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Delgado-Miguel C, García A, Delgado B, Muñoz-Serrano AJ, Miguel-Ferrero M, Barrena S, López-Santamaría M, Martínez L. Intussusception Management in Children: A 15-Year Experience in a Referral Center. Indian J Pediatr 2023; 90:1198-1203. [PMID: 35821554 DOI: 10.1007/s12098-022-04248-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 02/26/2022] [Accepted: 04/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To report a 15-y, single-center experience in the management and outcomes of ileocolic intussusception (ICI) episodes. METHODS A retrospective study was performed in patients with ICI episodes, who were treated at a single quaternary referral center from 2005 to 2019. Data evaluated included patient demographics, clinical presentation, treatment modalities, hospital stay, complications, and outcomes. RESULTS A total of 546 ICI episodes (66.1% males) were included, with a median age at diagnosis of 15 mo. Enema reduction was performed in 478 patients (87.6%), with an overall success rate of 85.8%. Hydrostatic saline enema was the most effective method (89.3%) when compared to pneumatic (80.6%) or barium enema (79.8%), this difference being statistically significant (p = 0.031). No associated complications were observed during nonoperative reduction. Surgical treatment was performed in 101 patients, in whom 36 bowel resections were performed. Postoperative complications were reported in 6 patients (5.9%). Hospital stay was significantly longer in patients with operative management (median 5 d vs. 1 d; p < 0.001). CONCLUSIONS Nonoperative management has a high overall success rate and low complication and recurrence rates. Saline enema reduction presents the highest effectiveness, and should be considered the first-line treatment.
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Affiliation(s)
- Carlos Delgado-Miguel
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain.
| | - Antonella García
- School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Bonifacio Delgado
- Department of Mathematics, Complutense University of Madrid, Madrid, Spain
| | - Antonio J Muñoz-Serrano
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Miriam Miguel-Ferrero
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Saturnino Barrena
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Manuel López-Santamaría
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Leopoldo Martínez
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
- Institute for Biomedical Resarch La Paz (IdiPaz), Network for Maternal and Children Health (SAMID), La Paz Children's Hospital, Madrid, Spain
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Pilkington M, Theivendram A, Brogly SB, Kolar M. Rising Incidence of Childhood Intussusception in Ontario: A Population-Based Study From 1997-2016. Am Surg 2023; 89:129-136. [PMID: 33877930 DOI: 10.1177/00031348211011139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Intussusception is the most common cause of bowel obstruction in children aged 3 months to 6 years of age. We sought to describe patterns of incident childhood intussusception. METHODS A retrospective longitudinal cohort study utilizing population-based health administrative data and a validated case definition was used to identify patients <18 years of age treated for intussusception between January 1, 1997 and December 31, 2016 in Ontario, Canada. Descriptive statistics, graphical analyses, and a Poisson regression model were performed for trend analysis. RESULTS The overall incidence of intussusception in Ontario children (<18 years) was 3.3 cases/100,000 child years (cyrs), 95% CI [3.2.3.5]. The overall incidence increased from .9 cases/100,000 cyrs to 2.3 cases/100,000 cyrs. The highest incidence was in children aged 6-12 months at 28.9 cases/100,000 cyrs, 95% CI [26.2.31.9]. Incidence increased in all age-groups between 6 months and 5 years (at a rate of 5% to 16% per year; all P < .05). Month of year did not predict intussusception counts in a log-linear Poisson models, nor did rotavirus immunization implementation in 2011. There was a 3-fold variability across geographic areas in the province. There was a high rate of readmission for recurrence within 1 year (10.7%). CONCLUSION The incidence of intussusception more than doubled in Ontario from 1997 to 2016. The incidence increased for children aged between 6 months and 5 years at a rate of 5-16% per year, suggesting that an increased rate of idiopathic intussusception is responsible for the increase in the province.
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Affiliation(s)
| | - Arany Theivendram
- Department of Public Health Sciences, 4257Queen's University, Kingston, Canada
| | - Susan B Brogly
- Department of General Surgery, 9978Queen's University, Kingston, Canada.,ICES Queen's, 9978Queen's University, Kingston, Canada
| | - Mila Kolar
- Department of General Surgery, 9978Queen's University, Kingston, Canada
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Kim S, Lim H, Park S, Koh H. Significance of Follow-Up Ultrasonography 24 Hours Post-Reduction in Detecting Intussusception Recurrence. Pediatr Gastroenterol Hepatol Nutr 2022; 25:21-29. [PMID: 35087730 PMCID: PMC8762597 DOI: 10.5223/pghn.2022.25.1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/28/2021] [Accepted: 12/17/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Sujin Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - HyeJi Lim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sowon Park
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hong Koh
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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Arshad SA, Hebballi NB, Hegde BN, Avritscher EBC, John SD, Lapus RM, Tsao K, Kawaguchi AL. Early discharge after nonoperative management of intussusception is both safe and cost-effective. J Pediatr Surg 2022; 57:147-152. [PMID: 34756701 DOI: 10.1016/j.jpedsurg.2021.09.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE We implemented a quality improvement (QI) initiative to safely reduce post-reduction monitoring for pediatric patients with ileocolic intussusception. We hypothesized that there would be decreased length of stay (LOS) and hospital costs, with no change in intussusception recurrence rates. METHODS A retrospective cohort study was conducted of pediatric ileocolic intussusception patients who underwent successful enema reduction at a tertiary-care pediatric hospital from January 2015 through June 2020. In September 2017, an intussusception management protocol was implemented, which allowed discharge within four hours of reduction. Pre- and post-QI outcomes were compared for index encounters and any additional encounter beginning within 24 h of discharge. An economic evaluation was performed with hospital costs inflation-adjusted to 2020 United States Dollars ($). Cost differences between groups were assessed using multivariable regression, adjusting for Medicaid and transfer status, P < 0.05 significant. RESULTS Of 90 patients, 37(41%) were pre-QI and 53(59%) were post-QI. Patients were similar by age, sex, race, insurance status, and transfer status. Pre-QI patients had a median LOS of 23.4 h (IQR: 16.1-34.6) versus 9.3 h (IQR 7.4-14.2) for post-QI patients, P < 0.001. Mean total costs per patient in the pre-QI group were $3,231 (95% CI, $2,442-$4,020) versus $1,861 (95% CI, $1,481-$2,240) in the post-QI group. The mean absolute cost difference was $1,370 less per patient in the post-QI group (95% CI, [-$2,251]-[-$490]). Five patients had an additional encounter within 24 h of discharge [pre-QI: 1 (3%) versus post-QI: 4 (8%), p = 0.7] with four having intussusception recurrence [pre-QI: 1 (3%) versus post-QI: 3 (6%), p = 0.6]. CONCLUSIONS Implementation of a quality improvement initiative for the treatment of pediatric intussusception reduced hospital length of stay and costs without negatively affecting post-discharge encounters or recurrence rates. Similar protocols can easily be adopted at other institutions. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative treatment study.
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Affiliation(s)
- Seyed A Arshad
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Nutan B Hebballi
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Brittany N Hegde
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Elenir B C Avritscher
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Susan D John
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Robert M Lapus
- Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Akemi L Kawaguchi
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States.
