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

Ileocolic Intussusception: Iterative Quality Improvement to Address a Recurring Problem

INTRODUCTION

Recent quality improvement (QI) initiatives indicate that pediatric patients with uncomplicated ileocolic intussusception can be safely discharged from the emergency department (ED) after fluoroscopic reduction. These programs improve patient experience and reduce cost. We sought to build on these efforts by developing a QI initiative at our own institution that included patients transferred from a satellite campus and focused on iterative improvement of our treatment pathway based on continual reassessment of our processes and data.

MATERIALS AND METHODS

We formed a multidisciplinary team, established a collaborative open-access clinical pathway, and implemented educational plans for each participating division. Data were tracked prospectively, and process adjustments were made as clinically indicated. In this report, we compare patients treated before and after the QI initiative.

RESULTS

There were 155 patients treated before the QI initiative (January 1, 2018-June 30, 2022) and 87 after the initiative began (July 1, 2022-October 31, 2023). There were significant improvements in the rate of ED discharge (4/155 (2.6%) versus 51/87 (59%), P < 0.001) and mean time to discharge (40.7 versus 23.1 h, P = 0.002), while the average cost of a visit fell by 30% (P = 0.012). The mean time to discharge from the ED increased (6.9 versus 11.0 h, P < 0.001), and the rate of readmission was unchanged. For patients transferred from the satellite campus, time to fluoroscopic reduction significantly improved during the initiative (9.4 versus 6.5 h, P = 0.048).

CONCLUSIONS

We implemented a QI program for patients with fluoroscopically reduced ileocolic intussusception that was serially adjusted based on continual reassessment of data. The protocol was associated with a decreased admission rate, total cost, and time to hospital discharge.

Ileo-ileal intussusception secondary to a Peutz-Jeghers hamartomatous polyp in an infant

We report the case of ileo-ileal intussusception secondary to a Peutz-Jeghers syndrome (PJS) hamartomatous polyp in a male infant. The patient presented with non-bilious vomiting and a single episode of passing blood in his stool. An upper gastrointestinal contrast study showed proximal bowel obstruction. At laparotomy, ileo-ileal intussusception was identified with a papillary mass acting as a lead point. The mass was resected, and a primary anastomosis was performed. The patient recovered well and was discharged on postoperative day 5. Histological assessment diagnosed a PJS hamartoma. The patient was well at 1 month follow-up. This case report describes a rare cause of intussusception in an infant that should be considered in the differential diagnosis. The diagnosis of PJS in infancy is uncommon and requires long-term follow-up.

Exploring the Infectious Contribution to Intussusception Causality Using the Effects of COVID-19 Lockdowns in Australia: An Ecological Study

BACKGROUND

Intussusception is the primary cause of acute bowel obstruction in infants. The majority of cases <2 years of age are classed as idiopathic, with viral infection implicated as one of the causes. Coronavirus disease 2019 (COVID-19) public health measures led to significant decreases in communicable disease prevalence. During these times, reductions in intussusception frequency were greater than would be expected with our previous understanding of its infectious etiology.

METHODS

We conducted a retrospective, multistate, ecological study over a 12-year period. Monthly case numbers of "intussusception"-coded admissions (code K56.1; International Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification) were acquired from state-wide admissions data sets from New South Wales, Victoria, and Queensland, representing 77.62% of the eligible Australian population. These counts within differing jurisdictional lockdowns were compared with non-lockdown periods in order to investigate a correlation between intussusception frequency and lockdown periods.

RESULTS

We found a negative association between intussusception frequency and lockdown periods in both eligible states. The largest reductions were seen in the <2-year age groups, with Victoria experiencing a 62.7% reduction (rate ratio, 0.37; P < .001) and New South Wales a 40.1% reduction (0.599; P = .006) during lockdown times. Controls for variations in lockdown restrictions between both regional and metropolitan areas also showed expected decreases.

CONCLUSIONS

Our ecological study demonstrates significant decreases in the frequency of pediatric intussusception admissions during the COVID-19 lockdown periods. The unexpected magnitude of the reductions suggests that the true proportion of infectious disease-caused idiopathic intussusception is greatly underestimated.

Colocolic intussusception as a rare cause of intestinal obstruction in a preschool child: A case report

INTRODUCTION AND IMPORTANCE

Colocolic intussusception occur in less than 5 % of all cases of intussusception. Median age at presentation is 4.4 years. Usually presents with features of intestinal obstruction. Common causes include pathological lead points like juvenile polyps, Meckel's diverticulum and lymphoma. However, rarely occurs without an organic cause as presented in the index case.

CASE PRESENTATION

We present a case of colocolic intussusception in a 5-year-old boy with clinical evidence of blood-stained mucoid stools, abdominal distention and post prandial vomiting. CT-scan confirmed the clinical diagnosis. Surgical exploration revealed left-sided colocolic intussusception without a pathological lead point.

CLINICAL DISCUSSION

Most cases of colonic intussusception have a pathological lead point. Clinical features are unspecific but mostly present with intestinal obstruction, hence, a CT-scan aids in establishing the diagnosis.

CONCLUSION

Colocolic intussusception is a rare subtype of intussusception in the paediatric age group especially in the absence of a pathological lead point. This case report presents a rare case of colocolic intussusception without pathological lead point, highlighting the importance of advanced imaging modalities like CT-scan in establishing the diagnosis and guiding management.

Ileocecal Intussusception in the Era of Coronavirus Disease 2019 (COVID-19) Infection and Multisystem Inflammatory Syndrome in Children (MIS-C): A Case Report and Literature Review

Ileocecal intussusception (ICI) is the most common abdominal emergency and cause of intestinal obstruction in young children, carrying a high risk of mortality and morbidity. Enteric viral infectious and inflammatory syndromes are known triggers for intussusception (ileoileal and ileocolic) by causing mesenteric lymphoid hyperplasia that may act as a leading point allowing the bowel to invaginate into itself. Gastrointestinal (GI) symptoms are common in children with coronavirus disease 2019 (COVID-19) infection, with a subset of patients solely having GI complaints at the time of presentation.  COVID-19 as a trigger for intussusception in children has been hypothesized and suggested in multiple cases reported to date, both during the acute phase of illness and as a part of multisystem inflammatory syndrome in children (MIS-C). We present a seven-month-old male who developed ICI and became a diagnostic dilemma due to viral co-infections and the gradual emergence of MIS-C during the hospital stay. We are describing this presentation in an attempt to expand the understanding of the implications of COVID-19 and MIS-C in this young and unique age group.

A comprehensive scoring system for the better prediction of bowel resection in pediatric intussusception

BACKGROUND

Intussusception presents a significant emergency that often necessitates bowel resection, leading to severe complications and management challenges. This study aims to investigate and establish a scoring system to enhance the prediction of bowel resection necessity in pediatric intussusception patients.

