Ileocolic versus small-bowel intussusception in children: can US enable reliable differentiation?

A rare case of intusscusception in a 6-month-old baby

This case report discusses the clinical presentation, imaging findings, and successful management of a rare case of intussusception in a 6-month-old female infant referred to a regional hospital in Ghana. The patient presented with vomiting, lethargy, fever, and currant jelly stool. Differential diagnoses considered included Merkel diverticulum, volvulus, lymphadenopathy, and hypertrophic pyloric stenosis. Ultrasound imaging revealed a concentric lesion with characteristic signs of intussusception. Ileo-caeco coli intussusception was confirmed as the diagnosis. Surgical management was used for this patient. The postsurgery phase was without any complications. The patient recovered well and was discharged with a switch to oral medications. Infant intussusception is still a disease with a low morbidity rate.

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.

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.

A unique case of enteric duplication cyst in the cecum presenting as ileocolic intussusception in a 3-year-old child: Case report and review of the literature

INTRODUCTION AND SIGNIFICANCE

This is a rare case of enteric duplication cyst presenting as ileocolic intussusception in a child. The literature review found that there have been only a few other reported cases of this condition. In most cases, enteric duplication cysts are asymptomatic and are found incidentally. However, in some cases, they can cause symptoms such as abdominal pain, vomiting, constipation, and diarrhea. Intussusception is a rare complication of enteric duplication cysts.

CASE PRESENTATION

We present a case of a enteric duplication cyst in the cecum that was discovered through its association with a ileocolic intussusception that reached the anus. We diagnosed the ileocolic intussusception through an ultrasound, and during surgery, we discovered the presence of the enteric duplication cyst in the cecum. We resected it and performed a ileocolic anastomosis.

CLINICAL DISCUSSION

The treatment for enteric duplication cysts that are causing symptoms is surgery. During surgery, the cyst is removed and the intestine is repaired.

CONCLUSION

This case report highlights the importance of considering enteric duplication cyst as a possible cause of ileocolic intussusception in children.

Acute care diagnostics in children for general radiologists - not alone in the hospital at night

BACKGROUND

Radiologic care for children and adolescents during night and weekend shifts is challenging. This is especially true when a dedicated pediatric radiology front or background service is not available.

METHODS

The purpose of this review is to present the approach, the most relevant diagnoses, and their differential diagnoses based on four common example cases - abdominal pain, respiratory/chest pain, headache, and refusal to walk. Essentials such as clinical classification (e. g., disease dynamics) and practical instructions (e. g., necessity of acute cross-sectional imaging) are presented.

RESULTS AND CONCLUSION

For the abdomen, appendicitis ranks first among acute diseases. Other important diseases are intussusception and volvulus. Far more frequently, however, gastroenteritis is the cause of abdominal pain. Usually no imaging is required in this case. In unclear clinical situations, ultrasound may be indicated. In suspected pulmonary infections, chest imaging is limited to inconclusive cases and suspicion of complications such as pleural empyema. Major emergencies include (spontaneous) pneumothorax and aspiration. Headache is a common symptom. Immediate imaging is only necessary in cases of suspected acute inflammatory (meningitis/encephalitis) or vascular disease (e. g., hemorrhage due to vascular malformations). MRI is the primary imaging modality in these cases. Restricted walking/refusal to walk is a classic nonspecific sign, particularly of acute musculoskeletal disease, especially in younger children. Clinical examination is essential to narrow down the field of investigation. Besides the frequent and symptomatic coxitis fugax, the rare but serious (septic) arthritis/osteomyelitis must not be overlooked.

KEY POINTS

· Radiological care of children and adolescents is challenging, especially during night and weekend shifts.. · However, in close cooperation with the referring colleagues/clinics, the appropriate approach can be effectively determined even if the symptoms are not clear.. · The selection of the optimal imaging method is based on guidance and guidelines, but also on the condition of the child/adolescent.. · A silent or whimpering child is cause for alarm..

CITATION FORMAT

· Beer M, Mentzel H, Steinborn M et al. Acute care diagnostics in children for general radiologists - not alone at night in the hospital. Fortschr Röntgenstr 2023; 195: 205 - 216.

A Surprising Lead Point in an Ileocolic Intussusception

ABSTRACT

Appendicitis and intussusception are 2 of the most common abdominal emergencies in children and have high rates of morbidity if not treated promptly. However, only rarely do they occur together. We present a case in which clinical suspicion for intussusception was not high. Point-of-care ultrasound (POCUS) was performed in the pediatric emergency department, revealing both ileocolic intussusception and appendicitis. This case reinforces the importance of maintaining a broad differential diagnosis in unclear clinical scenarios and of the potential utility of POCUS. In our case, identification of intussusception on POCUS facilitated expeditious treatment, identification of the lead point, and allowed the treating physicians to prepare for the possibility of surgical management.