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Aoki Y, Iguchi A, Kitazawa K, Kobayashi H, Senda M, Honda A. Differences in Clinical Findings Based on the Duration of Symptoms and Age of Children With Ileocolic Intussusception: A Single-Institution Survey in Rural Japan. Pediatr Emerg Care 2021; 37:537-542. [PMID: 32108726 DOI: 10.1097/pec.0000000000001750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to determine whether the rates of abdominal pain or irritability, vomiting, and hematochezia differ depending on the duration of symptoms and age of the children with ileocolic intussusception. METHODS We retrospectively investigated the charts of ileocolic intussusception children between January 2008 and December 2017 at a rural general hospital in Japan. Children were separated into 2 groups: the early visiting group, including children examined within 6 hours after onset, and the late visiting group, including children examined more than 6 hours after onset. We further separated them into 2 groups based on age: the infant group (age, <18 months) and the child group (age, ≥18 months). We compared clinical features, such as abdominal pain or irritability, vomiting, and hematochezia, between each group. RESULTS Among 105 children with ileocolic intussusception, 51 were in the early visiting group and 49 were in the infant group. Hematochezia less frequently occurred in the early visiting group than in the late visiting group (29% vs 50%, P = 0.046). Furthermore, abdominal pain or irritability occurred less frequently in the infant group than in the child group (79.6% vs 98.2%, P = 0.003). Conversely, vomiting and hematochezia were more frequent in the infant group than in the child group (83.7% vs 51.8%, P < 0.001; 55.1% vs 26.8%, P = 0.005). CONCLUSIONS Clinical features of pediatric ileocolic intussusception may depend on symptom duration and age.
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Affiliation(s)
| | - Akihiro Iguchi
- From the Department of Pediatrics, Asahi General Hospital, Chiba
| | | | | | - Masayoshi Senda
- From the Department of Pediatrics, Asahi General Hospital, Chiba
| | - Akihito Honda
- From the Department of Pediatrics, Asahi General Hospital, Chiba
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Kelley-Quon LI, Arthur LG, Williams RF, Goldin AB, St. Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A, Smith CA, Miniati D, Sola JE, Valusek P, Berman L, Raval MV, Gosain A, Dellinger MB, Sømme S, Downard CD, McAteer JP, Kawaguchi A. Management of intussusception in children: A systematic review. J Pediatr Surg 2021; 56:587-596. [PMID: 33158508 PMCID: PMC7920908 DOI: 10.1016/j.jpedsurg.2020.09.055] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/30/2020] [Accepted: 09/24/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. METHODS The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. RESULTS A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. CONCLUSIONS Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. LEVEL OF EVIDENCE Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.
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Affiliation(s)
- Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles and the Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California,Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - L. Grier Arthur
- Division of Pediatric Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA
| | - Regan F. Williams
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Adam B. Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | | | - Alana L. Beres
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California, Davis, CA
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth J. Renaud
- Alpert Medical School at Brown University, Hasbro Children’s Hospital, Providence, RI
| | - Robert Ricca
- Division of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Mark B. Slidell
- Section of Pediatric Surgery, The University of Chicago Medicine, Comer Children’s Hospital, Chicago, Illinois
| | - Amy Taylor
- Texas Medical Center Library, Houston, TX
| | - Caitlin A. Smith
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children’s Center, Roseville, California
| | - Juan E. Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Patricia Valusek
- Pediatric Surgical Associates, Ltd., Children’s Minnesota, Minneapolis, MN
| | - Loren Berman
- Division of Pediatric surgery, Department of Surgery, Nemours-AI DuPont Hospital for Children and Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE
| | - Mehul V. Raval
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ankush Gosain
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN,Children’s Foundation Research Institute, Le Bonheur Children’s Hospital, Memphis, TN
| | - Matthew B. Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Stig Sømme
- Division of Pediatric Surgery, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Cynthia D. Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | | | - Akemi Kawaguchi
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children’s Memorial Hermann Hospital, Houston, TX
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Ferrantella A, Quinn K, Parreco J, Quiroz HJ, Willobee BA, Ryon E, Thorson CM, Sola JE, Perez EA. Incidence of recurrent intussusception in young children: A nationwide readmissions analysis. J Pediatr Surg 2020; 55:1023-1025. [PMID: 32247601 DOI: 10.1016/j.jpedsurg.2020.02.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 02/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND/PURPOSE Recurrent intussusception following successful nonoperative reduction has previously been reported with a frequency of 8%-12% based on data from individual institutions. Meanwhile, the timing of discharge after successful reduction continues to be debated. Here, we evaluate readmissions for recurrent intussusception in young children using a large-scale national database. METHODS The National Readmissions Database (2010-2014) was queried to identify young children (age < 5 years) diagnosed with intussusception. We compared procedures performed during the index admission and frequency of readmissions for recurrent intussusception. Results were weighted for national estimates. RESULTS We identified 8289 children diagnosed with intussusception during an index admission. These patients received definitive treatment with nonoperative reduction alone (43%), surgical reduction (42%), or bowel resection (15%). Readmission for recurrent intussusception was required for 3.7% of patients managed with nonoperative reduction alone, 2.3% of patients that underwent surgical reduction, and 0% of those that underwent bowel resection. Median time to readmission was 4 days after nonoperative reduction, and only 1.5% of these patients experienced recurrence within 48 h of discharge. CONCLUSIONS Recurrent intussusception may be substantially less common than previously reported. Our findings support the practice of discharge shortly after successful nonoperative reduction. TYPE OF STUDY Retrospective, prognosis study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anthony Ferrantella
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kirby Quinn
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua Parreco
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hallie J Quiroz
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Brent A Willobee
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Emily Ryon
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Vo A, Levin TL, Taragin B, Khine H. Management of Intussusception in the Pediatric Emergency Department: Risk Factors for Recurrence. Pediatr Emerg Care 2020; 36:e185-e188. [PMID: 29232349 DOI: 10.1097/pec.0000000000001382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The standard treatment for intussusception is air reduction enema (ARE) with inpatient observation for 24 to 48 hours to monitor for recurrence. More recent but limited observations suggest that patients who have undergone successful ARE can safely be discharged after 4 to 6 hours of observation. Our primary objective was to identify risk factors associated with early recurrence. Our secondary objectives included validating risk criteria from prior studies and identifying risk factors for ARE failures. DESIGN/METHODS A retrospective cohort study of children discharged from a large urban quaternary hospital with a final diagnosis of intussusception (International Classification of Diseases, Ninth Revision, code 560.0) or who underwent ARE from 2005 to 2015 was identified. Demographic data, radiology images, and clinical course were recorded. Repeat visits, cases with incomplete medical records, and those with incorrect diagnoses were excluded. RESULTS A total of 250 cases were identified. Two hundred cases were included for analysis. Fifty were excluded. Of the 163 who had successful reduction with ARE, 22 patients (13.5%) recurred, and 12 (7.3%) recurred within 48 hours. Fever (odds ratio, 4.25; P = 0.04; 95% confidence interval, 1.04-17.3) and female sex (odds ratio, 7.94; P = 0.01; 95% confidence interval, 1.82-34.6) were independently associated with early recurrence. No radiologic features were associated with early recurrence. CONCLUSIONS Early recurrence after successful ARE was low, although more frequent in girls and in those with fever over 100.4°F. We therefore advocate for prospective studies to validate these risk criteria to identify patients who are at low risk for early recurrence and may qualify for early discharge from the emergency department.
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Affiliation(s)
| | - Terry L Levin
- Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY
| | - Benjamin Taragin
- Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY
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Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care 2020; 36:e90-e95. [PMID: 28926507 DOI: 10.1097/pec.0000000000001283] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate whether point-of-care ultrasound (POCUS) for intussusception screening streamlines the workflow of clinically nonspecific intussusception (CNI), an intussusception presenting with only 1 manifestation of the classic triad, and/or vomiting. METHODS We reviewed 274 consecutive children with intussusception, aged 6 years or younger, who visited a tertiary care hospital emergency department between May 2012 and April 2016. This period was dichotomized by May 2014 (the "PRE" and "POST" groups), starting point of implementation of the POCUS protocol for intussusception screening. All children with CNI who had positive results on or forwent POCUS underwent radiologist-performed ultrasound (US). We measured and compared emergency department length of stay (EDLOS), the sum of door-to-reduction and observation times, and the frequency of POCUS and positive US results between the 2 groups. RESULTS Of 160 children with CNI, 93 visited the emergency department since May 2014. The POST group showed a shorter median EDLOS (856 vs 630 minutes, P < 0.001), door-to-reduction time (137 vs 111 minutes, P = 0.002), and observation time (700 vs 532 minutes, P < 0.001). The POST group had a higher frequency of POCUS (12% vs 60%, P < 0.001) with positive US results (33% vs 59%, P < 0.001). The PRE group had a higher frequency of severe bowel edema (16% vs 1%, P < 0.001). No significant differences were found in the severity, recurrence, admission, and surgery. One child had a false-negative result on POCUS. CONCLUSIONS Point-of-care ultrasound could streamline the workflow of CNI via decrease in EDLOS and unnecessary referrals for US.