METHODS

This retrospective study analyzed 660 hospitalized patients with intussusception who underwent surgical management at a pediatric hospital in Southwest China from April 2008 to December 2020. The necessity of bowel resection was assessed and categorized in this cohort. Variables associated with bowel resection were examined using univariate and multivariate logistic regression analyses. Based on these analyses, a scoring system was developed, grounded on the summation of the coefficients (β).

RESULTS

Among the 660 patients meeting the inclusion criteria, 218 required bowel resection during surgery. Bowel resection occurrence was linked to an extended duration of symptoms (Odds Ratio [OR] = 2.14; 95% Confidence Interval [CI], 1.03-5.23; P = 0.0015), the presence of gross bloody stool (OR = 8.98; 95% CI, 1.76-48.75, P < 0.001), elevated C-reactive protein levels (OR = 4.79; 95% CI, 1.12-28.31, P = 0.0072), lactate clearance rate (LCR) (OR = 17.25; 95% CI, 2.36-80.35; P < 0.001), and the intussusception location (OR = 12.65; 95% CI, 1.46-62.67, P < 0.001), as determined by multivariate logistic regression analysis. A scoring system (totaling 14.02 points) was developed from the cumulative β coefficients, with a threshold of 5.22 effectively differentiating infants requiring surgical intervention from others with necrotizing enterocolitis (NEC), exhibiting a sensitivity of 78.3% and a specificity of 71.9%.

CONCLUSIONS

This study successfully identified multiple risk factors for bowel resection and effectively used a scoring system to identify patients for optimal clinical management.

Intussusception With a Pathological Lead Point in a Two-Month-Old Infant

Intussusception is one of the most common causes of acute intestinal obstruction in infancy and early childhood. Most cases of intussusception tend to occur in infancy, between the ages of four and six months. The causes can be split into two categories: non-pathologic and pathologic. Non-pathological causes include administration of the rotavirus vaccine, dehydration, and recent illness. Pathological causes can be attributed to Meckel's diverticulum (in 75% of cases), polyps (15%), and lymphoma or other tumors (3%). Intussusception rarely occurs in infants less than three months of age. If intussusception does occur in patients under three months of age, the cause is idiopathic in up to 75% of the cases. Additionally, myoglandular-type polyps are exceedingly rare and very rarely occur in patients under the age of 50. This case report discusses the diagnosis and treatment of intussusception in a two-month-old male patient who initially presented to the pediatric inpatient unit for dehydration secondary to a suspected viral illness, later developing colicky abdominal pain and bloody stools. He was found to have colo-colonic intussusception with a myoglandular-type polyp lead point. In discussing this case, the aim is to teach about intussusception and myoglandular-type polyps, as well as reveal a rarity in both etiologies for this age group.

Two cases of small bowel necrosis due to intussusception secondary to abnormal proliferation of intestinal Peyer's patches in infants after MMR vaccination

BACKGROUND

Intussusception is one of the most common acute abdominal conditions in pediatric patients, and if left untreated, it may result in intestinal necrosis and even death. The etiology of the disease is unknown and may be related to a variety of factors, and there are only limited reports of small bowel necrosis secondary to abnormal Peyer's node hyperplasia after MMR vaccination.

CASE PRESENTATION

In this report, we present two infants who had an abnormal proliferation of Peyer's nodes secondary to intussusception eventually leading to small bowel necrosis after MMR vaccination.

CONCLUSIONS

Intestinal necrosis and infectious shock are the most common causes of infant mortality, and early detection and management are critical.

Unveiling the Enigma of a Colonic Neuroendocrine Tumor Causing Ileocolic Intussusception: A Case Report

Intussusception in adults is rare and is often associated with a pathologic lead point. While colonic adenocarcinoma is a common cause, well-differentiated colonic neuroendocrine tumors are exceedingly rare. We present a unique case of an ileocolic intussusception due to a distal ascending colonic neuroendocrine tumor, emphasizing the diagnostic challenges and importance of prompt intervention. A 60-year-old male with a previous screening colonoscopy in June of 2022 presented to the Emergency Department with two days of cramping, right upper abdominal pain with associated nausea and two episodes of emesis. A Computed Tomography (CT) scan of the abdomen and pelvis revealed an ileocolic intussusception noted at the level of the hepatic flexure with a lead point. Emergent surgical intervention identified a mass in the distal ascending colon, and a right hemicolectomy with successful side-to-side functional end-to-end anastomosis was performed. Final pathology confirmed a well-differentiated stage III colonic neuroendocrine tumor. After a successful postoperative recovery, a full body Positron Emission Tomography (PET) scan was completed and resulted in no evidence of avid metastatic disease. The patient was placed in cancer remission. Intussusceptions in the adult population are uncommon, and the etiology typically involves a pathologic lead point causing intestinal invagination. In this case, prompt diagnosis and management resulted in successful health outcomes with reduced mortality and morbidity, as untreated intussusception can have devastating results. Given this patient's colonoscopy was approximately one year ago, the probability of a colonic neoplasm acting as the lead point was low. However, identification of the intussusception resulted in a timely and lifesaving emergent right hemicolectomy, as this stage III tumor has a five-year median survival rate of only 50% if left untreated. This case report highlights a rare case of adult ileocolic intussusception involving a lead point at the distal ascending colon identified as an uncommon, well-differentiated stage III neuroendocrine tumor. It showcases the importance of considering intussusception as a diagnosis when evaluating adults with abdominal pain for prompt and adequate intervention, especially when malignant lead points and bowel necrosis are suspected.

Effects of sedatives on radiologic enema reduction in children with ileocolic intussusception: A systematic review and meta-analysis

BACKGROUND

In children with ileocolic intussusception, sedatives such as midazolam, ketamine and propofol may facilitate radiologic enema reduction, but studies on their separate and joint effects remain controversial.

OBJECTIVES

We aimed to systematically analyze studies for the effects of sedatives on the radiologic reduction of ileocolic intussusception in children.

METHODS

We searched PubMed, EMBASE, CINAHL, Scopus and Web of Science from database inception through March 2023 for articles that enrolled children with ileocolic intussusception who underwent non-operative pneumatic or hydrostatic enema reduction under ultrasound or fluoroscopic guidance with or without the use of sedatives. The primary and secondary outcomes were success rate in radiologic reduction of ileocolic intussusception and risk of perforation, respectively. Effect estimates from the individual studies were extracted and combined using the Hartung-Knapp-Sidik-Jonkman log-odds random-effects model. Heterogeneity between studies was checked using Cochran's Q test and the I2 statistic.