Transient Colonic Intussusception Versus Colon Adenocarcinoma: A Case Report on Ultrasound Features in the Emergency Department

Intussusception in adults is a rare pathology due to the telescoping of a bowel segment into a section adjacent to it. Almost all cases are linked to a pathological lead point, which is often a colorectal carcinoma where the intussusception involves the large intestine. Likely to occur in the same clinical setting, the differential diagnosis between intussusception and colon carcinoma by ultrasound in the emergency department can be quite challenging. We present a rare case of transient colonic intussusception with a well-differentiated colon adenocarcinoma as the lead point in a 43-year-old patient. The point of care ultrasound (POCUS) revealed the target sign characteristic of intussusception at the level of maximum pain, associated with a pseudokidney sign. However, the pseudokidney sign was indeed an adenocarcinoma of the ascending colon visualized by colonoscopy and per op.

Bleeding per rectum in pediatric population: A pictorial review

Bleeding per rectum in children can be seen in congenital as well as acquired conditions that may require medical or surgical management. The present review article is aimed to discuss the imaging findings of some common and uncommon causes of bleeding per rectum in children.

Bleeding per rectum in pediatric population: A pictorial review

Bleeding per rectum in children can be seen in congenital as well as acquired conditions that may require medical or surgical management. The present review article is aimed to discuss the imaging findings of some common and uncommon causes of bleeding per rectum in children.

Ileocolic intussusception in pediatric SARS-CoV-2 patients: experience at a tertiary pediatric center

PURPOSE

COVID-19 disease can manifest with intussusception in pediatric patients, but prevalence of abnormalities on ultrasounds performed for intussusception is uncertain. We aim to report our experience in children with COVID-19 presenting with suspected intussusception imaged with ultrasound.

METHODS

Children under 18 years who had an ultrasound for possible intussusception underwent retrospective analysis and were tested for COVID-19 between April 1 and December 14, 2020. Patients' demographic, clinical, radiological and surgical characteristics were reviewed.

RESULTS

Twenty-four COVID-19-positive patients were identified; 19 boys with mean age 3 years (range: 3 months-18 years). Ultrasound was abnormal in 11 patients (11/24, 46%). Sonographic features of enterocolitis were documented in seven children (7/24, 29%). Three boys (3/24, 13%) were found to have ileocolic intussusception on ultrasound and underwent air enema with failed reduction (3/3, 100%), precipitating surgical reductions, all with favorable outcomes. One patient (1/24, 4%) was found to have a long segment of persistent small bowel-small bowel intussusception which was surgically repaired.

CONCLUSION

Given the known association between failed reduction at air enema and delayed presentation, heightened awareness for intussusception in the setting of COVID-19 should be maintained, though more often, the etiology was attributed to other GI manifestations of COVID-19.

Significance of Follow-Up Ultrasonography 24 Hours Post-Reduction in Detecting Intussusception Recurrence

PURPOSE

The objective of this study was to identify the significance of 24-hour post-reduction ultrasonography (US) in pediatric patients with intussusception.

METHODS

A total of 229 patients with intussusception who were treated with saline reduction at Severance Children's Hospital between January 2014 and September 2020 were retrospectively reviewed. The 229 patients with successful saline reduction were divided into two groups: a recurrence at 24 hours group (R, n=41) and a non-recurrence group (NR, n=188). The full patient sample was divided into two groups: follow-up US (FU) or no follow-up US (NFU); the recurrence group was divided into follow-up (R-FU) and non-follow-up (R-NFU) subgroups, and stratified analyses were performed.

RESULTS

There were no significant differences in age, sex, laboratory findings, symptoms, and sonographic findings between the NR and R groups. In the R group, 24 patients underwent follow-up US, and 17 patients did not. Specific sonographic findings were statistically significant in the R-FU group compared to the R-NFU group (p=0.002). The R-FU group had fewer admissions (p=0.012) and longer mean hospitalization times (p<0.001) than the R-NFU group. The NFU group had a 12.2% recurrence rate, while the R-FU group recurrence rate was 25.8% (p=0.0099), suggesting that the omission of some recurrent events and follow-up US was a significant variable in the recurrence of intussusception. The median time to recurrence was 21 hours which supports the 24-hour follow-up protocol.

CONCLUSION

Twenty-four-hour follow-up US was shown to be valuable for detecting early recurrence of intussusception.

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.

Triple Intussusception in an Adult-A Rare Presentation of Adenocarcinoma Ileum

Intestinal intussusception is uncommon in adults. It occurs more often in the small intestine than in the colon. In adults, when small bowel intussusception occurs, it can be due to a malignant lead point. Malignant etiology is most frequently due to diffuse metastatic disease. We present a rare case of an 18-year-old woman who was diagnosed with jejunojejunal, jejunoileal, and colocolic intussusceptions. She presented with vomiting, abdominal pain, and passage of semisolid stools for 5 days. During emergency exploratory laparotomy, multiple polyps were found in the jejunum, ileum, and sigmoid. Jejunotomy and sigmoidotomy were done to remove the respective polyps. The ileal polyp showed hemorrhagic changes; hence, an intraoperative decision was taken to proceed with resection and anastomosis. On histopathological examination, the resected ileal part showed moderately differentiated adenocarcinoma (grade 2) arising from an adenomatous polyp, while the jejunal polyp and sigmoid polyp were adenomatous polyps with low-grade dysplasia. Patient received six cycles of adjuvant chemotherapy consisting of capecitabine and oxaliplatin (CAPEOX regimen). After 2 years, she is symptom free with a normal colonoscopy. The treatment of intussusception in adults typically involves surgery, often with bowel resection as there is always a pathologic leading cause which may be malignant, like in our case.

