trang, Vietnam between 2009 and 2011

Rotavirus is a leading cause of severe diarrhea among children worldwide. Thus, the World Health Organization recommended including rotavirus vaccines in national immunization programs. One concern about rotavirus vaccine, however, is a possible association with intussusception. Thus, it is crucial to know the baseline incidence of intussusception in the first year of life. A study conducted in Hanoi, Vietnam showed that the incidence of intussusception was the highest in the world. This retrospective cross-sectional study was undertaken to determine the incidence of intussusception among children <5 years of age in Nha Trang, Vietnam. Hospital charts between 2009 and 2011 were reviewed in Khanh Hoa Provincial General Hospital where virtually all cases of intussusception occurring in the city were assumed to have been encountered. The incidence of intussusception among children <1 year of age was 296 per 100,000 person-years (95% confidence interval [CI]: 225–382), and that among children <5 years of age was 196 per 100,000 person-years (95% CI: 169–226), confirming the high incidence of intussusception in Vietnam. Nevertheless, there was no intussusception in the first three months of life. We therefore recommend that the first dose of any rotavirus vaccine be administered to infants between 6 and 12 weeks of age.

Predictors of failed enema reduction in childhood intussusception

BACKGROUND

Initial management of intussusception is enema reduction. Data are scarce on predicting which patients are unlikely to have a successful reduction. Therefore, we reviewed our experience to identify factors predictive of enema failure.

METHODS

A retrospective review of all episodes of intussusception over the past 10 years was conducted. Demographics, presentation variables, colonic extent of intussusceptions, and hospital course were collected. Extent of intussusception was classified as right, transverse, descending, and rectosigmoid. Episodes were grouped as success or failure of enema reduction and compared using the Student t test for continuous variables and χ(2) test for dichotomous variables. Significance was P less than .05.

RESULTS

We identified 405 episodes of intussusception and 371 attempts at enema reduction. There were 285 successful enema reductions. There was no difference between groups in age; sex; or the presence of emesis, fever, or abdominal mass. The failed enema group was more likely to have had symptoms over 24 hours before presentation (P = .006), bloody diarrhea (P < .001), and lethargy (P < .001). The chance of success diminished with colonic extent (right, 88%; transverse, 73%; left, 43%; colorectal, 29%; P < .001).

CONCLUSION

Predictors of failed enema reduction of intussusception include presence of symptoms over 24 hours, diarrhea, lethargy, and distal extent of intussusception.

Does the length of the history influence the outcome of pneumatic reduction of intussusception in children?

PURPOSE

Intussusception is the most common cause of acute abdomen in infants and preschool children. Nonoperative reduction using air enema is an established treatment in children with intussusception. The aim of this study was to determine whether length of the history influences the outcome of pneumatic reduction of intussusception in children?

METHODS

The medical records of 256 consecutive children with intussusception between July 1998 and June 2010, who underwent air enema reduction regardless of the length of the history were reviewed. In all 256 patients, intussusception was confirmed by ultrasound before proceeding to air enema.

RESULTS

The length of history ranged from 2 to 240 h with median time of 18.5 h. The median age in 256 patients was 7 months (range 1 day to 12 years). The presenting clinical features included irritability/abdominal pain (77%), vomiting (80%), bleeding per rectum (36%) and palpable abdominal mass (50%). Air enema reduction was successful in 234 (91.5%) of the 256 patients. In 22 (8.5%) patients, air enema failed to reduce the intussusception and 3 (1.1%) of these patients had colonic perforation during the procedure. All 22 patients required surgery. The duration of symptoms did not influence the outcome of pneumatic reduction. 37 (14%) patients developed recurrence after successful pneumatic reduction of intussusception, with 58% presenting within 48 h of the initial procedure.

CONCLUSION

Our data suggest that pneumatic reduction should be first-line treatment in all children with intussusception regardless of the length of the history.

Intussusception incidentally detected by FDG-PET/CT in a pediatric lymphoma patient

An FDG-PET/CT scan was performed in a 14-year-old boy for the purpose of staging known lymphoma. The PET images identified the primary bowel lymphoma while the corresponding CT portion of the study found the intussusception caused by the lymphoma. The incidental finding of intussusception changed the management regime of the patient. Careful evaluation of both PET and CT images of the PET/CT is essential in providing the best patient care.

Three-year surveillance of intussusception in children in Switzerland

OBJECTIVE

We attempted to obtain baseline data on the incidence of intussusception and its association with gastroenteritis in a cross-sectional observational study in children.

METHODS

Admissions to all 38 pediatric units in Switzerland because of intussusception were reported to the Swiss Pediatric Surveillance Unit from April 2003 to March 2006. Patient and disease characteristics were assessed prospectively with the use of a standardized questionnaire based on the case definition for intussusception developed by the Brighton Collaboration. Completeness of reporting was verified through capture-recapture analysis.

RESULTS

There were 294 patients with reported intussusception; 35 cases were excluded for various reasons, and 29 additional patients were identified through International Classification of Diseases, 10th Revision, codes. After capture-recapture analysis, we estimated underreporting to the Swiss Pediatric Surveillance Unit to be 32% and we calculated a true number of 381 intussusception episodes. The highest level of diagnostic certainty was reached by 248 patients, and 20 fulfilled level 2 criteria; for the remaining 20 patients, available information was insufficient. The mean age of the patients was 2.7 years. The yearly mean incidence of intussusception was 38, 31, and 26 cases per 100,000 live births in the first, second, and third year of life, respectively, with no apparent seasonality. Seventy patients had a history of coinciding gastroenteritis, and 5 of 61 tested positive for rotavirus. Spontaneous devagination was observed for 38 patients; enemas reduced intussusception successfully in 183 cases, whereas surgical treatment was required in 67. All patients recovered without sequelae.