RESULTS

A total of 17 studies with 2094 participants were included in the final review, of which 15 were included in the meta-analysis. Nine studies reported on the success rate of radiologic reduction performed under sedation in all participants, while six studies compared the success rate in two patient groups undergoing the procedure with or without sedation. The pooled success rate of non-operative reduction under sedation was 87 % (95 % CI: 80-95 %), P = 0.000 with considerable heterogeneity (I2 = 85 %). A higher success rate of 94 % (95 % CI: 88-99 %) and homogeneity (I2 = 12 %) were found in studies with pneumatic enema reduction. Among comparative studies, the odds of success of non-operative reduction were increased when the procedure was performed under sedation, with a pooled odds ratio of 2.41 (95 % CI: 1.27-4.57), P = 0.010 and moderate heterogeneity (I2 = 60 %). In a sensitivity analysis, homogeneity was found between analyzed studies when two outliers were excluded (I2 = 0.73 %). The risk of perforation was not significantly different (OR 1.52, 95 % CI: 0.09-23.34), P = 0.764 indicating small study effects. No publication, bias was detected on visual inspection of the funnel plots or the Begg's and Egger's bias tests. Most studies were categorized as having a low risk of bias using Joanna Briggs Institute checklists.

CONCLUSIONS

In selected patient groups, sedation can increase the success rate of radiologic enema reduction in children with ileocolic intussusception without evidence of increased risk of perforation. Systematic review protocol registration: PROSPERO CRD42023404887.

Lymphoma-related intussusception in children: diagnostic challenges and clinical characteristics

Intussusception is a common cause of acute abdominal pain in children and the most frequent cause of intestinal obstruction in infants. Although often idiopathic, it can stem from conditions like lymphoma. This study delves into lymphoma-related intussusception in children, aiming to enhance early detection and management. A retrospective review encompassed children admitted from 2012 to 2023 with intussusception due to intestinal lymphoma. Demographic, clinical, and imaging data were meticulously extracted and analyzed. The study included 31 children in the lymphoma-related intussusception group. Contrasted with non-lymphoma-related cases, the patients of lymphoma-related intussusception were notably older (median age: 87 months vs. 18.5 months), predominantly male, and demonstrated protracted abdominal pain. Ultrasound unveiled mesenteric lymph node enlargement and distinct intra-abdominal masses; enema reduction success rates were notably diminished. Detecting lymphoma-related intussusception remains intricate. Age, prolonged symptoms, and distinctive ultrasound findings can arouse suspicion. Timely surgical intervention, based on preoperative imaging, proves pivotal for accurate diagnosis.

CONCLUSION

 Swift identification of lymphoma-related intussusception, distinguished by unique clinical and ultrasound features, is imperative for timely intervention and treatment. Further research is warranted to refine diagnostic approaches.

WHAT IS KNOWN

• Intussusception in pediatric patients can be caused by a wide spectrum of underlying diseases including lymphoma. • Early Identifying the exact underlying cause of intussusception is crucial for tailored therapy, however often challenging and time-consuming.

WHAT IS NEW

• Lymphoma-related intussusception may present with increased abdominal fluid accumulation, intestinal obstruction, and a higher likelihood of failed reduction during enema procedures. • For high-risk children, repeated ultrasound examinations or further investigations may be necessary to confirm the diagnosis.

The Management of Intussusception: A Systematic Review

Intussusception (ISN) is a dangerous condition where a portion of the intestine slides into an adjacent area of the intestine. This telescoping motion frequently prevents liquids or food from flowing through. Developing management guidelines for ileocolic (IC) intussusception was the aim of this systematic study. Data sources were PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, and Embase databases. Our review investigated English-language articles (from 2010 to 2023) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Overall, there were 15 articles. Surveys and analyses of national databases were the most widely used methods (n=15). The search identified 561 studies; 15 were eligible for inclusion in the analysis. Further understanding of the management of intussusception may help improve evaluation and management in the future. The use of preventive antibiotics does not reduce problems following radiologic reduction. When clinically appropriate, repeated attempts at enema reduction may be made. After the enema reduction of ileocolic intussusception, patients can be safely watched in the emergency room (ER), thereby avoiding hospitalization. Success rates for laparoscopic reduction are high. When it comes to intussusception in children who are hemodynamically stable and do not have a serious illness, there is no need for pre-reduction antibiotics. Prioritizing nonoperative outpatient (OP) therapy is recommended as the primary approach, with the utilization of minimally invasive procedures to avoid the necessity for laparotomy. The management of colonic intussusception involves complete removal in one piece, while enteric intussusception can be addressed through reduction followed by resection. A targeted approach is recommended, recognizing the intermediate forms of intussusception that may exist between the colonic and enteric types. It is essential to note that the prevailing treatment for adult intussusception remains to be surgical intervention.

Development and evaluation of an artificial intelligence system for children intussusception diagnosis using ultrasound images

Accurate identification of intussusception in children is critical for timely non-surgical management. We propose an end-to-end artificial intelligence algorithm, the Children Intussusception Diagnosis Network (CIDNet) system, that utilizes ultrasound images to rapidly diagnose intussusception. 9999 ultrasound images of 4154 pediatric patients were divided into training, validation, test, and independent reader study datasets. The independent reader study cohort was used to compare the diagnostic performance of the CIDNet system to six radiologists. Performance was evaluated using, among others, balance accuracy (BACC) and area under the receiver operating characteristic curve (AUC). The CIDNet system performed the best in diagnosing intussusception with a BACC of 0.8464 and AUC of 0.9716 in the test dataset compared to other deep learning algorithms. The CIDNet system compared favorably with expert radiologists by outstanding identification performance and robustness (BACC:0.9297; AUC:0.9769). CIDNet is a stable and precise technological tool for identifying intussusception in ultrasound scans of children.

Epidemiology, clinical characteristics, and treatment of children with acute intussusception: a case series

BACKGROUND

To summarize the clinical and epidemiological characteristics of acute intussusception.

METHODS

This retrospective study included pediatric patients with acute intussusception admitted to the Department of Pediatric Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, from January 2014 to December 2019.

RESULTS

A total of 402 infants/children were included (301 males and 101 females) with a mean age of 2.4 ± 1.5 years (2 months to 9 years). Thirty patients (7.5%) had a history of cold food intake, diarrhea, and upper respiratory infection before disease onset. Paroxysmal abdominal pain and crying occurred in 338 patients (84.1%). Eight patients (2.0%) had the typical triad, 167 (41.5%) had vomiting, 24 (6.0%) had bloody stools, and 273 (67.9%) had palpable abdominal mass. The average intussusception depth was 4.0 ± 1.4 cm. Air enema reduction was performed in 344 cases: 335 (97.3%) were successful. Fifty-eight patients were treated with intravenous phloroglucinol (2 mg/kg), and 53 (91.4%) were successful. Sixty-five patients suffered relapses, with a relapse rate of 16.8%.

CONCLUSIONS

Pediatric acute intussusception is common. There was no obvious etiology. The clinical manifestations are mostly atypical. Abdominal pain is the most common complaint. Air enema reduction is an effective treatment. The recurrence rate is high.