Point-of-Care Ultrasound For Differentiating Ileocolic From Small Bowel-Small Bowel Intussusception

BACKGROUND

Intussusception is a common pediatric emergency. The two types of intussusception are ileocolic intussusception (ICI) and small bowel-small bowel intussusception (SB-SBI), and neither are easily distinguished clinically. ICI requires radiology personnel and potentially surgical assistance for its reduction. SB-SBI is managed expectantly, as many resolve spontaneously. Differentiating between ICI and SB-SBI through point-of-care ultrasound (POCUS) requires an understanding of their salient features. Identification of the correct type of intussusception immediately assists decision making and patient disposition.

OBJECTIVE OF THE REVIEW

Our objective was to provide guidance on POCUS technique for intussusception identification, and to review the ultrasound literature differentiating ICI from SB-SBI.

METHODS

We systematically searched 3 separate databases and gray literature to identify articles that met our criteria and assessed them for final review. The final articles were graded for quality using The National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

A total of 858 articles were identified. Six articles were included in the final review. All studies were conducted in pediatric patients in different countries. Most were found to have a fair quality of evidence. The linear transducer is used when evaluating intussusception. Both ICI and SB-SBI are identified easily on POCUS, but they differ sonographically with respect to region within the abdomen, intussusception parameters, lymph nodes, and other salient features seen on real-time video.

CONCLUSIONS

ICI and SB-SBI can be identified and differentiated using several sonographic features. POCUS is capable of expeditiously aiding the emergency physician's decision making and disposition when managing intussusception.

Evaluation of spontaneous reduction among the invagination cases admitted to the paediatric emergency department; retrospective study

AIMS

We aimed to determine the factors that determine the conditions in cases of invagination with spontaneous reduction.

METHODS

Study was conducted retrospectively in the Paediatric Emergency Department (PED) of the tertiary University Hospital in Ankara, Turkey. Invagination cases admitted between January 1, 2019 and December 31, 2019 were included in the study. Patient information (demographic data such as age, gender, physical examination findings, laboratory and imaging methods, treatment and follow-up) were recorded on the data form prepared by the researchers before the study, using patient files and hospital patient information system. Data were analysed with IBM SPSS V23.

RESULTS

During the study period, the number of cases who applied to the PED was 33,849 and 74 of these cases were diagnosed with invagination. In the cases diagnosed with invagination, 69 (93%) of them spontaneously reduced during the follow-up. Among all cases, the male sex ratio was 56.5% (39/69). The average age was 44.6 months (minimum: 6; maximum: 154). The mean follow-up time in the emergency room was 12 hours and in the hospital service was 38 hours. Vomiting was observed in 89.9% (58/69) of all cases, abdominal pain in 68.1% (44/69) and rectal bleeding in 1.4% (1/69).The invagination of 21.7% (15/69) of the patients at the first USG was ileo-ileal. 63.8% (44/69) of the patients were discharged after followed up in emergency observation. The number of USGs was lower in the group that was discharged after the follow-up in the emergency room, than the follow-up groups in the service monitoring (P = .012).

CONCLUSION

Invagination is one of the surgical emergencies. With the widespread use of USG, most of these cases are followed up by clinical and USG follow-up in paediatric emergency services. Spontaneous reduction frequently develops in cases of intussusception with small bowel localisation and short bowel segment (less than 3 cm).

Diagnostic Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound has become an essential part of pediatric emergency medicine training and practice. It can have significant clinical benefits, including improving diagnostic accuracy and decreasing length of stay, and does not require radiation exposure for patients. In this review, we summarize the current diagnostic point-of-care ultrasound applications in pediatric emergency medicine, their evidence, and techniques.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests

STUDY OBJECTIVE

To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction.

METHODS

We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings.

RESULTS

The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23).

CONCLUSION

Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

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.

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.

Child with dengue haemorrhagic fever complicated by ileocaecal intussusception

Dengue fever is one of the most common neglected tropical diseases with an increasing trend seen in Sri Lanka and many other tropical countries. A number of unusual presentations and complications of dengue fever have been reported, and acute abdomen is one such presentation. However, intussusception as the cause of acute abdomen in a patient with dengue haemorrhagic fever has not been previously reported. The authors report a child who was diagnosed to have intussusception during the critical phase of dengue haemorrhagic fever while having a platelet count of 15×103/cumm. The child had initial point-of-care ultrasound followed by detailed ultrasound of the abdomen by the radiologist, and the diagnosis of ileocaecal intussusception was confirmed. Intussusception was relieved by saline reduction and without needing laparotomy. Early diagnosis and non-operative management prevented emergency laparotomy.