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Abstract
Intussusception is common emergency condition in children. Pneumatic or hydrostatic reduction (HR) is considered the first-choice management strategy in cases lacking indications for surgical intervention. Generally, sedatives are not used in children undergoing interventional radiology procedures. Surgical management is associated with long hospitalization durations and high costs, unlike nonsurgical reduction. To avoid surgery, reduction procedures are repeated despite initial treatment failure. However, in cases involving repeated failures, children should be referred for surgery.To ensure good response to reduction, we planned HR under sedation during the third reduction attempt. Sedative reduction (SR) was performed with the administration of ketamine, midazolam, and atropine. All patients with contraindications against HR underwent laparoscopic reduction (LR) without HR.During 3 years, SR was performed in 43 patients, and in 28 (65.1%), the treatment was successful. Among the 15 patients in whom the procedure failed, 14 underwent LR without intestinal resection. There was no significant risk factor contributing to failed reduction under sedation.During the second or third HR attempt, successful reduction may be ensured with the SR procedure with intravenous ketamine, midazolam, and atropine; this procedure may further reduce surgery rates in pediatric intussusception.
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Otero HJ, White AM, Khwaja AB, Griffis H, Katcoff H, Bresnahan BW. Imaging Intussusception in Children’s Hospitals in the United States: Trends, Outcomes, and Costs. J Am Coll Radiol 2019; 16:1636-1644. [DOI: 10.1016/j.jacr.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 11/26/2022]
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Development and Implementation of a Surgical Quality Improvement Pathway for Pediatric Intussusception Patients. Pediatr Qual Saf 2019; 4:e205. [PMID: 31745508 PMCID: PMC6805102 DOI: 10.1097/pq9.0000000000000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/30/2019] [Indexed: 11/26/2022] Open
Abstract
Children with intussusception can be admitted or discharged from the emergency department (ED) following enema reduction, but little is known about best practices for surgical follow-up and the need for a return to care. Methods We developed a standardized clinical assessment and management plan (SCAMP) for ileocolic intussusception to enable the discharge from the ED of successfully reduced patients meeting certain criteria with 2 planned follow-up phone calls by surgical personnel after discharge. Outcomes included incidence of complications in discharged patients, bacteremia, the success of follow-up phone calls, rates of recurrent intussusception, and return to care. Results Of the 118 patient encounters treated through the SCAMP in 2 pilot studies from February 2013 to December 2017, 76% met discharge criteria, of whom 88% underwent outpatient management. There were no instances of bowel perforation, necrosis, or death in the discharged group. No patients developed bacteremia despite withholding antibiotics for the indication of intussusception. Sixty-two percent and 59% of patients received 24-hour follow-up phone calls, and 28% and 55% of patients received second follow-up phone calls in pilots 1 and 2, respectively. Of those successfully discharged, 74% did not return to care, 19% returned for recurrent intussusception, and 7% returned for unrelated symptoms. Nearly all patients who returned to care did so through the ED and not the clinic. Conclusions Implementation of the SCAMP demonstrated that patients meeting certain criteria could be safely discharged from the ED, avoid antibiotics, and safely undergo phone-based follow-up for concerns of recurrent intussusception.
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A Practice Guideline for Postreduction Management of Intussusception of Children in the Emergency Department. Pediatr Emerg Care 2019; 35:533-538. [PMID: 28146013 DOI: 10.1097/pec.0000000000001056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effects of a practice guideline of postreduction management of intussusception in children on the length of stay (LOS) from reduction in the pediatric emergency department (PED) and on the incidence of recurrence. METHODS We developed a practice guideline of postreduction management of intussusception in the PED. The practice guideline involved feeding 2 hours after reduction and discharge 2 hours after successful feeding. The guideline was implemented on October 1, 2012. Retrospective quasi-experimental study was conducted for evaluation of the difference in LOS in the PED after reduction of intussusceptions, and the recurrence rate of intussusceptions between the preimplementation and postimplementation periods. Piecewise regression was performed to determine the differences between groups. RESULTS In total, 45 and 52 patients were included in the preimplementation and postimplementation periods, respectively. The median LOS in the postimplementation period was significantly shorter than that in the preimplementation period (289 vs 532 minutes, respectively; P = 0.001). The slope of the LOS changed from 0.68 to -0.29. The slope decreased by 0.97 after practice guideline implementation. This difference was not statistically significant (P = 0.123), but it changed from a positive to negative gradient. The recurrence rate was not significantly different between the 2 periods (P = 0.605). CONCLUSIONS Implementation of a practice guideline involving early feeding and discharge after reduction of intussusception resulted in a reduced LOS from reduction of intussusception in the PED and was not associated with recurrence of intussusception.
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Litz CN, Amankwah EK, Polo RL, Sakmar KA, Danielson PD, Chandler NM. Outpatient management of intussusception: a systematic review and meta-analysis. J Pediatr Surg 2019; 54:1316-1323. [PMID: 30503194 DOI: 10.1016/j.jpedsurg.2018.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Variability in management of intussusception after enema reduction exists. Historically, inpatient observation was recommended; however, there is a lack of evidence-based guidelines for this practice. METHODS A systematic review and meta-analysis evaluating outcomes between inpatient (IP) and outpatient (OP) management after enema reduction was performed. The following databases were searched: PubMed, EBSCOhost CINAHL, EMBASE, Web of Science, and Cochrane Database. Data from an institutional review were included in the meta-analysis. RESULTS Ten studies of patients aged 0-18 years with intussusception who underwent successful enema reduction that reported outcomes of outpatient management were included. Overall recurrence rates were 6% for IP and 8% for OP (p = 0.20). Recurrences within 24 (IP: 1% vs OP: 0%, p = 0.90) and 48 h (IP: 1% vs OP: 2%, p = 0.11) were similar. There was no significant difference in the rate of return to the emergency department (IP: 6% vs OP: 14%, p = 0.11). Both groups had a similar rate of requiring an operation (IP: 2% vs OP: 1%, p = 0.84). CONCLUSIONS Outpatient management of intussusception after enema reduction results in a shorter hospital stay with no difference in the rate of return to the emergency department, recurrence, need for operation, or mortality. The findings of the meta-analysis suggest that outpatient management may be safe and could reduce hospital resource utilization. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cristen N Litz
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.
| | - Ernest K Amankwah
- Clinical and Translational Research Organization, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Randall L Polo
- Shimberg Health Sciences Library, University of South Florida, Tampa, FL, USA
| | - Kristen A Sakmar
- Shimberg Health Sciences Library, University of South Florida, Tampa, FL, USA
| | - Paul D Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Simanovsky N, Issachar O, Koplewitz B, Lev-Cohain N, Rekhtman D, Hiller N. Early recurrence of ileocolic intussusception after successful air enema reduction: incidence and predisposing factors. Emerg Radiol 2018; 26:1-4. [DOI: 10.1007/s10140-018-1635-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/16/2018] [Indexed: 12/17/2022]
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Abstract
OBJECTIVES The aim of this study was to identify risk factors for recurrent intussusception after a successful reduction by fluoroscopy-guided air enema, the time required for recurrence, and the association between delayed reduction and the recurrence. METHODS Medical records of 479 consecutive children with intussusception who underwent fluoroscopy-guided air enema between January 2004 and September 2014 were reviewed. Recurrent intussusception was defined as a recurrence within 48 hours of a reduction. Symptom-to-door time was defined as the time from symptom onset to emergency department arrival. Door-to-reduction time was defined as the time from emergency department arrival to reduction. Time-to-recurrence was defined as the time required for recurrence from the first ultrasound diagnosis. RESULTS Of the 360 eligible children, 32 had recurrent intussusceptions (8.9%). Multivariable logistic regression showed that age 2 years or older is an independent predictor of recurrent intussusception (odds ratio, 2.39; 95% confidence interval, 1.13-5.02; P = 0.02). Median time to recurrence was 25 hours (18.0-36.0 hours). Although symptom-to-door and door-to-reduction times tended to be longer in the recurrence group, these differences were not significant (12.5 vs 7.0 hours, P = 0.18; 154.0 vs 143.0 minutes, P = 0.67, respectively). CONCLUSIONS Our data suggest that provision for early recurrence and extended observation may be beneficial for children 2 years or older. Delayed reduction was not associated with recurrent intussusception, but further studies with larger sample sizes are needed to explain this issue.