Current diagnosis and image-guided reduction for intussusception in children

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

The Ileoileal intussusception due to a tubular duplication in a child: A case report

Intussusception is a surgical emergency that may result in the perforation of the intestinal wall if not immediately treated. Pathologic lead points, such as intestinal duplication, are present in 2.2%-15% of the cases.We describe a 4-year-old girl with a necrotic ileoileal intussusception diagnosed with a rare tubular ileal duplication.

Intussusception and COVID-19 in Children: A Systematic Review and Meta-Analysis

Background: Intussusception (ISN) post-COVID-19 infection in children is rare but can occur. SARS-CoV-2 may play a role in the pathogenesis of ISN and trigger immune activation and mesenteric adenitis, which predispose peristaltic activity to “telescope” a proximal bowel segment into the distal bowel lumen. Objectives: To estimate the prevalence of SARS-CoV-2 infection in ISN children and analyze the demographic parameters, clinical characteristics and treatment outcomes in ISN pediatric patients with COVID-19 illness. Methods: We performed this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies reporting on the incidence of ISN post-SARS-CoV-2 infection in children, published from 1 December 2019 until 1 October 2022, in PROQUEST, MEDLINE, EMBASE, PUBMED, CINAHL, WILEY ONLINE LIBRARY, SCOPUS and NATURE, with a restriction to articles available in the English language, were included. Results: Of the 169 papers that were identified, 34 articles were included in the systematic review and meta-analysis (28 case report, 5 cohort and 1 case-series studies). Studies involving 64 ISN patients with confirmed COVID-19 (all patients were children) were analyzed. The overall pooled proportions of the ISN patients who had PCR-confirmed SARS-CoV-2 infection was 0.06% (95% CI 0.03 to 0.09, n = 1790, four studies, I2 0%, p = 0.64), while 0.07% (95% CI 0.03 to 0.12, n = 1552, three studies, I2 0%, p = 0.47) had success to ISN pneumatic, hydrostatic and surgical reduction treatment and 0.04% (95% CI 0.00 to 0.09, n = 923, two studies, I2 0%, p = 0.97) had failure to ISN pneumatic, hydrostatic and surgical reduction treatment. The median patient age ranged from 1 to 132 months across studies, and most of the patients were in the 1−12 month age group (n = 32, 50%), p = 0.001. The majority of the patients were male (n = 41, 64.1%, p = 0.000) and belonged to White (Caucasian) (n = 25, 39.1%), Hispanic (n = 13, 20.3%) and Asian (n = 5, 7.8%) ethnicity, p = 0.000. The reported ISN classifications by location were mostly ileocolic (n = 35, 54.7%), and few children experienced ileo-ileal ISN (n = 4, 6.2%), p = 0.001. The most common symptoms from ISN were vomiting (n = 36, 56.2%), abdominal pain (n = 29, 45.3%), red currant jelly stools (n = 25, 39.1%) and blood in stool (n = 15, 23.4%). Half of the patients never had any medical comorbidities (n = 32, 50%), p = 0.036. The approaches and treatments commonly used to manage ISN included surgical reduction of the ISN (n = 17, 26.6%), pneumatic reduction of the ISN (n = 13, 20.2%), antibiotics (n = 12, 18.7%), hydrostatic reduction of the ISN (n = 11, 17.2%), laparotomy (n = 10, 15.6%), intravenous fluids (n = 8, 12.5%) and surgical resection (n = 5, 7.8%), p = 0.051. ISN was recurrent in two cases only (n = 2, 3.1%). The patients experienced failure to pneumatic (n = 7, 10.9%), hydrostatic (n = 6, 9.4%) and surgical (n = 1, 1.5%) ISN treatment, p = 0.002. The odds ratios of death were significantly higher in patients with a female gender (OR 1.13, 95% CI 0.31−0.79, p = 0.045), Asian ethnicity (OR 0.38, 95% CI 0.28−0.48, p < 0.001), failure to pneumatic or surgical ISN reduction treatment (OR 0.11, 95% CI 0.05−0.21, p = 0.036), admission to ICU (OR 0.71, 95% CI 0.83−1.18, p = 0.03), intubation and placement of mechanical ventilation (OR 0.68, 95% CI 0.51−1.41, p = 0.01) or suffering from ARDS (OR 0.88, 95% CI 0.93−1.88, p = 0.01) compared to those who survived. Conclusion: Children with SARS-CoV-2 infection are at low risk to develop ISN. A female gender, Asian ethnicity, failure to ISN reduction treatment (pneumatic or surgical), admission to ICU, mechanical ventilation and suffering from ARDS were significantly associated with death following ISN in pediatric COVID-19 patients.

Prediction of Outcomes of Ultrasound-Guided Saline Enema in the Treatment of Pediatric Intussusception: A Retrospective Case-Control Study

OBJECTIVES

Outcomes of ultrasound-guided saline enema include successful treatment, unsuccessful treatment, or recurrence. This study aimed to investigate the value of ultrasonic parameters of the ileocecal region during hydrostatic reduction to predict enema outcomes.

METHODS

Ultrasound images of patients diagnosed with ileocolic intussusception and treated with ultrasound-guided saline enema at two different institutions between January 2019 and April 2021 were retrospectively analyzed to assess ileocecal-valve diameter (ICVD), intussusceptum thickness (IT), and the ratio of IT to ICVD (I/I). Logistic regression analysis was used to explore correlations between ICVD, IT, I/I, and patient characteristics (sex, age, symptom duration, and enema outcome).

RESULTS

Of 291 patients with ileocolic intussusception (207 boys; mean ICVD, 8.6 [SD: 0.1] mm; mean IT, 26 [SD: 0.2] mm; mean I/I, 3.0 [SD: 0.01]), 268 had first successful reduction; 23, first failed reduction; 7, final failed reduction; and 41, early recurrence. Significant risk factors for failed reduction included symptom duration >24 hours (odds ratio [OR] = 10, P = .012), ICVD ≤ 8.5 mm (OR = 8, P = .01), and I/I > 3.25 (OR = 16, P < .001). Significant risk factors for early recurrence post-enema included age >1 year (OR = 10, P = .028), ICVD > 8.5 mm (OR = 4, P = .003), and I/I ≤ 2.95 (OR = 6, P < .001).

CONCLUSIONS

ICVD and IT measured during ultrasound-guided hydrostatic reduction can predict enema outcomes. The mismatch between IT and ICVD is the primary cause of poor outcomes.

A Technique to Reduce the Early Recurrence of Intussusception in Ultrasound-Guided Hydrostatic Reduction

OBJECTIVES

Ultrasound-guided saline enema is highly successful in treating pediatric intussusception; however, early recurrence-within 48 hours-is possible. This study aimed to explore effective methods of reducing early recurrence.

METHODS

This study included patients aged 0 to 14 years diagnosed with ileocolic intussusception with a symptom duration of <48 hours from January 2019 to March 2021. The patients were divided into control and intervention groups. All patients received successful treatment with ultrasound-guided saline enema; however, in patients treated before January 4, 2020 (control group), the intestinal fluid was drained immediately, and in patients treated after January 4, 2020 (intervention group), the intestinal fluid was drained after 15 minutes of intestinal pressure maintenance. Early recurrence rates of the groups were compared.