Paediatric small-bowel intussusception on ultrasound - a case report with differentiating features from the ileocolic subtype

Aim of the study: Intussusception is a common paediatric emergency which can be diagnosed with relative certainty by ultrasonography in trained hands. Both the ileocolic and small-bowel intussusception have overlapping clinical features and imaging findings on ultrasound. The aim is to differentiate between both subtypes based on selective differentiating features which should always be looked for while performing an ultrasound examination in suspected cases. Differentiating between the two subtypes is essential, since patient management may differ depending on the subtype. Case description: We present a case of a 12-year-old boy who presented to our hospital with pain in the abdomen. An emergency ultrasound revealed findings suggestive of small-bowel intussusception. A brief description of the differentiating points from the ileocolic subtype is also described. Conclusions: Based on the features described, it is possible to confidently differentiate between the two subtypes, which is a guiding factor for treatment.

Management and Outcome of Pediatric Patients With Transient Small Bowel-Small Bowel Intussusception

OBJECTIVE

The aim of this study was to assess the management and outcomes of healthy pediatric patients diagnosed radiologically with transient and benign small bowel-small bowel intussusception (SB-SBI).

METHODS

Retrospective cohort study of healthy patients 0 to 18 years of age who presented to a children's hospital emergency department from January 1, 2005, to June 30, 2015, and had transient and benign SB-SBI characterized by spontaneous resolution (ie, transient), diameter of less than 2.5 cm, no lead point, normal bowel wall thickness, nondilated proximal small bowel, and no colonic involvement (ie, benign radiographic features). Charts were reviewed for demographics, clinical presentation, radiologic studies obtained, outcomes, and further management. Medical and radiologic records were also reviewed for 1 year after presentation for any subsequent pathologic diagnoses.

RESULTS

Sixty-eight patients were included in our study, with a total of 87 episodes of transient and benign SB-SBI on initial or follow-up examination. Overall, 39 patients (57%) were admitted to the hospital, and 38 patients (56%) had a surgical consultation. Twenty-four patients (35%) had further radiologic studies obtained, including computed tomography scans, esophagogastroduodenoscopy, Meckel's scan, barium swallow studies, and magnetic resonance imaging. All studies were negative for concerning pathology including apparent lead points. None of the patients required surgical intervention or had any complications.

CONCLUSIONS

Transient and benign SB-SBIs with reassuring radiologic and clinical features diagnosed in healthy pediatric patients are likely incidentally found and are unlikely to be associated with a pathologic lead point.

Endoscopic reduction of colocolonic intussusception due to metastatic malignant melanoma: A case report

BACKGROUND

Intussusception rarely causes intestinal obstruction in adults. Metastatic malignant melanoma is the main cause of intussusception of the small intestine among adults. However, malignant melanoma rarely causes intussusception of the colorectum. Moreover, emergent surgery is usually performed for such cases. Here, we report a case of a patient with colocolonic intussusception caused by a malignant melanoma, for which endoscopic reduction and elective surgery were performed.

CASE SUMMARY

The patient was a 64-year-old woman who underwent multiple surgeries and received chemotherapy and immunotherapy for a malignant melanoma. During immunotherapy, she had abdominal pain, diarrhea, and bloody stool. Physical examination and laboratory studies did not reveal any findings that warranted emergent surgery. Computed tomography revealed intussusception in the descending colon without intestinal necrosis and perforation. Intussusception was reduced endoscopically, and elective surgery was performed.

CONCLUSION

This report suggests that endoscopic reduction and elective surgery constitute a treatment option for colocolonic intussusception of metastatic malignant melanomas.

Nationwide Population-Based Epidemiologic Study on Childhood Intussusception in South Korea: Emphasis on Treatment and Outcomes

PURPOSE

This was a nationwide population-based study conducted to investigate the epidemiology, treatment, disease outcomes, and associated factors of childhood intussusception in South Korea.

METHODS

Data from the Korean National Health Insurance Service database on all patients <18 years old diagnosed with intussusception from 2007 to 2017 were analyzed.

RESULTS

A total of 34,688 cases were identified among 30,444 patients. The overall incidence was 28.3/100,000 person-years with a male predominance. Most cases (83.1%) occurred in children <3 years old, with an annual incidence of 195.2, 200.1, and 118.6 cases per 100,000 children in their first, second, and third year of life, respectively. The median age at the first occurrence was 18.7 months, and it was higher in boys than in girls. The post-discharge recurrence rate was 10.6% (3,226/30,444) and the in-hospital recurrence rate was 6.1% (1,842/30,444). The total recurrence rate (post-discharge recurrence and/or in-hospital recurrence) was 15.0% (4,580/30,444). Enema reduction was successful in 90.0% of cases. Enema reduction was more successful in girls than in boys. A total of 3,296 (10.8%) patients underwent 3,481 surgeries, including 735 (21.1%) laparoscopic surgeries. Post-discharge recurrence and surgery were significantly affected by age, sex, and hospital type. Mortality was noted in nine cases (0.03%).

