Intussusception of the bowel in adults: A review

Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment. This condition is frequent in children and presents with the classic triad of cramping abdominal pain, bloody diarrhea and a palpable tender mass. However, bowel intussusception in adults is considered a rare condition, accounting for 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction. Eight to twenty percent of cases are idiopathic, without a lead point lesion. Secondary intussusception is caused by organic lesions, such as inflammatory bowel disease, postoperative adhesions, Meckel’s diverticulum, benign and malignant lesions, metastatic neoplasms or even iatrogenically, due to the presence of intestinal tubes, jejunostomy feeding tubes or after gastric surgery. Computed tomography is the most sensitive diagnostic modality and can distinguish between intussusceptions with and without a lead point. Surgery is the definitive treatment of adult intussusceptions. Formal bowel resection with oncological principles is followed for every case where a malignancy is suspected. Reduction of the intussuscepted bowel is considered safe for benign lesions in order to limit the extent of resection or to avoid the short bowel syndrome in certain circumstances.

Intussusception in adults: Clinical characteristics, diagnosis and operative strategies

AIM: To evaluate 20 adults with intussusception and to clarify the cause, clinical features, diagnosis, and management of this uncommon entity.

METHODS: A retrospective review of patients aged > 18 years with a diagnosis of intestinal intussusception between 2000 and 2008. Patients with rectal prolapse, prolapse of or around an ostomy and gastroenterostomy intussusception were excluded.

RESULTS: There were 20 cases of adult intussusception. Mean age was 47.7 years. Abdominal pain, nausea, and vomiting were the most common symptoms. The majority of intussusceptions were in the small intestine (85%). There were three (15%) cases of colonic intussusception. Enteric intussusception consisted of five jejunojejunal cases, nine ileoileal, and four cases of ileocecal invagination. Among enteric intussusceptions, 14 were secondary to a benign process, and in one of these, the malignant cause was secondary to metastatic lung adenocarcinoma. All colonic lesions were malignant. All cases were treated surgically.

CONCLUSION: Adult intussusception is an unusual and challenging condition and is a preoperative diagnostic problem. Treatment usually requires resection of the involved bowel segment. Reduction can be attempted in small-bowel intussusception if the segment involved is viable or malignancy is not suspected; however, a more careful approach is recommended in colonic intussusception because of a significantly higher coexistence of malignancy.

PDGF-BB regulates splitting angiogenesis in skeletal muscle by limiting VEGF-induced endothelial proliferation

VEGF induces normal or aberrant angiogenesis depending on its dose in the microenvironment around each producing cell in vivo. This transition depends on the balance between VEGF-induced endothelial stimulation and PDGF-BB-mediated pericyte recruitment, and co-expression of PDGF-BB normalizes aberrant angiogenesis despite high VEGF doses. We recently found that VEGF over-expression induces angiogenesis in skeletal muscle through an initial circumferential vascular enlargement followed by longitudinal splitting, rather than sprouting. Here we investigated the cellular mechanism by which PDGF-BB co-expression normalizes VEGF-induced aberrant angiogenesis. Monoclonal populations of transduced myoblasts, expressing similarly high levels of VEGF alone or with PDGF-BB, were implanted in mouse skeletal muscles. PDGF-BB co-expression did not promote sprouting and angiogenesis that occurred through vascular enlargement and splitting. However, enlargements were significantly smaller in diameter, due to a significant reduction in endothelial proliferation, and retained pericytes, which were otherwise lost with high VEGF alone. A time-course of histological analyses and repetitive intravital imaging showed that PDGF-BB co-expression anticipated the initiation of vascular enlargement and markedly accelerated the splitting process. Interestingly, quantification during in vivo imaging suggested that a global reduction in shear stress favored the initiation of transluminal pillar formation during VEGF-induced splitting angiogenesis. Quantification of target gene expression showed that VEGF-R2 signaling output was significantly reduced by PDGF-BB co-expression compared to VEGF alone. In conclusion, PDGF-BB co-expression prevents VEGF-induced aberrant angiogenesis by modulating VEGF-R2 signaling and endothelial proliferation, thereby limiting the degree of circumferential enlargement and enabling efficient completion of vascular splitting into normal capillary networks despite high VEGF doses.

Age at presentation of common pediatric surgical conditions: Reexamining dogma

PURPOSE

The commonly cited ages at presentation of many pediatric conditions have been based largely on single center or outdated epidemiologic evidence. Thus, we sought to examine the ages at presentation of common pediatric surgical conditions using cases from large national databases.

METHODS

A retrospective analysis was performed on Healthcare Cost and Utilization Project databases from 1988 to 2009. Pediatric discharges were selected using matched ICD9 diagnosis and procedure codes for malrotation, intussusception, hypertrophic pyloric stenosis (HPS), incarcerated inguinal hernia (IH), and Hirschsprung disease (HD). Descriptive statistics were computed.

RESULTS

A total of 63,750 discharges were identified, comprising 2744 cases of malrotation, 5831 of intussusception, 36,499 of HPS, 8564 of IH, and 10,112 of HD. About 58.2% of malrotation cases presented before age 1. Moreover, 92.8% of HPS presented between 3 and 10weeks. For intussusception, 50.3% and 91.4% presented prior to ages 1 and 4years, respectively. Also, 55.8% of IHD cases presented before their first birthday. For HD, 6.5% of cases presented within the neonatal period and 45.9% prior to age 1year.