RESULTS

Ileocolic intussusception was treated successfully by ultrasound-guided saline enema in 231 patients (116, control group;115, intervention group). The early recurrence rate in the intervention group (10%; 95% CI: 4.9-16.5) was numerically lower than that in the control group (19%; 95% CI: 12.3-27.3). No significant difference was observed in the number of recurrences per person between the groups (P = .448). Patients without early recurrence were older (P = .004) and received enemas of a shorter duration (P < .001) and lower pressure (P < .001) than patients without early recurrence.

CONCLUSIONS

Maintaining reduction pressure for 15 minutes after a successful ultrasound-guided saline enema may reduce the early recurrence of intussusception. A randomized controlled trial is needed because the intervention and control cohorts were most probably incomparable (due to the COVID-19 pandemic).

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

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

Outcomes in pediatric patients with documented delays between ileocolic intussusception diagnosis and therapeutic enema attempt: evaluation of reduction efficacy and complication rate

BACKGROUND

Ileocolic intussusception is considered a pediatric emergency, with concerns for risk of significant morbidity in children with a prolonged intussusception state. Emergent therapy is standard of care, as prior studies have shown poor outcomes in patients with long delays (> 24 h) before intervention. Various factors can result in shorter delays, and there are limited studies evaluating outcomes in these patients. This study aimed to determine if there were differences in reduction success rates associated with short in-hospital time delays.

OBJECTIVE

This study is to determine enema success rate and morbidity in patients with documented time delays between intussusception diagnosis and therapeutic enema.

MATERIALS AND METHODS

A retrospective evaluation of pediatric patients with intussusception at a single children's hospital between 2007 and 2019 was performed. Patient's records were reviewed for time of symptom onset, radiologic diagnosis, and attempted enema. Ultrasounds and radiographs were reviewed for bowel obstruction, free peritoneal fluid, trapped fluid around the intussusceptum, and absent bowel wall perfusion. Patients were evaluated for efficacy of reduction attempt, requirement for surgical reduction, and complications including bowel resection and bowel perforation.

RESULTS

There were 175 cases of ileocolic intussusception requiring enema reduction. Successful reduction occurred in 72.2% (13/18) of cases performed within 1 h of diagnosis; 74.3% (78/105) between 1 and3 h; 73.2% (30/41) between 3 and 6 h; and 81.2% (9/11) with greater than 6 h. Need for bowel resection was not associated with short delays between diagnosis and reduction attempts (p = .07).

CONCLUSIONS

There was no difference in intussusception reduction efficacy or complication rate in patients with increasing time between imaging diagnosis of ileocolic intussusception and reduction attempt, including delay intervals up to 8 h.

Ultrasound Findings to Predict Risk of Recurrence in Pediatric Intussusception After Air Enema Reduction

OBJECTIVES

Intussusception is one of the most common abdominal emergencies in early children. Intussusception recurs in 8-20% of children after successful nonoperative reduction. The aim of this study was to explore the ultrasound findings to predict risk of recurrence in pediatric intussusception after air enema reduction.

METHODS

A total of 336 intussusception children were followed up for 1 year after received successful air enema reduction. They were divided into the recurrent group and the non-recurrent group. The differences of clinical characteristics, ultrasonic features, and laboratory tests were analyzed by univariate analyses and the Cox proportional hazard model.

RESULTS

Sixty-five children with recurrent intussusception were identified. There were statistically significances in the diameter of the mass, in the presence or absence of enlarged lymph nodes out of the sleeve, and in the sleeve between recurrent and non-recurrent groups (P < .05). Other ultrasonic features, clinical characteristics, and blood parameters had no differences (P > .05). Multivariate Cox proportional hazard model showed that the diameter of the mass and abdominal lymph nodes may be the risk factors of intussusception recurrence (HR = 1.395, 95% CI: 1.045~1.863 and HR = 2.078, 95% CI: 1.118~3.865, P < .05). The cut-off value of mass diameter was 2.55 cm, above which recurrence is more likely.

CONCLUSIONS

Intussusception recurrence was prone with greater mass diameter (>2.55 cm) and enlarged abdominal lymph nodes. Although these ultrasound findings for recurrence do not necessarily reduce the rate of recurrence, it can predict the recurrent possibility, and help the emergency physicians to be more vigilant in these children and better counsel parents upon discharge.

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

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

Intussusception in the setting of severe acute respiratory syndrome coronavirus 2 infection following rotavirus vaccination

Most cases of intussusception are thought to be idiopathic, related to viral infections, structural abnormalities, or certain vaccinations. In this report, we present the development of intussusception in a pediatric patient who was coronavirus 2019 (COVID-19) positive. Although the most common gastrointestinal symptoms of COVID-19 virus are diarrhea and vomiting, there recently have been rare case reports of intussusception in patients throughout the world who are severe acute respiratory syndrome coronavirus 2 positive. This case is only the second known report in the United States and the second case reported globally that required surgical intervention for definitive management.

Changes in the Incidence of Intussusception and Infectious Diseases After the COVID-19 Pandemic in Korea

BACKGROUND

Intussusception refers to the invagination of a part of the intestine into itself. The exact cause for this condition is unknown in most cases. The active implementation of coronavirus disease 2019 (COVID-19) infection control guidelines has reduced the spread of COVID-19 and the incidence of other infectious diseases in children. The current study aimed to identify changes in pediatric intussusception and infectious diseases after the implementation of infection control guidelines and confirm the association between intussusception and contagious diseases.

METHODS

We analyzed the electronic medical records of pediatric patients diagnosed with intussusception from seven hospitals in Korea between January 2017 and December 2020. We used open data from the Korea Disease Control and Prevention Agency to investigate changes in infectious diseases over the same period.

RESULTS

Altogether, we evaluated 390 children with intussusception. There was a statistically significant decrease in the incidence of monthly visits with intussusception in the COVID-19 period group (9.0 vs. 3.5, P < 0.001). When the monthly incidence of infectious diseases was compared between the pre-COVID-19 and the COVID-19 periods, a statistically significant decrease in respiratory viruses (7979.0 vs. 815.2, P < 0.001), enterovirus infection (262.2 vs. 6.6, P < 0.001), and viral enteritis (916.2 vs. 197.8, P < 0.001) were confirmed in the COVID-19 period. Through interrupted time series analysis, it was confirmed that the incidence of intussusception and viral infectious diseases have drastically decreased since March 2020, when COVID-19 infection control guidelines were actively implemented.

CONCLUSION

We confirmed that implementing infection control guidelines during the COVID-19 pandemic resulted in a decrease in intussusception and viral infectious diseases. Through this result, it was possible to indirectly confirm the existing hypothesis that viral infections play a significant role in the pathophysiologic mechanism of intussusception.