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Balakrishnan K, Lu A, Bamji N, Stringel G. Colocolic intussusception in a 3 year old boy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Mallicote MU, Isani MA, Roberts AS, Jones NE, Bowen-Jallow KA, Burke RV, Stein JE, Gayer CP. Hospital admission unnecessary for successful uncomplicated radiographic reduction of pediatric intussusception. Am J Surg 2017; 214:1203-1207. [PMID: 28969892 DOI: 10.1016/j.amjsurg.2017.08.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/25/2017] [Accepted: 08/05/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE After radiologic reduction, patients with ileocolic intussusception are often admitted. We hypothesize that discharge of stable patients after 4 h of emergency department (ED) observation does not result in an increase of adverse outcomes. METHODS We retrospectively reviewed pediatric patients with ileocolic intussusception between 2011 and 2016, managed with either 24-h inpatient or 4-h ED observation. Outcomes included length of stay, adverse outcomes, and total hospital charges. RESULTS Fifty-one patients were managed with ED observation and 79 with inpatient observation. Recurrence rates, time to recurrence, and adverse outcomes were similar in both protocols. Total recurrence rates for ED observation was 15% versus 14% for inpatient observation. ED observation reduced time in the hospital by 26.8 h (4.9 versus 31.7 h). CONCLUSION Discharging patients following uncomplicated hydrostatic reduction of ileocolic intussusception after a 4-h observation period does not result in an increase in adverse outcomes.
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Affiliation(s)
| | - Mubina A Isani
- Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | - Anne S Roberts
- Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | - Nicole E Jones
- Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | | | - Rita V Burke
- Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | - James E Stein
- Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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Savoie KB, Thomas F, Nouer SS, Langham MR, Huang EY. Age at presentation and management of pediatric intussusception: A Pediatric Health Information System database study. Surgery 2016; 161:995-1003. [PMID: 27842915 DOI: 10.1016/j.surg.2016.09.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/23/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intussusception is uncommon in children older than 3 years, and use of enema reduction in older children is controversial. We sought to determine whether older children are at greater risk of requiring operative intervention and/or having pathology causing lead points, such that enema reduction should not be attempted. METHODS The Pediatric Health Information System database was reviewed from January 1, 2009-June 30, 2014. Patients were followed for 6 months from initial presentation or until bowel resection occurred. Successful enema reduction was defined as having radiologic reduction without additional procedures. RESULTS A total of 7,412 patients were identified: 6,681 were <3 years old, 731 patients were >3 years old. In those >3 years old, 450 (62%) were treated successfully with enema reduction; the rate of patients with a tumor diagnosis was similar in patients <3 years old and patients >3 years old (5% vs 6%, P = .07). The rate of a Meckel's diagnosis was greater in patients >3 years old (2% vs 14%, P < .0001). In patients >3 years old, duration of stay between patients who underwent primary operative therapy versus those who underwent operative therapy after enema reduction was similar (4 days vs 4 days, P = .06). Older age was not associated with increased risk of recurrent admission for intussusception (P = .45). CONCLUSION Pediatric Health Information System data suggest that enema reduction may be safe and effective for a majority of children even if older than 3 years.
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Affiliation(s)
- Kate B Savoie
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN; College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Simonne S Nouer
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN.
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Raval MV, Minneci PC, Deans KJ, Kurtovic KJ, Dietrich A, Bates DG, Rangel SJ, Moss RL, Kenney BD. Improving Quality and Efficiency for Intussusception Management After Successful Enema Reduction. Pediatrics 2015; 136:e1345-52. [PMID: 26459654 DOI: 10.1542/peds.2014-3122] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The purpose of this project was to implement a protocol facilitating discharge from the emergency department (ED) after successful radiologic ileocolic intussusception reduction in a pediatric referral center. METHODS A multidisciplinary team identified drivers for successful quality improvement including educational brochures, a standardized radiologic report, an observation period in the ER with oral hydration challenges, and follow-up phone calls the day after discharge. Patient outcomes were tracked, and quarterly feedback was provided. RESULTS Of 80 patients identified over a 24-month period, 34 (42.5%) did not qualify for discharge home due to need for surgical intervention (n = 9), specific radiologic findings (n = 11), need for additional intravenous hydration (n = 4), or other reasons (n = 7). Of 46 patients who qualified for discharge, 30 (65.2%) were successfully sent home from the ED. One patient returned with recurrent symptoms that required repeat enema reduction. Sixteen patients were observed and discharged within 23 hours. Adherence with discharge from the ED improved over time. Discharge from the ED was associated with cost savings and improved net margins at the hospital level for each encounter. CONCLUSIONS A sustainable multidisciplinary quality improvement project to discharge intussusception patients from the ED after air-contrast enema reduction was successfully integrated in a high-volume referral center through education, standardized radiologic reporting, and protocoled follow-up.
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Affiliation(s)
- Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia;
| | | | | | - Kelli J Kurtovic
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, Ohio
| | - Ann Dietrich
- Ohio University College of Medicine, Athens, Ohio; and
| | - D Gregory Bates
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Shawn J Rangel
- Division of Pediatric Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Brian D Kenney
- Division of Pediatric Surgery, Department of Surgery, and
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Lessenich EM, Kimia AA, Mandeville K, Li J, Landschaft A, Tsai A, Bachur RG. The Frequency of Postreduction Interventions After Successful Enema Reduction of Intussusception. Acad Emerg Med 2015; 22:1042-7. [PMID: 26292193 DOI: 10.1111/acem.12741] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/13/2015] [Accepted: 04/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to determine the frequency of postreduction, hospital-level interventions among children with successful reduction of ileocolic intussusception and identify factors that predict the need for such interventions. METHODS This was a retrospective cross-sectional study of children who underwent successful enema reduction for ileocolic intussusception at a single emergency department. Hospital-level interventions were included if they occurred within 24 hours of reduction and were further classified as either major (recurrence or possible perforation) or minor (imaging for suspected recurrence or administration of parenteral narcotics or antiemetics). Binary logistic regression was used to identify predictors for hospital-level interventions. RESULTS A total of 464 children underwent enema reduction. The median age was 1.7 years (interquartile range [IQR] = 0.8 to 2.5 years), and 66% were male. A total of 435 (94%) were hospitalized with a median hospital stay of 25 hours (IQR = 19 to 34 hours). Nineteen percent (95% confidence interval [CI] = 15% to 22%) needed postreduction interventions, including 6% (95% CI = 4% to 9%) who required major interventions. The median time to any hospital intervention was 9.9 hours (IQR = 6.3 to 16.4 hours). We identified two independent predictors for hospital-level interventions: duration of symptoms > 24 hours (adjusted odds ratio [OR] = 2.1, 95% CI = 1.3 to 3.4) and location of the intussusception tip at (or proximal to) the hepatic flexure (adjusted OR = 1.9, 95% CI = 1.1 to 3.3); the latter factor was also a predictor of a major intervention. None of the children (95% CI = 0 to 1.0%) had an acute decompensation after an initially successful enema reduction. CONCLUSIONS Clinical decompensation is rare and recurrence is relatively low after an uncomplicated reduction of ileocolic intussusception. However, one in five children required hospital-level interventions after reduction. Children with the intussusception tip at (or proximal to) the hepatic flexure, and those with symptoms for longer than 24 hours, are more likely to require subsequent interventions. Although outpatient management appears safe after a period of observation, caregivers should be counseled about the risk of ongoing symptoms and recurrence.