CONCLUSIONS

This is the first prospective nationwide surveillance of intussusception in childhood using a standardized case definition. Most cases occurred beyond infancy, and association with rotavirus gastroenteritis was rare.

Paediatric intussusception: epidemiology and outcome

OBJECTIVES

(i) To describe the clinical presentation of intussusception and determine features associated with earlier diagnosis; (ii) to describe outcomes of children diagnosed with intussusception; and (iii) to determine whether time to diagnosis is associated with poorer prognosis.

METHODS

A retrospective review was performed of all patients presenting to a tertiary paediatric hospital with a diagnosis of intussusception during a 10 year study period.

RESULTS

One hundred and forty-one confirmed cases met the inclusion criteria, giving an incidence of one case per 1450 ED presentations. The median age of presentation was 9 months, with a ratio of male to female of 2:1. Three or more of the four 'classic' features of intussusception (vomiting, abdominal pain, bloody/red currant jelly stool, or abdominal mass) were reported in only 46% of presentations. Median time to confirmation of diagnosis was 19 h from onset of symptoms. Ultrasound was the most commonly employed method used to confirm the diagnosis. Air enema had a success rate of 80%, with a reduced success rate beyond the first attempt. Early diagnosis was associated with decreased frequency of surgical intervention and need for bowel resection.

CONCLUSION

The 'classic' picture of intussusception might frequently not be present in children with intussusception. Reliance on 'classic' features alone might delay diagnosis. Delayed diagnosis is associated with poorer patient outcomes. Air enema has a high success rate for reduction of intussusception.

Intussusception among young children in Europe

Intussusception, a potentially lethal condition with poorly understood etiology, is the most common cause of acute intestinal obstruction in children younger than 5 years old. In some cases, the condition has been associated with administration of the first licensed rotavirus vaccine, the reassortant rhesus-human tetravalent rotavirus vaccine (RRV-TV; RotaShield). No such association has to date been reported from large phase III safety trials with new rotavirus vaccines. As 2 new, live-attenuated oral rotavirus vaccines are currently under review for approval by the European Union regulatory authorities, a review of the clinical, etiologic and epidemiologic aspects of intussusception in Europe is urgently needed. We conducted a review of Medline literature, published from 1995 onwards on intussusception in the World Health Organization's European Region. The results are compared with data from previous reviews and other regions. The classic triad of intussusception symptoms (abdominal pain, abdominal mass, bloody stools) was present in 29-33% of patients according to the medical literature reviewed. Conservative treatment (barium, air or saline enema) was the rule (81% of cases), and few complications were observed during treatment. Treatment outcome was generally favorable, with recurrence occurring in approximately 1 in 10 patients, and only 1 death reported. Structural lead points were seen in 3% of patients; no other reliable data on the etiology of intussusception were found. The incidence of acute intussusception in young children in Europe, according to 6 heterogeneous hospital-based studies, ranged from 0.66 to 2.24 per 1000 children in inpatient departments and from 0.75 to 1.00 per 1000 children in emergency departments. Peak incidences were found in children 3-9 months of age. There are still gaps in our knowledge of intussusception with respect to its etiology and especially by which mechanisms RRV-TV might have caused it to occur. Data from regions outside Europe showed that rotavirus infection and disease are not associated with intussusception. As new rotavirus vaccines become available for use in Europe, postlicensure surveillance for intussusception is indicated and may be instrumental in further understanding the epidemiology of this condition and in further assessing the safety of future vaccines.

Paediatric acute abdomen

A large proportion of children assessed in hospital with abdominal pain will leave with no definitive diagnosis. The challenge is to treat the majority of children with self-limiting but benign conditions and to swiftly identify and treat the child with an uncommon but potentially life-threatening cause of pain.

The diagnosis of intussusception

The aims of this study were to identify features in the history, physical examination, and radiologic studies that were associated with the diagnosis of intussusception and to determine if there was a subset of patients being evaluated for intussusception who can be spared from undergoing a contrast enema based on a combination of historical, clinical, and radiographic findings. A retrospective cohort study at a regional children's hospital emergency department (ED) was conducted. Mean age was 1.2 years among both those with and without intussusception. Predictors of intussusception in the univariate analysis included history of vomiting (P=0.02), abdominal pain (P=0.1), and rectal bleeding (P=0.003); physical examination findings of abdominal mass (P<0.001), abdominal tenderness (P=0.02), and guiac positive stool (P=0.004); and plain radiograph finding of the absence of stool in the ascending colon (P<0.05). We were unable to develop a prediction model that would reliably identify all patients with the diagnosis of intussusception. Previously identified predictors of intussusception remain important in increasing suspicion of this important diagnosis. At this point there is no reliable prediction model that can accurately identify all patients with intussusception. A prospective study may aid in the development of a clinically more useful model.

An evidence and consensus based guideline for acute diarrhoea management

OBJECTIVE

To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home.

EVIDENCE

A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated.

CONSENSUS

An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panelists' responses. Consensus was predefined as 83% of panelists agreeing with the statement.

RECOMMENDATIONS

Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated.

VALIDATION

The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.