Laparoscopic and open surgery methods in managing surgical intussusceptions: A randomized clinical trial of postoperative complications

PURPOSE

To compare postoperative complications of laparoscopic surgery (LS) with open surgery (OS) in surgical intussusception patients.

METHODS

From March 2015 to February 2018, infants between 6 to 24 months old had the clinical and sono-graphical signs of intussusception enrolled in this double-blind, randomized clinical trial. We divided surgical intussusception patients into two groups. In the LS group, we evaluated patients by direct laparoscopic observation, on-table hydrostatic enema, and mechanical reduction of intussusception. In the OS group, we performed the conventional technique. These patients were followed for 2 years after procedures for comparison of postoperative complications between the two groups.

RESULTS

We had 52 patients who needed surgical exploration (26 in each group). There were four (15%) and seven (27%) patients with self-reduced intussusception in LS and OS groups, respectively. The conversion rate was 31% (eight cases). Five cases (19%) in the LS group and four cases (15%) in the OS group needed bowel resections. Operating time was longer in the LS group (P ≤ 0.006), and the postoperative complication rate was higher in the OS group (P ≤ 0.021).

DISCUSSION

Laparoscopy is a screening tool to determine the need for OS in surgical intussusception patients. Laparoscopy reduces the incidence of OS and its complications.

A Child's Acute Intestinal Intussusception and Literature Review

Acute intestinal intussusception remains a surgical emergency in infants and young children aged 3 months to 3 years. It results from the incarceration of the upstream intestinal segment in the downstream segment. In the majority of cases it is idiopathic, but can be secondary to certain pathologies notably Meckel’s diverticulum. The site is most often ileo cecal. The symptomatological triad is made up of pain, vomiting, and rectal bleeding. The diagnosis is confirmed by imaging, dominated by ultrasound which remains the reference imaging. We report the case of a 3 year-old boy, followed for a malformation who presented with abdominal distension, abdominal pain, and rectal bleeding. The diagnosis of acute ileo-ileal intussusception was made. After an attempt at hydrostatic reduction under ultrasound guidance, he underwent surgical management. The postoperative period was simple and uncomplicated. Intestinal intussusception remains a pathology with a low morbidity and mortality rate of 0% to 1% due to delayed diagnosis and delayed therapeutic management.

Surgical Management of Intussusception in Children: A Retrospective Review of 212 Cases

Objectives The primary objective of this study was to analyze and review the demographics of children operated upon for intussusception. Secondary objectives were to review the clinical characteristics, surgical procedures performed, postoperative complications, and outcome.

Materials and Methods It is a single-institution, retrospective study and consists of children below the age of 12 years. This study was conducted at the author’s department of pediatric surgery for the past 21 years, from January 1, 2000 to December 31, 2020.

Results During the study period, 212 children were operated upon for intussusceptions and included 146 (68.86%) boys and 66 (31.13%) girls. This review consisted of infants 158 (74.52%), and children of 1 to 5 years of age (30; 14.15%), and 6 to 12 years of age (24; 11.32%). Clinically, 177 (83.49%) children presented with the features of acute intestinal obstruction, and the remaining 35 (16.5%) presented with features of perforation peritonitis. Primary (idiopathic) intussusception was documented in 188 (88.67%) of the cases. Gangrenous bowel was evident in 98 (46.22%) children. Sixty-two percent of the cases required bowel resection. Surgical procedures were executed in children for intussusception in the following order of frequency: (1) operative reduction with or without serosal tear/bowel perforation repair, n = 81 (38.2%); (2) resection of diseased ileum and ileoileal anastomosis, n = 52 (24.52%); (3) resection of diseased ileum ± part of colon and an ileostomy, n = 36 (16.98%); and (4) resection of diseased ileum, cecum, part of colon, and ileocolic (ileo-ascending or ileo-transverse) anastomosis, n = 43 (20.28%). Postoperatively, 9 (4.24%) children required reexploration for the management of their complications. Twenty-one (9.9%) children died during the postoperative period.

Conclusion Intussusception remains the most common cause of acute intestinal obstruction in infants and young children. Delay in the referral, diagnosis, and seeking treatment were significantly associated with bowel gangrene, required bowel resection during the surgical therapy, and also culminated in significantly higher mortalities.

Clinical presentation and management of childhood intussusception in South Africa

PURPOSE

We assessed management and outcomes for intussusception at nine academic hospitals in South Africa.

METHODS

Patients ≤ 3 years presenting with intussusception between September 2013 and December 2017 were prospectively enrolled at all sites. Additionally, patients presenting between July 2012 and August 2013 were retrospectively enrolled at one site. Demographics, clinical information, diagnostic modality, reduction methods, surgical intervention and outcomes were reviewed.

RESULTS

Four hundred seventy-six patients were enrolled, [54% males, median age 6.5 months (IQR 2.6-32.6)]. Vomiting (92%), bloody stool (91%), abdominal mass (57%), fever (32%) and a rectal mass (29%) represented advanced disease: median symptom duration was 3 days (IQR 1-4). Initial reduction attempts included pneumatic reduction (66%) and upfront surgery (32%). The overall non-surgical reduction rate was 28% and enema perforation rate was 4%. Surgery occurred in 334 (70%), 68 (20%) patients had perforated bowel, bowel resection was required in 61%. Complications included recurrence (2%) and nosocomial sepsis (4%). Length of stay (LOS) was significantly longer in patients who developed complications. Six patients died-a mortality rate of 1%. There was a significant difference in reduction rates, upfront surgery, bowel resection, LOS and mortality between centres with shorter symptom duration compared longer symptom duration.

CONCLUSION

Delayed presentation was common and associated with low success for enema reduction, higher operative rates, higher rates of bowel resection and increased LOS. Improved primary health-care worker education and streamlining referral pathways might facilitate timely management.

Small Bowel Obstruction

Small bowel obstruction (SBO) remains a common problem for surgeons and nonsurgeons alike. Management of SBO has shifted from primarily being surgical to a nonoperative approach, which can be attributed to a multitude of reasons, including better understanding of the pathophysiology of SBO, the advent of laparoscopy, and improvement in diagnostic imaging. But given the nature of SBO, the need for surgical consultation continues to remain a necessity. This article will review the etiology, diagnosis, and management of SBO.

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

STUDY OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intussusception in Adults: A Retrospective Review from a Single Institution

Purpose

Intussusception is uncommon in adults and often manifests as nonspecific symptoms. Owing to its low incidence and the lack of knowledge on the symptoms, causes, and treatment of adult intussusception (AI), many surgeons may have limited experience in the diagnosis and treatment of intussusception. This study aimed to describe the experience of AI and discuss its clinical presentation, etiology, and management.

Material and Methods

I retrospectively reviewed patients aged 19 years and older who were diagnosed with intussusception at a single institution between March 2010 and December 2019.