CONCLUSION

Our study provides accurate epidemiologic data on the treatment and outcomes of intussusception through complete enumeration during an 11-year-period.

Evolving Concepts in Ultrasonography of Pediatric Intussusceptions: Unequivocal Differentiation of Ileocolic, Obstructive and Transient Small-Bowel Intussusceptions

The main aim of the study was to elaborate on the various ultrasonographic parameters that can be used for definite differentiation of ileocolic, obstructive small-bowel and transient small-bowel intussusceptions (SBI). In this study, 90 children (63 boys and 27 girls) with suspected intussusception were evaluated. Of these, 54 cases were diagnosed as obstructive intussusceptions (33 ileocolic and 21 ileoileal), 15 cases were classified as transient SBIs and 21 cases were negative for intussusception. The mean fat core diameter was 1.45 ± 0.32 cm for ileocolic versus 0.37 ± 0.06 cm for obstructive SBI versus 0.29 ± 0.08 cm for transient SBI (p < 0.001). The mean lesion diameter was 3.23 ± 0.08 cm for ileocolic intussusceptions and 2.12 ± 0.038 cm for SBI (p < 0.001), and the ratio of inner fat core to outer wall thickness was greater than 1 for ileocolic intussusceptions and less than 1 for SBI. A statistically significant difference was found between segmental invagination of transient versus obstructive SBIs with mean values of 1.93 ± 0.39 cm and 3.17 ± 0.25 cm, respectively, and an "optimal" threshold at 2.5 cm.

Terminal Ileitis Presenting With a Spontaneously Reduced Ileocolic Intussusception Diagnosed by Point-of-Care Ultrasonography

Point-of-care ultrasound can be used in the initial workup of ileocolic (IC) intussusception. In general, these lesions require immediate attention and reduction to prevent ischemic bowel injury. We discuss the case of a 27-month-old boy whose IC intussusception was found to spontaneously reduce before a radiology performed ultrasound and the planned air enema reduction procedure. Radiology ultrasound revealed significant inflammatory changes of the terminal ileum. The incidence of spontaneous reduction of IC intussusception is not definitively known. It is important to be familiar with the possibility of spontaneous reduction as children are often referred to academic centers for radiological or surgical reduction. This may also impact the sensitivity of studies that evaluate test characteristics of point-of-care ultrasound compared with radiology performed ultrasound for the diagnosis of IC intussusception. We review the diagnostic technique for IC intussusception and the importance of a prereduction ultrasound immediately before image-guided pressure reduction attempt.

Cecal Intussusception Diagnosed by Total Colonoscopy in a Child: A Case Report

Background: Ileocolic intussusception is the most common form of intussusception in children. Intussusception in the appendix or cecum without a lead point in a child is very rare and was found with total colonoscopy (TCS) and computed tomography. Case Presentation: A 9 year-old boy was admitted to our hospital with fever, vomiting, and two episodes of bloody diarrhea. Inflammatory bowel disease was suspected; TCS was performed and revealed intussusception whose advanced region was in the cecum. The diagnosis was idiopathic cecum intussusception. This case was unusual in that intussusception had occurred at a young age but without lead point; in addition, the intussusception had also occurred at the tip of the cecum. The intussusception was safely reduced by endoscopic procedures, and after improvement in the vomiting, the patient was safely discharged and has had no bloody stools since. Conclusion: We demonstrated cecal intussusception without lead point observed on TCS in a child.

Can intussusceptions of small bowel and colon be transient? A prospective study

We performed a prospective study to explore a diagnosis and treatment protocol of transient intussusception in children (TIC). Totally, 143 children with intussusception who met the inclusion criteria were firstly divided into intussusception involving only the small bowel and intussusception involving the colon group. And in each group, they were further divided into short-segment (≤ 3.0 cm) and long-segment (> 3.0 cm) groups according to the length of intussusception. After a period of conservative treatment, the incidence of TIC, the incidence of surgery, and recurrence were collected and analyzed. Finally, we found that the incidence of TIC in the short-segment group of small bowel intussusception (96.29%) was significantly higher than that in other groups (P ≤ 0.001). Besides, the incidence of surgery and recurrence in this group was relatively low too. Therefore, we summarized the inclusion criteria and treatments to the short-segment group of small bowel intussusception as the suggested protocol to TIC.Conclusion: For cases of small bowel intussusception with no identified pathologic lead point, a short duration of symptoms, a length of ≤ 3.0 cm, a relatively abundant vascular flow signal, and a stable general condition, the spontaneous reduction could be expected and a period of conservative treatment with careful monitoring is recommended. What is Known: • The phenomenon of spontaneous reduction in intussusception (transient intussusception) among pediatric patients has been widely reported. • To distinguish the transient intussusception from the other types is important for the transient ones only need conservative treatment rather than enema reduction or surgery. What is New: • This is the first prospective study to explore a diagnosis and treatment protocol of transient intussusception in children. • Short-segment small bowel intussusceptions have a higher rate (96.29%) to get spontaneous reduction than the other types of intussusception.