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Affiliation(s)
| | - Amir A. Kimia
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Katherine Mandeville
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Joyce Li
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Assaf Landschaft
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Andy Tsai
- Department of Radiology; Children's Hospital Boston; Boston MA
| | - Richard G. Bachur
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
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Cator AD, Weber JS, Lozon MM, Macy ML. Effect of using pediatric emergency department virtual observation on inpatient admissions and lengths of stay. Acad Pediatr 2014; 14:510-6. [PMID: 25169162 DOI: 10.1016/j.acap.2014.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 03/09/2014] [Accepted: 03/12/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether using emergency department (ED) virtual observation for select pediatric conditions decreases admission rates for these conditions, and to examine effects on length of stay. METHODS The option of ED virtual observation care for 9 common pediatric conditions was introduced in 2009; associated order sets were developed. Retrospective secondary analyses of administrative data from our tertiary care pediatric ED and children's hospital were performed for the year before (year 0) and after (year 1) this disposition option was introduced. The proportion of visits admitted to the inpatient unit and length of stay (LOS) were determined for all visits considered eligible for ED virtual observation care on the basis of diagnosis codes for both study years. RESULTS There were 1614 observation-eligible visits in year 0 and 1510 in year 1. In year 1, 18% (n = 266) of observation-eligible visits received ED virtual observation care. Admission rates for observation-eligible visits were similar after this model of care was introduced (25% year 0, 29% year 1, P = .02). Median LOS for ED virtual observation visits was 8.8 hours (interquartile range 6.5-12.4). ED LOS was shorter for ED discharges (5.6 hours year 0, 5.1 hours year 1, P < .001) and unchanged for admissions (6.0 hours year 0, 5.8 hours, year 1, P = .41) after introducing ED virtual observation. CONCLUSIONS Admission rates for observation-eligible visits were not lower in the year after ED virtual observation care was introduced. LOS decreased for ED discharges and was unchanged for admissions. Reevaluation of the effects of pediatric ED virtual observation on admission rates and LOS after longer periods of use is indicated.
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Affiliation(s)
- Allison D Cator
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich; Department of Pediatrics, University of Michigan, Ann Arbor, Mich.
| | - Julie S Weber
- Wayne State University School of Medicine, Detroit, Mich
| | - Marie M Lozon
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich; Department of Pediatrics, University of Michigan, Ann Arbor, Mich
| | - Michelle L Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich; Division of General Pediatrics, Department of Pediatrics, Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, Mich
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Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics 2014; 134:110-9. [PMID: 24935997 DOI: 10.1542/peds.2013-3102] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Reported rates of recurrence after enema reduction for intussusception are variable. Concerns for recurrence influence postreduction management. The objective of this study was to conduct a systematic review and meta-analysis to estimate overall, 24-hour, and 48-hour recurrence rates after enema reduction in children. METHODS PubMed, Cochrane Database, and OVID Medline were searched from 1946 through December 2011 using the search terms: intussusception, recurrence, and enema. Sixty-nine studies of patients age 0 to 18 years with radiographically proven intussusception reduced by enema that report the number of enema reductions and the number of recurrences were included. Extraction was done by the primary author (M.P.G.) with 10% of included studies independently audited to ensure concordance. RESULTS Overall recurrence rates were 12.7% (95% confidence interval [CI]: 11.1%-14.4%, I2 = 28.8%) for contrast enema (CE), 7.5% (95% CI: 5.7%-9.8%, I2 = 52.4%) for ultrasound-guided noncontrast enema (UGNCE), and 8.5% (95% CI: 6.9%-10.4%, I2 = 50.1%) for fluoroscopy-guided air enema (FGAE). Recurrence rates within 24 hours were 3.9% (95% CI: 2.2%-6.7%, I2 = 47.0%) for CE, 3.9% (95% CI: 1.5%-10.1%, I2 = 0.0%) for UGNCE, and 2.2% (95% CI: 0.7%-6.5%, I2 = 59.8%) for FGAE. Recurrence rates within 48 hours were 5.4% (95% CI 3.7%-7.8%, I2 = 32.3%) for CE, 6.6% (95% CI: 4.0%-10.7%, I2 = 0.0%) for UGNCE, and 2.7% (95% CI: 1.2%-6.5%, I2 = 73.8%) for FGAE. Most included studies are retrospective and vary in quality of reporting. Few studies reported detailed patient characteristics including timing of recurrences. CONCLUSIONS The risk of early (within 48 hours) recurrence after enema reduction is low, suggesting outpatient management of well-appearing patients should be considered.
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Affiliation(s)
| | - Shun-Hwa Li
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WisconsinQuantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Raymond G Hoffmann
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WisconsinQuantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Marc H Gorelick
- Sections of Emergency Medicine, andChildren's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Recurrent Intussusception in a 4-Year-Old Male. Adv Emerg Nurs J 2014; 36:215-25. [DOI: 10.1097/tme.0000000000000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Beres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg 2014; 49:750-2. [PMID: 24851762 DOI: 10.1016/j.jpedsurg.2014.02.059] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Controversy persists about the need to admit patients after successful reduction of intussusception. Our hypothesis is that pediatric intussusception can be managed with discharge from the emergency department (ED) after reduction without increasing morbidity, yielding significant cost savings. METHODS A chart review over 10 years was performed at two Canadian institutions. Data abstracted included: demographics, length of stay (LOS), initial and recurrence management. Primary outcome was early recurrence and resultant management, including LOS and need for operative intervention. Costs were calculated using hospital-specific data. RESULTS 584 patient records were assessed: 329 patients were managed with admission after reduction, 239 as outpatients. In the admission group, 28 patients had at least one recurrence (8.5%), with 8 after discharge. In the outpatient group, 21 patients had at least one recurrence (8.8%), with 19 after discharge. The difference post-discharge was significant (p=0.004). Outcomes of recurrence did not differ, with 2 patients in each group requiring operative intervention. Average LOS in the admission group was 90 h, with additional average cost of $1771 per non-operated patient. CONCLUSIONS Pediatric intussusception can be safely managed as an outpatient with reliable follow up. Discharge from the ED reduces hospital charges without increasing morbidity. This approach should be considered in managing patients with intussusception.
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Affiliation(s)
- Alana L Beres
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre
| | - Robert Baird
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre.
| | - Eleanor Fung
- The Hospital for Sick Children, Division of General and Thoracic Surgery, University of Toronto
| | - Helen Hsieh
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre
| | - Maria Abou-Khalil
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre
| | - J Ted Gerstle
- The Hospital for Sick Children, Division of General and Thoracic Surgery, University of Toronto
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Abstract
OBJECTIVE The objective of this study was to describe fluoroscopy screen time (FST) for children undergoing contrast enema (CE) for suspected intussusception. METHODS This is a single-center, retrospective cohort study of children younger than 7 years examined for intussusception by CE. We reviewed medical records for demographics, radiographic results, and FST. We used nonparametric descriptive statistical tests and calculated odds ratios (OR). RESULTS The median FST for 457 included CEs was 116 seconds. The median FST for positive CEs (n = 194) was 138 seconds (95% confidence interval [CI], 126-152); for negative CEs (n = 250), 86 seconds (95% CI, 78-102); and for uncertain studies (n = 13), 138 seconds (95% CI, 89-208) (P < 0.01). There was no difference in median FST if symptoms were present 24 hours or less versus longer than 24 hours. There was no difference between contrast types. Median FST for successful reductions was 122 seconds (95% CI, 114-138). In cases of failed reductions, median FST for those undergoing surgery was 277 seconds (95% CI, 195-370) and 175 seconds (95% CI, 128-271) (P < 0.01) for those undergoing delayed repeat CE. The OR for receiving a repeat CE was 1.3 (95% CI, 1.1-1.4; P < 0.01) for every minute of FST. The OR for undergoing surgical reduction was 1.3 (95% CI, 1.2-1.5; P < 0.01) for every minute of FST and 3.7 (95% CI, 2.0-6.9; P < 0.01) for FST longer than 3 minutes. CONCLUSIONS Fluoroscopy screen time for the evaluation and diagnosis of intussusception is shorter than that previously described. When an initial screening ultrasound is not available or nondiagnostic and the suspicion is high, further evaluation with a CE may be warranted because the radiation exposure is likely lower than that previously reported.