Results

Among 28 patients who were finally analyzed, abdominal pain was the most commonly observed symptom. Ileocolic and ileoileal intussusceptions were the most common locations, and a lead point was observed in 19 cases (68%), of which malignancy was observed in six (21%). Bowel resection was performed in 27 cases. According to the pathological findings of the tissue from the resected section, nine and three cases of small bowel intussusception (SBI) were benign and malignant, respectively, whereas 13 and three cases of colonic intussusception (CI) were benign and malignant, respectively. On comparing SBI and CI, it was observed that most variables did not significantly differ, except for the duration of symptoms.

Conclusion

SBI had a higher lead point than CI. The rate of malignancy in CI cases in this study was lower than that reported in other studies. En-bloc resection can be considered the first option for the treatment of AI.

Intussusception and COVID19, Successful Mechanic Reduction, Case Report

The COVID 19 pandemic has greatly affected the world population. SARS CoV2 infection in pediatric patients is related to the development of mild symptoms and in some cases gastrointestinal manifestations. We present the case of a patient with intussusception as a manifestation associated with SARS CoV2 infection, treated by ultrasound-guided hydrostatic reduction with successful results.

Predictors of failed enema reduction in children with intussusception: a systematic review and meta-analysis

OBJECTIVE

To identify predictors of failed enema reduction in children with intussusception.

METHODS

PubMed and EMBASE were searched for all studies published over a 20-year time frame, prior to March 25, 2020. Original articles that reported predictors of failed enema reduction were included. The pooled odds ratio (OR) for successful enema reduction according to various features was calculated. The combined estimates were meta-analytically pooled by random-effects modeling. The risk of bias was assessed using the National Institute of Health Quality Assessment Tool. This review was registered to the PROSPERO (CRD42020190178).

RESULTS

A total of 38 studies, comprising 40,133 cases, were included. The shorter duration of symptoms (< 24 h; combined OR, 3.812; 95% CI, 2.150-6.759) and abdominal pain (combined OR, 2.098; 95% CI, 1.405-3.133) were associated with the success (all p < 0.001). Age < 1 year (combined OR, 0.385; 95% CI, 0.166-0.893; p = 0.026), fever (combined OR, 0.519; 95% CI, 0.371-0.725; p < 0.001), rectal bleeding (combined OR, 0.252; 95% CI, 0.165-0.387; p < 0.001), and vomiting (combined OR, 0.497; 95% CI, 0.372-0.664; p < 0.001) were associated with the failed reduction. The ascites (combined OR, 0.127; 95% CI, 0.044-0.368; p = 0.001), left-sided intussusception (combined OR, 0.121; 95% CI, 0.058-0.252; p < 0.001), and trapped fluid (combined OR, 0.179; 95% CI, 0.061-0.525; p = 0.017) on US were associated with the failed reduction.

CONCLUSIONS

Successful predictors for intussusception reduction have been summarized. This evidence can help identify patients who are more likely to fail non-operative reduction and could be potential surgical candidates.

KEY POINTS

• A shorter duration of symptoms and presence of abdominal pain were associated with increased probability of success. • Age (less than 1 year), presence of fever, rectal bleeding, vomiting, and presence of ascites, left-sided intussusception, or trapped fluid on ultrasonography were associated with decreased probability of success. • This study suggests that various clinical and ultrasonography predictors would help identify patients who are more likely to fail nonoperative reduction and identify potential preoperative candidates.

Accurately distinguishing pediatric ileocolic intussusception from small-bowel intussusception using ultrasonography

PURPOSE

The clinical treatment of ileocolic intussusception is different from that of small-bowel intussusception (SBI). This study aimed to analyze the differences between the two groups using ultrasonoscopy to avoid misdiagnosis.

METHODS

We conducted a retrospective study of intussusception in patients aged 0-18 years from September 2018 to March 2020. Clinical and ultrasonoscopy data were reviewed.

RESULTS

A total of 183 cases of intussusception were included in this study (123 cases of SBI and 60 of ileocolic intussusception). Ultrasonoscopy features that were significantly different between the two groups (p<0.05) included the lesion diameter, fat core thickness, outer wall thickness, lymph nodes inside intussusception, and lesion length. In the SBI group, 85% (104/123) of the normal ileocecal region was found in the right lower quadrant and 98% (120/123) of the normal ascending colon was found in the right side of the abdomen. In the ileocolic intussusception group, none of the normal ileocecal region was found and the ascending colon was found in only 5 cases (8%) (p<0.05).

CONCLUSIONS

The use of ultrasonography is the most practical method to distinguish SBI from ileocolic intussusception. In addition to comparing the differences between lesions, conventional probing of the ileocecal region and ascending colon will help to accurately differentiate between the types of intussusception and avoid misdiagnosis.

LEVELS OF EVIDENCE

Diagnostic.

Suspecting Intussusception and Recurrence Risk Stratification Using Clinical Data and Plain Abdominal Radiographs

PURPOSE

Although ultrasonography is the gold standard of diagnosing intussusception, plain abdomen radiograph (AXR) is often used to make differential diagnosis for pediatric patients with abdominal pain. In intussusception patients, we aimed to analyze the AXR and clinical data to determine the characteristics of early AXR findings associated with diagnosis of intussusception and recurrence after reduction.

METHODS

Between January 2011 and June 2018, 446 patients diagnosed with intussusception based on International Classification of Diseases-10 code of K56.1 were admitted. We retrospectively reviewed medical records of 398 patients who received air reduction; 51 of them have recurred after initial reduction. We evaluated six AXR features including absent ascending colon gas, absent transverse colon gas, target sign, meniscus sign, mass, and ileus. Clinical data and AXR features were compared between single episode and recurrence groups.

RESULTS

Two groups did not show significant differences regarding clinical data. Mean time to recurrence from air reduction was 3.4±3.2 days. Absent ascending colon gas (63.9%) was the most common feature in intussusception, followed by mass (29.1%). All of six AXR features were observed more frequently in the recurrence group. Absent transverse colon gas was the most closely associated AXR finding for recurrence (odds ratio, 2.964; 95% confidence interval, 1.327-6.618; p=0.008).

CONCLUSION

In our study, absence of ascending colon gas was the most frequently seen AXR factor in intussusception patients. Extended and careful observation after reduction may be beneficial if such finding on AXR is found in intussusception patients.

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

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.

Appendix around ileocolic intussusception with acute appendicitis: A rare presentation

Intussusception and appendicitis share similar clinical features. However, their concurrent occurrence is exceedingly rare. Appendix involvement in intussusception must be ruled out when appendix is not visualized on high-resolution ultrasonography in cases with ileocolic intussusception. This case report describes the sonological appearance of a combination of ileocolic intussusception with concurrent acute appendicitis in a 4-year-old child.