The Correlation Between Pediatric Intussusceptions and Celiac Disease

The most common acute abdominal disorder in the pediatric population appears as a telescoping of the bowel, resulting in either intermittent or complete obstruction. Intussusceptions transpire as the bowel prolapses into a more distal bowel segment and is propelled forward. A case is presented of multiple small bowel intussusceptions, pneumatosis, intraperitoneal fluid, and pericardial effusion. Sonography initially visualized the obstructions, along with multiple other indicators of an abdominal disorder. The use of computed tomography followed to provide a more comprehensive view of the child’s abdomen. Each imaging technique revealed new aspects of the abdominal disorder and concluded in the diagnosis of celiac disease. This case supports the idea that small bowel intussusceptions should not be disregarded as insignificant incidental findings but rather should alert sonographers to further investigate for evidence of celiac disease.

Point-of-care ultrasound diagnosis of small bowel-small bowel vs ileocolic intussusception

BACKGROUND

Identification of intussusception is feasible with emergency department (ED) point-of-care ultrasound (PoCUS) due to its ease-of-use and high accuracy. Little is known about the clinical characteristics and outcomes of small bowel-small bowel intussusception (SB-SBI) relative to ileocolic intussusception (ICI) identified by PoCUS.

METHODS

We conducted a retrospective cohort study at a single, tertiary care, urban pediatric ED of intussusception identified by PoCUS. Demographic information, clinical data, and outcomes, including clinical course, intussusception characteristics, recurrence rates, and interobserver agreement (Cohen's kappa), were evaluated.

RESULTS

ED PoCUS identified thirty-seven patients with intussusception over a 4-year period. Twenty-one patients (57%) identified were SB-SBI. The median age was 54 months (IQR 35-76 months) for SB-SBI and 8 months (IQR 5.8-13.5 months) for ICI. The mean diameter was 1.68 cm (SD 0.52 cm) for SB-SBI and 2.74 cm (SD 0.43 cm) for ICI (p < 0.05). Two of 21 (9.5%) SB-SBI subjects required surgical intervention, while the rest spontaneously reduced. Fourteen of 16 (88%) ICI subjects required intervention. There were two (9.5%) recurrences of SB-SBI and 1 (6.3%) recurrence of ICI confirmed on PoCUS. Cohen's kappa was 0.85 (95% CI 0.68-1.0).

CONCLUSIONS

SB-SBI may be identified more frequently than previously thought when screened with ED PoCUS. Older children with SB-SBI may have underlying lead-points and may require surgical intervention. PoCUS can help differentiate between variants of intussusception that range from a surgical emergency to a transient source of abdominal pain that may be recurrent and otherwise unexplained, allowing clinicians to better manage these patients accordingly.

An ileo-ileal intussusception secondary to polypoid lipoma in a child, a case report and review of the literature

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Small intestinal lipoma is a rare reason for ileoileal intussusception but should be included in the differential diagnosis for lead points causing intussusception in children.

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Dexamethasone as an adjuvant treatment may improve the outcome in cases of intussusceptions but this point needs future researches.

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Intermittent attacks of small intestinal intussusception may lead to dilation of the distal segment (Intussuscipiens). This mechanism may delay vascular compromise.

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High level of clinical suspicion needs to diagnose intussusception with unusual presentation.

Background

Intramuscular intestinal lipoma is one of the rare benign tumours of the small intestine in children and acts as a lead point of intussusception.

Presentation of case

We describe a case in which a 4-year-old boy presented with recurrent attacks of colicky abdominal pain and non-bilious vomiting. Abdominal examination was irrelevant. Per rectum (PR) examination indicated an empty rectum without red currant jelly stool and non-palpable mass. Abdominal ultrasonography revealed a target sign of intussusception. After a period of conservative treatment, the child passed normal coloured and well-formed stool. Exploratory laparotomy referred to a long segment ileo-ileal intussusception with a polypoid lipoma as a lead point. Microscopic examination showed a benign non-capsulated intramuscular ileal lipoma.

Discussion

Small bowel lipoma produces symptoms of intermittent bowel obstruction. Herein, the child presented with non- bilious vomiting, we attribute this to reflex sympathetic stimulation of the pylorus leading to pylorospasm.

Conclusion

Small intestinal lipoma is a rare finding in children that may cause intussusception which does not resolve spontaneously.

Fever as a Presenting Symptom in Children Evaluated for Ileocolic Intussusception: The Experience of a Large Tertiary Care Pediatric Hospital

BACKGROUND

Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation. The objective of this study was to determine the prevalence of fever in patients with ileocolic intussusception and to determine its utility as a predictive symptom.

METHODS

This was a 3-year retrospective study, at a tertiary care center, of children aged 1 month to 6 years, presenting with possible intussusception. Charts were reviewed for clinical signs and symptoms at presentation, and all diagnostic studies were retrieved. A pediatric radiologist reviewed all ultrasounds.