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Lochhead A, Jamjoom R, Ratnapalan S. Intussusception in children presenting to the emergency department. Clin Pediatr (Phila) 2013; 52:1029-33. [PMID: 24137037 DOI: 10.1177/0009922813506255] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A retrospective chart review of children diagnosed with intussusceptions from March 2005 to March 2007 was conducted at a tertiary care pediatric hospital. There were 152 children with 170 episodes of intussusceptions during the study period. Around one third (30%) of children diagnosed with intussusceptions had a concurrent infection. There were 114 large bowel intussusceptions, with a mean age of 27 months (SD = 25) and a success rate of 91% for air enema reductions. Bowel resection was performed in 8.8% of children with large bowel intussusceptions. Small bowel intussusceptions (n = 38) were associated with gastrostomy tubes in 42% (n = 16) of patients, and 81% needed tube shortening. The varying age range of many children diagnosed with intussusceptions and the high incidence of intercurrent illnesses and fever in our study alert health professionals to suspect intussusceptions in children presenting with abdominal pain or crying.
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Abstract
The evaluation of the child with acute abdominal pain often poses as a diagnostic challenge due to the wide range of diagnoses. Surgical emergencies need to be rapidly identified and managed appropriately to minimize morbidity and mortality. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. This article reviews common surgical causes of abdominal pain in children.
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Saliakellis E, Borrelli O, Thapar N. Paediatric GI emergencies. Best Pract Res Clin Gastroenterol 2013; 27:799-817. [PMID: 24160935 DOI: 10.1016/j.bpg.2013.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/21/2013] [Indexed: 01/31/2023]
Abstract
Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.
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Affiliation(s)
- Efstratios Saliakellis
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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Management of the Child after Enema-Reduced Intussusception: Hospital or Home? J Emerg Med 2013; 44:53-7. [DOI: 10.1016/j.jemermed.2012.02.030] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 10/05/2011] [Accepted: 02/13/2012] [Indexed: 11/20/2022]
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Rice-Townsend S, Chen C, Barnes JN, Rangel SJ. Variation in practice patterns and resource utilization surrounding management of intussusception at freestanding Children's Hospitals. J Pediatr Surg 2013; 48:104-10. [PMID: 23331801 DOI: 10.1016/j.jpedsurg.2012.10.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/13/2012] [Indexed: 12/23/2022]
Abstract
PURPOSE To characterize variation in practice patterns and resource utilization associated with the management of intussusception at Children's Hospitals. METHODS A retrospective cohort study (1/1/09-6/30/11) of 27 Children's Hospitals participating in the Pediatric Health Information System database was performed. Hospitals were compared with regard to their rates of operative management following attempted enema reduction, prophylactic antibiotic utilization, same-day discharge for those successfully managed non-operatively, 48-h readmission rates, and case-related cost and charges. RESULTS 2544 patients were identified (median: 93 cases/center) with a median age of 17 months. The rate of operation following attempted enema reduction varied significantly across hospitals (overall rate: 21.1%: range: 11%-62.8%; p<0.0001). For patients managed non-operatively, significant variability was found for prophylactic antibiotic utilization (overall rate: 23.3%; range: 1.4%-93.2%; p<0.0001), same-day discharge (overall rate: 15.2%; range: 0%-83.8%; p<0.0001), readmission rates (overall rate: 17.5%; range: 5.3%-32.1%; p<0.0001), treatment-related costs (overall median: $2490; range: $829-$5905; p<0.0001), and charges (overall median: $6350; range: $2497-$10,306; p<0.0001). Variability in costs and charges was even greater when analyzing all patients (operative and non-operative) with intussusception (overall cost median: $2865; range: $1574-$6763; p<0.0001; overall charge median: $7110; range: $3544-$22,097; p<0.0001). CONCLUSION Significant variation in practice patterns and resource utilization exists between Children's Hospitals in the management of intussusception. Prospective analysis of practice variation and appropriately risk-adjusted outcomes through a collaborative quality-improvement platform could accelerate the dissemination of best-practice guidelines for optimizing cost-effective care.
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Affiliation(s)
- Samuel Rice-Townsend
- Department of Pediatric Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
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Ito Y, Kusakawa I, Murata Y, Ukiyama E, Kawase H, Kamagata S, Ueno S, Osamura T, Kubo M, Yoshida M. Japanese guidelines for the management of intussusception in children, 2011. Pediatr Int 2012; 54:948-58. [PMID: 22748165 DOI: 10.1111/j.1442-200x.2012.03622_1.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death. METHODS Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels. RESULTS Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable. CONCLUSIONS The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.
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Affiliation(s)
- Yasuo Ito
- Guideline Committee of Japanese Society of Emergency Pediatrics, Department of Pediatric Surgery, International University of Health and Welfare, Atami Hospital, Atami, Japan.
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Vazquez JL, Ortiz M, Doniz MC, Montero M, Del Campo VM. External manual reduction of paediatric idiopathic ileocolic intussusception with US assistance: a new, standardised, effective and safe manoeuvre. Pediatr Radiol 2012; 42:1197-204. [PMID: 22875204 DOI: 10.1007/s00247-012-2424-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/26/2012] [Accepted: 04/27/2012] [Indexed: 01/17/2023]
Abstract
BACKGROUND The ultimate goal in the management of paediatric ileocolic intussusception is to achieve non-operative reduction and therefore patient cure. The standard non-surgical treatment consists of enema (air or liquid media). OBJECTIVE The purpose of this study is to present external manual reduction for paediatric ileocolic intussusception. We present a new manoeuvre that is standardised, simple, safe and effective for the radiologist in the non-surgical management of this pathology. MATERIALS AND METHODS External manual reduction is performed under sedation. Execution of the manoeuvre is detailed and illustrated. The procedure was carried out 15 times in 13 paediatric patients with idiopathic ileocolic intussusception. RESULTS Complete reduction exclusively by external manual reduction was accomplished on 12 occasions (80%). In the remaining three procedures, partial reduction to the cecum was obtained. Subsequent enema achieved complete reduction in two. Overall non-surgical reduction rate was 93%. CONCLUSION External manual reduction is a radiation-free, safe and effective procedure. In case of incomplete reduction, it facilitates enema performance. External manual reduction incorporates and additional initial step in the non-surgical reduction of intussusception and should be considered a first-line procedure.
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Affiliation(s)
- Jose L Vazquez
- Department of Radiology, Complejo Hospitalario Universitario de Vigo, Rúa de Pizarro 22, Vigo, Spain.