Intussusception in a child with COVID-19 in the USA

COVID-19, caused by the novel coronavirus strain SARS-CoV-2 that emerged in late 2019, has resulted in a global pandemic. COVID-19 was initially believed to occur less frequently in children with relatively mild disease. However, severe disease and varied presentations have been reported in infected children, one of such being intussusception. There have only been three reported cases of intussusception in the pediatric population infected with COVID-19. In this paper, we will discuss the management and treatment of a novel fourth case of COVID-19-associated intussusception. This case is the first reported in the USA and suggests that COVID-19 may be implicated in the development of intussusception. Pediatricians should consider the possibility of intussusception when a child with COVID-19 presents with abdominal pain.

Diagnosis and treatment of childhood intussusception from 1997 to 2016: A population-based study

OBJECTIVES

Describe changes in the diagnostic approach and treatment for pediatric intussusception over two decades.

STUDY DESIGN

Administrative universal healthcare data were used to conduct a population-based cohort study of intussusception between January 1997 and December 2016 in Ontario, Canada. A validated case definition was used to identify all patients (<18 years) treated for intussusception in the province at community or tertiary care centers. Treatment modality was determined using physician billing data and databases linked at ICES; it was categorized as nonoperative alone, surgical alone, or failed nonoperative. Descriptive statistics, Cochrane-Armitage for trend analyses, and graphical and multinomial logistic regression were performed.

RESULTS

Over 20 years, 1895 pediatric patients were treated for intussusception. Pretreatment imaging use rose from 57.5% to 99.3%. Nonoperative management increased from 23.4% to 75.2%. However, 43% of children who presented to a community hospital underwent immediate surgical management, compared with just 11% of children at tertiary centers (RR 0.39, 95% CI: 0.25-0.62). Among children who underwent surgery, there was an increase in bowel resection over time (41.7% to 57.6%).

CONCLUSIONS

Over the 20 year period of study, pretreatment imaging became universal, and management shifted from predominantly surgical to nonoperative reduction in Ontario. The rate of surgical intervention remains higher in community versus tertiary centers.

LEVEL OF EVIDENCE

Treatment study, III.

Pediatric emergency gastrointestinal ultrasonography: pearls & pitfalls

Ultrasonography is an essential tool in pediatric imaging, particularly in the emergency setting. Although ultrasound is often the favored initial modality for abdominal imaging in children, it is highly operator-dependent and therefore prone to misinterpretation which can lead to false positive or negative exams, or even incorrect diagnoses. Conditions discussed in this series include ileocolic intussusception, hypertrophic pyloric stenosis, appendicitis, and ingested foreign bodies. We will review diagnostic criteria, highlight crucial findings, and illustrate commonly-encountered difficulties and mimics.

Intussusception in children: lessons learned from intestinal lymphoma as a rare lead-point

BACKGROUND

Most cases of intussusception in children are idiopathic. Rarely, a malignant disease such as intestinal lymphoma may cause intussusception. Due to dramatic changes of expected outcome with chemotherapy regime alone, the surgical management of patients with intestinal lymphoma presenting with intussusception has to be reevaluated.

METHODS

Retrospective chart review from May 2011 to February 2017. We included all patients with intestinal lymphoma presenting with intussusception.

RESULTS

We found five patients with a mean age of 6.4 years (range 3-16). The most common presenting symptom was abdominal pain for several weeks which had acutely worsened. In all but one patient an ultrasound before pneumatic or hydrostatic reduction showed a finding suspicious of a pathological lead-point. Pneumatic or hydrostatic reduction was attempted in all patients, no complications were noted. In one patient reduction was not successful. Recurrence after reduction occurred in two patients. Two patients needed surgery, three had a percutaneous ultrasound-guided biopsy for diagnostic purposes. All patients had aggressive mature B cell non-Hodgkin lymphoma.

CONCLUSION

A high index of suspicion for the presence of a pathological lead-point in children older than 4 years and children with recurrent intussusception is necessary in patients presenting with intussusception. Malignant, highly aggressive B cell non-Hodgkin lymphoma, although rare, must actively be searched for. Pneumatic or hydrostatic reduction should remain the first line treatment in most cases.

Postoperative intestinal intussusception in children, an easily missed culprit of postoperative intestinal obstruction: Case series and literature review

•

Most of our patients presented in the first two weeks after the primary operation and managed successfully with operative manual reduction with no postoperative complications.

•

Postoperative intestinal intussusception secondary to surgical reduction of ileocolic intussusception is an exceedingly rare cause of postoperative intestinal obstruction.

•

Usually, postoperative intestinal intussusception is misdiagnosed as postoperative adhesive obstruction.

•

Postoperative intestinal intussusception is challenging in diagnosis and needs a very high index of suspicion.

•

By keeping the possibility of POI in mind, one can easily diagnose it and prevent its consequences.

Background

Postoperative intestinal intussusception (POI) is a rare cause of intestinal obstruction with POI after surgical reduction of ileocolic intussusception being an extremely rare variant. POI was reported to follow many abdominal and non-abdominal operations. A late diagnosis can risk ischemia and necrosis. POI also increases the morbidity and mortality, rendering an early diagnosis and prompt management as lifesaving.

Methods

We reviewed the medical charts retrospectively for the last ten years for patients with POI at Palestine Red Crescent Society Hospital, Hebron, Palestine. We reviewed the literature and presented the characteristics of the most reported cases of POI following surgical reduction of ileocolic intussusception.

Results

We presented three cases of ileoileal POI and one case of ileocolic POI followed different primary operations. All but one patient presented in the first two weeks. The delayed presentation came two months after revision of a prolapsed colostomy. All patients managed successfully with operative manual reduction with no postoperative complications. Initially, we had struggles in the diagnosis of POI largely due to a low suspicion for this rare entity, but thereafter we kept POI in mind and managed the after-coming cases in an expeditious manner.

Conclusion

Frequently, POI is misdiagnosed as postoperative adhesive obstruction. POI is challenging in diagnosis and needs a very high index of suspicion, mainly due to its rarity and atypical presentation. By keeping the possibility of POI in mind, one can easily diagnose it and prevent its consequences.

Missed case of intussusception, a rare cause of abdominal pain in adults: A case report emphasizing the imaging findings and review of the literature

Intussusception, a process whereby a segment of the intestine telescopes into the adjoining intestinal lumen, is a rare source of pain in adults that present with nonspecific abdominal pain. Imaging is the mainstay for diagnosis, which requires prompt and accurate interpretation to prevent complications. The following report details the misdiagnosis of intussusception in a 54-year-old male, whom presented to the emergency department with a 4-day history of nonrelenting abdominal pain, nausea, vomiting, and constipation. Following blood tests, chest, and abdominal imaging, the patient was discharged with a suspected passed renal stone. He soon represented to the General Practitioner, however, with equivalent pain; prompting a review of the images. It was apparent that the initial radiologist failed to recognize the subtle presence of intussusception. This case highlights the necessary consideration of intussusception as a differential diagnosis in adult patients presenting with intermittent abdominal pain. The case further emphasizes that radiologists should be familiar with the subtler signs of intussusception.