RESULTS

A total of 488 ultrasounds were performed on suspicion of intussusception. In 30 patients with confirmed ileocolic intussusception, mean age was 27 months and all were successfully reduced by air enema. Of 118 patients with fever, 2 had confirmed intussusception, 1 with pneumonia and 1 with acute otitis media, compared with 116 febrile patients with negative ultrasounds (P < 0.05).

CONCLUSIONS

Traditional teaching is that intussusception presents as intermittent colicky abdominal pain, red currant jelly stool, vomiting, and a palpable abdominal mass, but it is important to remember that this classic triad is a very late finding and this condition should be recognized before the development of these findings. The concurrence of fever can help to rule out the possibility of intussusception and prompt the health care professional to search diligently for alternative infectious etiologies but cannot eliminate the possibility, especially when other findings suggestive of intussusception are present.

Point-of-Care Ultrasound in Pediatric Diagnostic Dilemmas: Two Atypical Presentations of Intussusception

Diagnostic dilemmas are ubiquitous in pediatric emergency medicine because of the varied and often insidious presentations of many pediatric conditions. Point-of-care ultrasound (POCUS) in emergency departments is being used for some of these diagnostic challenges and can often provide rapid and valuable information to supplement a physician's clinical assessment. Intussusception is a pediatric condition that may be challenging to recognize because of its subtle and varied presenting symptoms. An unrecognized or delayed diagnosis of intussusception can be catastrophic, with complications including bowel obstruction, bowel perforation, and death. Here we present two challenging cases of intussusception, one due to its atypical age of presentation and the other due to its unique symptoms. These cases demonstrate the benefits of point-of-care ultrasound for diagnostically challenging cases in the emergency department.

Intussusception: past, present and future

Intussusception is a common etiology of acute abdominal pain in children. Over the last 70 years, there have been significant changes in how we diagnose and treat intussusception, with a more recent focus on the role of ultrasound. In this article we discuss historical and current approaches to intussusception, with an emphasis on ultrasound as a diagnostic and therapeutic modality.

Unusual ultrasound appearance of small bowel intussusception and secondary bowel obstruction in a child with Peutz-Jeghers syndrome

Small bowel intussusception (SBI) in pediatric patients resolves spontaneously in the majority of cases. Pathologic small bowel intussusception with a lead point is rare in children. Ultrasound (US) is the preferred initial imaging study for the diagnosis of intussusception. We report a case of long-segment SBI and secondary bowel obstruction caused by a large hamartomatous polyp. This case emphasizes unique, atypical ultrasound findings that may be encountered in small bowel intussusception, with correlative radiographic, CT (computed tomography) and intra-operative findings. Increased awareness of these atypical imaging features can lead to early diagnosis and decrease the risk of potential complications including mesenteric venous thrombosis, bowel ischemia and necrosis.

Intestinal Intussusception: Etiology, Diagnosis, and Treatment

Intussusception is defined as the invagination of one segment of the bowel into an immediately adjacent segment of the bowel. Idiopathic ileocolic intussusception is the most common form in children and is typically managed with nonoperative reduction via pneumatic and/or hydrostatic enemas. In the adult population, intussusception is uncommon and occurs more often in the small intestine than in the colon. It is associated with lead point pathology in most symptomatic cases presenting as bowel obstruction. When lead point pathology is present in adult small bowel intussusception, it is usually benign, though when malignant it is most frequently due to diffuse metastatic disease, for example, melanoma. In contrast, adult ileocolic and colonic intussusception lead point pathology is most frequently primary adenocarcinoma when malignant. The diagnosis is typically made intraoperatively or by cross-sectional imaging. With increasingly frequent CT/MRI of the adult abdomen in the current era, transient and/or asymptomatic intussusceptions are increasingly found and may often be appropriately observed without intervention. When intervention in the adult population is warranted, usually oncologic bowel resection is performed due to the association with lead point pathology.

Abdominal ultrasonography of the pediatric gastrointestinal tract

Ultrasound is an invaluable imaging modality in the evaluation of pediatric gastrointestinal pathology; it can provide real-time evaluation of the bowel without the need for sedation or intravenous contrast. Recent improvements in ultrasound technique can be utilized to improve detection of bowel pathology in children: Higher resolution probes, color Doppler, harmonic and panoramic imaging are excellent tools in this setting. Graded compression and cine clips provide dynamic information and oral and intravenous contrast agents aid in detection of bowel wall pathology. Ultrasound of the bowel in children is typically a targeted exam; common indications include evaluation for appendicitis, pyloric stenosis and intussusception. Bowel abnormalities that are detected prenatally can be evaluated after birth with ultrasound. Likewise, acquired conditions such as bowel hematoma, bowel infections and hernias can be detected with ultrasound. Rare bowel neoplasms, vascular disorders and foreign bodies may first be detected with sonography, as well. At some centers, comprehensive exams of the gastrointestinal tract are performed on children with inflammatory bowel disease and celiac disease to evaluate for disease activity or to confirm the diagnosis. The goal of this article is to review up-to-date imaging techniques, normal sonographic anatomy, and characteristic sonographic features of common and uncommon disorders affecting the gastrointestinal tract in children.