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Macy ML, Hall M, Shah SS, Harding JP, Del Beccaro MA, Hain PD, Hronek C, Alpern ER. Pediatric observation status: are we overlooking a growing population in children's hospitals? J Hosp Med 2012; 7:530-6. [PMID: 22371384 DOI: 10.1002/jhm.1923] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 01/19/2012] [Accepted: 01/21/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Inpatient administrative datasets often exclude observation stays, as observation is considered to be outpatient care. The extent to which this status is applied to pediatric hospitalizations is not known. OBJECTIVE To characterize trends in observation status code utilization and 1-day stays among children admitted from the emergency department (ED), and to compare patient characteristics and outcomes associated with observation versus inpatient stays. DESIGN Retrospective longitudinal analysis of the 2004-2009 Pediatric Health Information System (PHIS). SETTING Sixteen US freestanding children's hospitals contributing outpatient and inpatient data to PHIS. PATIENTS Admissions to observation or inpatient status following ED care in study hospitals. MEASUREMENTS Proportions of observation and 1-day stays among all admissions from the ED were calculated each year. Top ranking discharge diagnoses and outcomes of observation were determined. Patient characteristics, discharge diagnoses, and return visits were compared for observation and 1-day stays. RESULTS The proportion of short-stays (including both observation and 1-day stays) increased from 37% to 41% between 2004 and 2009. Since 2007, observation stays have outnumbered 1-day stays. In 2009, more than half of admissions from the ED for 6 of the top 10 ranking discharge diagnoses were short-stays. Fewer than 25% of observation stays converted to inpatient status. Return visits and readmissions following observation were no more frequent than following 1-day stays. CONCLUSIONS Children admitted under observation status make up a substantial proportion of acute care hospitalizations. Analyses of inpatient administrative databases that exclude observation stays likely result in an underestimation of hospital resource utilization for children.
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Affiliation(s)
- Michelle L Macy
- Department of Emergency Medicine and the Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, MI, USA.
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Conners GP, Melzer SM, Betts JM, Chitkara MB, Jewell JA, Lye PS, Mirkinson LJ, Shaw KN, Ackerman AD, Chun TH, Conners GP, Dudley NC, Fein JA, Fuchs SM, Moore BR, Selbst SM, Wright JL. Pediatric observation units. Pediatrics 2012; 130:172-9. [PMID: 22732171 DOI: 10.1542/peds.2012-1358] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.
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Abstract
BACKGROUND Intussusception is the most common cause of infant bowel obstruction. Because delays in diagnosis can lead to severe outcomes, differentiating milder cases from those with potentially serious outcomes is important. OBJECTIVE The objective of this study was to identify factors associated with bowel resection among intussusception cases using data from a large nationwide study, which investigated the association between intussusception and Rotashield. METHODS We examined characteristics of 376 intussusception cases not associated with Rotashield use. Cases were confirmed by a radiologic procedure, surgery, or autopsy. Clinical characteristics of infants with and without bowel resection were compared. RESULTS During the week before hospitalization, 93% of the 376 infants with intussusception had vomiting, 72% reported bloody stool, 63% had hemoccult positive stool, 51% had diarrhea, 43% reported fever, and 14% had documented fever. Surgery was performed on 209 cases (56%). Of these 209 cases, 33% (67/209) required bowel resection. Documented fever on admission significantly increased the risk of bowel resection (odds ratio, adjusted for race and sex, 2.7; 95% confidence interval, 1.2-6.0). Among infants with intussusception, the presence of a reported symptom for at least 2 days before hospital admission was also an independent predictor of bowel resection (adjusted odds ratio, 2.7; 95% confidence interval, 1.5-4.8). CONCLUSIONS Bowel resection appears to be more likely among intussusception patients with documented fever and symptoms for at least 2 days. However, because resection also occurred among those without fever or prolonged symptoms, severe disease must also be considered in absence of these symptoms.
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Yen C, Tate JE, Steiner CA, Cortese MM, Patel MM, Parashar UD. Trends in intussusception hospitalizations among US infants before and after implementation of the rotavirus vaccination program, 2000-2009. J Infect Dis 2012; 206:41-8. [PMID: 22539812 DOI: 10.1093/infdis/jis314] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although US data have not documented an intussusception risk with current rotavirus vaccines, international data indicate a possible low risk, primarily after the first dose. METHODS Among infants in 26 US states comprising 75% of the birth cohort, we examined age-specific trends in population-level intussusception hospitalization rates before (2000-2005) and after (2007-2009) rotavirus vaccine introduction. RESULTS Compared with 2000-2005 (35.3 per 100,000), the rate was greater in 2007 (39.0 per 100,000; rate ratio [RR], 1.10; 95% confidence interval [CI], 1.04-1.18), similar in 2008 (33.4 per 100,000; RR, 0.95; 95% CI, .89-1.01), and lower in 2009 (32.9 per 100,000; RR, 0.93; 95% CI, .87-.99). Among infants aged 8-11 weeks, compared with 2000-2005 (6.9 per 100,000), a small, significant increase was observed in each of 2007 (11.4 per 100,000; RR, 1.64; 95% CI, 1.08-2.50), 2008 (12.2 per 100,000; RR, 1.76; 95% CI, 1.17-2.65), and 2009 (11.0 per 100,000; RR, 1.59; 95% CI, 1.04-2.44). CONCLUSIONS Following rotavirus vaccine introduction, a small increase in intussusception rates was seen among US infants aged 8-11 weeks, to whom most first doses of vaccine are given; no sustained population-level change in overall rates was observed.
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Affiliation(s)
- Catherine Yen
- Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, University of Cape Town, Cape Town.
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Incidence of intussusception among infants in a large commercially insured population in the United States. Pediatr Infect Dis J 2012; 31:287-91. [PMID: 22173141 DOI: 10.1097/inf.0b013e31824213b1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To estimate the incidence of intussusception among infants treated in inpatient and emergency department settings during the period preceding the US launch of second-generation rotavirus vaccines. METHODS From a large US health insurance claims database, we sampled 100,000 infants aged 1 to 3 months at first diphtheria-tetanus-acellular pertussis vaccination between 2001 and 2005. Potential intussusception cases were identified on the basis of claims and were confirmed by medical record review. Incidence rates (IRs) and 95% confidence intervals (CIs) were estimated based on follow-up from first diphtheria-tetanus-acellular pertussis dose to up to 1 year of age, and within 21, 30, and 60 days after each dose. RESULTS The IR of intussusception in the first year of life was 0.33/1000 person-years based on 22 confirmed cases (95% CI: 0.21-0.50/1000 person-years). The age-specific incidence peaked among infants aged 5 months (IR: 0.82/1000 person-years; 95% CI: 0.30-1.78/1000 person-years). During the 21, 30, and 60 days following any dose, the incidence per 1000 person-years was 0.27, 0.24, and 0.33, respectively. CONCLUSION The rates described in this study can serve as a benchmark for comparison with incidences observed after the introduction of the second-generation rotavirus vaccines.
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Gilmore AW, Reed M, Tenenbein M. Management of childhood intussusception after reduction by enema. Am J Emerg Med 2011; 29:1136-40. [DOI: 10.1016/j.ajem.2010.08.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Revised: 08/16/2010] [Accepted: 08/19/2010] [Indexed: 11/26/2022] Open
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Essa AE, Eltayeb AA, Mansour E. Evaluation of the role of dexamethasone in decreasing early recurrence of intussusception: Using ultrasound-guided saline enema for reduction. SURGICAL PRACTICE 2011. [DOI: 10.1111/j.1744-1633.2011.00560.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Abdominal pain is one of the most common reasons pediatric patients seek emergency care. The emergency physician must be able to distinguish diagnoses requiring immediate attention from self-limiting processes. Pediatric patients can be challenging, particularly those who are preverbal, and therefore, the clinician must rely on a detailed history from a parent or caregiver as well as a careful physical examination in order to narrow the differential diagnosis. This article highlights several pediatric diagnoses presenting as abdominal pain, including surgical emergencies, nonsurgical diagnoses, and extraabdominal processes, and reviews the clinical presentation, diagnostic evaluation, and management of each.
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Affiliation(s)
- Jennifer R Marin
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
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Loukas M, Pellerin M, Kimball Z, de la Garza-Jordan J, Tubbs RS, Jordan R. Intussusception: An anatomical perspective with review of the literature. Clin Anat 2011; 24:552-61. [DOI: 10.1002/ca.21099] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 08/10/2010] [Accepted: 10/25/2010] [Indexed: 12/24/2022]
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Sociodemographic and dietary risk factors for natural infant intussusception in the United States. J Pediatr Gastroenterol Nutr 2010; 51:458-63. [PMID: 20562726 DOI: 10.1097/mpg.0b013e3181d3273f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND In 1999, a US case-control study demonstrated a strong association between intussusception and a rotavirus vaccine (Rotashield). However, because most (87%) cases were not temporally associated with vaccination, we reanalyzed these data to assess risk factors for intussusception cases unrelated to Rotashield. PATIENTS AND METHODS Case-patients were infants with intussusception between November 1998 and June 1999. Controls were matched by age and hospital of birth. Sociodemographic and feeding practice data were collected through parent and provider interviews. Conditional logistic regression was used to identify risk factors for intussusception, controlling for exposure to Rotashield <21 days before intussusception. RESULTS Four hundred twenty-nine cases and 1763 controls were enrolled. Among case-patients, 372 (87%) had not received Rotashield within 21 days before intussusception. After adjusting for recent Rotashield administration, factors associated with intussusception included male sex (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.3-2.2), Hispanic (OR 2.1; 95% CI 1.4-3.2) or black (OR 1.8; 95% CI 1.2-2.7) race/ethnicity, and Medicaid enrollment (OR 1.5; 95% CI 1.1-2.0). Feeding practices modified the risk of intussusception. Interaction was found between introduction of solid food (ISF) and type of formula consumption. Using breast milk as the referent group, infants with ISF for at least 5 weeks who consumed soy milk-based formula had a lower risk (OR 0.26; 95% CI 0.1-0.7) and infants without ISF who consumed cow's-milk formula had an increased risk (OR 2.33; 95% CI 1.4-3.9). CONCLUSIONS Risk of intussusception among US infants varies based on sociodemographic characteristics and feeding patterns.
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Whitehouse JS, Gourlay DM, Winthrop AL, Cassidy LD, Arca MJ. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg 2010; 45:1182-6. [PMID: 20620317 DOI: 10.1016/j.jpedsurg.2010.02.085] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 02/22/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this study was to evaluate whether discharge from the emergency department (ED) after successful hydrostatic reduction (HR) of intussusception is safe. METHODS We conducted a single institution review of patient records with a diagnosis code of intussusception from 1995 to 2006. Data collected included age, clinical presentation, imaging, surgical interventions, pathology, recurrence, and disposition. Statistical analysis utilized chi(2) tests, where P < or = .05 was considered significant. RESULTS A total of 309 patients with intussusception were identified. One hundred twenty-three patients (39.8%) required surgical intervention, 138 (44.6%) patients were managed nonoperatively as inpatients, and 48 (15.5%) were treated nonoperatively and discharged from the ED. There were 18 recurrences (5.8%). Recurrence rates did not significantly differ between patients who required operative reduction and those who were managed nonoperatively with HR and either observed as inpatients or discharged from the ED. Seven patients with recurrences required surgical intervention, and 1 of those children had a pathologic lead point, which was nonneoplastic. CONCLUSIONS Recurrence rates do not differ between children observed as inpatients and those discharged home after successful HR. Missed neoplastic pathologic lead points were not found in the patients who required an operation after a recurrence. Our data suggests that it is safe to discharge patients selectively from the ED after successful HR.
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Affiliation(s)
- Jill S Whitehouse
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Abstract
BACKGROUND As more efficient and value-based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children. PURPOSE To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States. DATA SOURCES Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis-Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies. STUDY SELECTION English language peer-reviewed publications on pediatric OU care in the United States. DATA EXTRACTION Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form. DATA SYNTHESIS A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research. CONCLUSIONS Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays.
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Affiliation(s)
- Michelle L Macy
- Division of General Pediatrics, Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, Michigan 48109-5456, USA.
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Lehnert T, Sorge I, Till H, Rolle U. Intussusception in children--clinical presentation, diagnosis and management. Int J Colorectal Dis 2009; 24:1187-92. [PMID: 19418060 DOI: 10.1007/s00384-009-0730-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate the clinical presentation, diagnosis and management of patients with intussusception, with special regard to the duration of symptoms, referral from other hospitals, outcome and complications related to delayed diagnosis. METHODS This retrospective study was performed using hospital charts, ultrasound and radiological reports and surgical notes from patients treated in our institution from 1996-2005. RESULTS Altogether 98 patients were included in the study. The study revealed idiopathic intussusception in 95% of the cases. The remaining patients presented with Meckel's diverticulum and schwannoma of the small bowel. We used ultrasound as the primary modality for diagnosis in all the patients, with a diagnostic accuracy of 100% in our study. Conservative treatment using an air enema was successful in 79.5% of cases. A higher rate of surgical intervention was found in patients who had symptoms for more than 24 h and in referred patients. CONCLUSIONS Particular attention needs to be paid to the rapid diagnosis and appropriate treatment of intussusception. Uncertain cases should be urgently referred to specialised paediatric centres. Ultrasound should be the diagnostic method of choice, since it is very effective in making this diagnosis. The first treatment option for intussusception remains the enema. Delayed diagnosis leads to an increased number of open surgeries.
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Affiliation(s)
- Thomas Lehnert
- Department of Paediatric Surgery, University of Leipzig, Leipzig, Germany
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Macy ML, Stanley RM, Lozon MM, Sasson C, Gebremariam A, Davis MM. Trends in high-turnover stays among children hospitalized in the United States, 1993-2003. Pediatrics 2009; 123:996-1002. [PMID: 19255031 PMCID: PMC2746715 DOI: 10.1542/peds.2008-1428] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Brief hospitalizations for children may constitute an opportunity to provide care in an alternative setting such as an observation unit. The goal of this study was to characterize recent national trends in brief inpatient stays for children in the United States. METHODS Using the Nationwide Inpatient Sample from 1993-2003, we analyzed hospital discharges among children <18 years of age, excluding births, deaths, and transfers. Hospitalizations with lengths of stay of 0 and 1 night were designated as "high turnover." Serial cross-sectional analyses were conducted to compare the proportion of high-turnover stays across and within years according to patient and hospital-level characteristics. Diagnosis-related groups and hospital charges associated with these observation-length stays were examined. RESULTS In 2003, there were an estimated 441 363 high-turnover hospitalizations compared with 388 701 in 1993. The proportion of high-turnover stays increased from 24.9% in 1993 to 29.9% in 1999 and has remained >/=30.0% since that time. Diagnosis-related groups for high-turnover stays reflect common pediatric medical and surgical conditions requiring hospitalization, including respiratory illness, gastrointestinal/metabolic disorders, seizure/headache, and appendectomy. Significant increases in the proportion of high-turnover stays during the study period were noted across patient and hospital-level characteristics, including age group, payer, hospital location, teaching status, bed size, and admission source. High-turnover stays contributed $1.3 billion (22%) to aggregate hospital charges in 2003, an increase from $494 million (12%) in 1993. CONCLUSIONS Consistently since 1999, nearly one third of children hospitalized in the United States experience a high-turnover stay. These high-turnover cases constitute hospitalizations, that may be eligible for care in an alternative setting. Observation units provide 1 model for an efficient and cost-effective alternative to inpatient care, in which resources and provider interactions with patients and each other are geared toward shorter stays with more timely discharge processes.
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Affiliation(s)
- Michelle L. Macy
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan, Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rachel M. Stanley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Marie M. Lozon
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Comilla Sasson
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Matthew M. Davis
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan, Division of Internal Medicine and Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, Michigan
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Abstract
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.
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50
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Abstract
Intussusception is the most common cause of intestinal obstruction in children between 3 months and 6 years. Intussusception occurs when a more proximal portion of bowel invaginates into more distal bowel. These patients often present with a wide range of non-specific symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. Thus, the diagnosis continues to rely on clinical suspicion. This review article discusses the clinical presentation of intussusception and the state-of-the art diagnostic and treatment options, as well as a review of the pertinent literature.
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