Failed Intussusception Reduction in Children: Correlation Between Radiologic, Surgical, and Pathologic Findings

OBJECTIVE

The objective of this study was to identify causes of irreducible intussusception after contrast enema and to correlate imaging findings with surgical and histopathologic findings.

MATERIALS AND METHODS

Between 2005 and 2013, a total of 543 children underwent reduction of intussusception with the use of an enema technique (hereafter referred to as "enema reduction"). The medical records of 72 children (56 boys [mean age, 24.8 months; range, 3.8 months to 10.9 years] and 16 girls [mean age, 14.2 months; range, 1.5 months to 6.9 years) who underwent unsuccessful reduction and were treated surgically were retrospectively analyzed. The data collected included information on the cause of intussusception, the risk factors noted on ultrasound, operative management, outcome, and the length of the hospital stay. The imaging findings for these patients were compared with findings for statistically similar age-matched control subjects.

RESULTS

Ultrasound detected 56 of 57 cases of intussusception, but it failed to detect the lead point in three cases and failed to detect ischemic necrosis in seven cases. Positive predictors of failed enema reduction were the presence of a distal mass and observation of the dissecting sign. Of the 72 patients who underwent surgical treatment of intussusception, 26 (36.1%) underwent laparoscopy, 38 (52.8%) underwent laparotomy, and eight (11.1%) underwent conversion from laparoscopy to laparotomy. Surgical reduction was performed in 61.1% of cases, small bowel resection in 19.4%, ileocecectomy in 12.5%, and self-reduction in 69%. Pathologic lead points (noted in 25% of cases) included lymphoid hyperplasia (n = 7), Meckel diverticulum (n = 3), Burkitt lymphoma (n = 3), enteric duplication cyst (n = 2), juvenile polyp (n = 2), and adenovirus appendicitis (n = 1). The length of the hospital stay was significantly longer after laparotomy.

CONCLUSION

The distalmost location of the intussusception mass and presence of the dissecting sign on images obtained during contrast enema have a higher positive predictive value for failed reduction. Screening ultrasound decreases the number of unnecessary contrast enemas performed; however, classic pathologic lead points, such as Burkitt lymphoma and Meckel diverticulum, may be difficult to diagnose with the use of ultrasound. Laparotomy and laparoscopy are equally safe and efficacious in reducing intussusception, with the length of the hospital stay after laparoscopy significantly shorter than that noted after laparotomy. Most failed enema reductions are idiopathic, and pathologic lead points are noted in 25% of cases.

Sonography of Abdominal Pain in Children: Appendicitis and Its Common Mimics

Abdominal pain is very common in the pediatric population (<18 years of age). Sonography is a safe modality that can often differentiate the frequently encountered causes of abdominal pain in children. This pictorial essay will discuss the sonographic findings of acute appendicitis, including the imaging appearance of a perforated appendicitis. It will also present the sonographic features of the relatively common mimics of appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diverticulum, and ovarian torsion.

Clinician-performed abdominal sonography

INTRODUCTION

Point-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions.

METHODS

A literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies.

CONCLUSION

Clinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside.

Perforated appendicitis: an underappreciated mimic of intussusception on ultrasound

BACKGROUND

We encountered multiple cases in which the US appearance of ruptured appendicitis mimicked intussusception, resulting in diagnostic and therapeutic delay and multiple additional imaging studies.

OBJECTIVE

To explore the clinical and imaging discriminatory features between the conditions.

MATERIALS AND METHODS

Initial US images in six children (age 16 months to 8 years; 4 boys, 2 girls) were reviewed independently and by consensus by three pediatric radiologists. These findings were compared and correlated with the original reports and subsequent US, fluoroscopic, and CT images and reports.

RESULTS

All initial US studies demonstrated a multiple-ring-like appearance (target sign, most apparent on transverse views) with diagnostic consensus supportive of intussusception. In three cases, US findings were somewhat discrepant with clinical concerns. Subsequently, four of the six children had contrast enemas; two were thought to have partial or complete intussusception reduction. Three had a repeat US examination, with recognition of the correct diagnosis. None of the US examinations demonstrated definite intralesional lymph nodes or mesenteric fat, but central echogenicity caused by debris/appendicolith was misinterpreted as fat. All showed perilesional hyperechogenicity that, in retrospect, represented inflamed fat "walling off" of the perforated appendix. There were four CTs, all of which demonstrated a double-ring appearance that correlated with the US target appearance, with inner and outer rings representing the dilated appendix and walled-off appendiceal rupture, respectively. All six children had surgical confirmation of perforated appendicitis.

CONCLUSION

Contained perforated appendicitis can produce US findings closely mimicking intussusception. Clinical correlation and careful multiplanar evaluation should allow for sonographic suspicion of perforated appendicitis, which can be confirmed on CT if necessary.