CONCLUSION

Our findings support generally cited presenting ages for HPS and intussusception. However, the ages at presentation for HD, malrotation, and IH differ from commonly cited texts.

Intussusception: past, present and future

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

Bowel Obstruction

Small bowel obstruction and large bowel obstruction account for approximately 20% of cases of acute abdominal surgical conditions. The role of the radiologist is to answer several key questions: Is obstruction present? What is the level of the obstruction? What is the cause of the obstruction? What is the severity of the obstruction? Is the obstruction simple or closed loop? Is strangulation, ischemia, or perforation present? In this presentation, the radiologic approach to and imaging findings of patients with known or suspected bowel obstruction are presented.

Meckel's diverticulum in the adult

Meckel's diverticulum (MD) is the most common gastro-intestinal congenital malformation (approximately 2% in the overall population). The lifetime risk of related complications is estimated at 4%. These include gastro-intestinal bleeding, obstruction or diverticular inflammation. Diagnosis is difficult and rarely made, and imaging, especially in the case of complicated disease, is often not helpful; however exploratory laparoscopy is an important diagnostic tool. The probability of onset of complication decreases with age, and the diagnosis of MD in the adult is therefore often incidental. Resection is indicated in case of complications but remains debatable when MD is found incidentally. According to an analysis of large series in the literature, surgery is not indicated in the absence of risk factors for complications: these include male gender, age younger than 40, diverticulum longer than two centimetres and the presence of macroscopically mucosal alteration noted at surgery. Resection followed by anastomosis seems preferable to wedge resection or tangential mechanical stapling because of the risk of leaving behind abnormal heterotopic mucosa.

Lipoma induced jejunojejunal intussusception

Intussusception in adults is rare. The clinical picture of intussusception in adults is subtle and the diagnosis is, therefore, elusive. The presence of a structural abnormality in the great majority of the adult cases mandates high clinical suspicion. Gastrointestinal lipomas are rare benign tumors and intussusception due to a gastrointestinal lipoma constitutes an infrequent clinical entity. The present report describes a case of jejunojejunal intussusception in an adult with a history of severe episodes of hematochezia and colicky upper abdominal pain. The diagnosis was suspected preoperatively but computed tomography scan could not rule out malignancy. Exploratory laparotomy revealed jejunojejunal intussusception secondary to a lipoma which was successfully treated with segmental intestinal resection.

The risk of intussusception following monovalent rotavirus vaccination in England: A self-controlled case-series evaluation

OBJECTIVE

To investigate the risk of intussusception after monovalent rotavirus vaccine (RV1) given to infants aged 2 and 3 months in England.

METHODS

Hospital Episode Statistics (HES) were used to identify infants aged 48-183 days admitted between 11/03/2013 and 31/10/2014 with intussusception. Diagnosis was confirmed from medical records and HES procedure codes. Vaccination status was obtained from general practitioners. The risk of admission within 1-7 and 8-21 days of vaccination was analysed using the self-controlled case-series (SCCS) method with age effect adjustment by including historical data before RVI introduction in July 2013.

RESULTS

A total of 119 cases were identified during the study period and intussusception confirmed in 95 of whom 39 were vaccinated 1-21 days before onset. An increased relative incidence (RI) in this period was found, 4.53 (95% confidence interval 2.34-8.58) and 2.60 (1.43-4.81) respectively after the 1st and 2nd doses with an attributable risk of 1.91 and 1.49 per 100,000 doses respectively. The peak risk was 1-7 days after the first dose, RI 13.81 (6.44-28.32), with an estimated 93% of the 15 cases being vaccine-attributable. Mean interval between onset and admission, and clinical features were similar between vaccine-associated and background cases. Despite intussusception being a contraindication to rotavirus vaccination, 10 infants received a further dose; none had a recurrence. The RIs in a meta-analysis combing our results with Australia, Mexico, Brazil and Singapore using RV1, a 2, 4 month schedule and SCCS gave pooled RI estimates of 2.35 (1.45-3.8) and 1.77 (1.29-2.43) in the 21 day period after the 1st and 2nd doses, respectively. The earlier age at the 2nd dose in England did not affect the risk.

CONCLUSION

We estimate that the RVI programme causes around 21 intussusception admissions annually in England but, since it prevents around 25,000 gastro-intestinal infection admissions, its benefit/risk profile remains strongly positive.

Intussusception due to inflammatory fibroid polyp: a case report and comprehensive literature review

AIM

To give an overview of the literature on intussusception due to inflammatory fibroid polyp (IFP).

METHODS

We present a new case of ileal intussusception due to IFP and a literature review of studies published in English language on intussusception due to IFP, accessed via PubMed and Google Scholar databases. For the search, the keywords used were: intussusception, IFP, intussusception and IFP, intussusception due to IFP, and IFP presenting as intussusception. The search covered all articles from 1976 to November 2011.

RESULTS

We present a 38-year-old woman who was admitted 10 d after experiencing abdominal pain, vomiting, and nausea. Ultrasonography demonstrated small bowel intussusception. An ileal intussusception due to a mass lesion 50 cm proximal to the ileocecal junction was found during laparotomy. Partial ileal resection and anastomosis were performed. A diagnosis of ileal IFP was made based on the immunohistochemical findings. In addition, a total of 56 reports concerning 85 cases of intussusception due to IFP meeting the aforementioned criteria was included in the literature review. The patients were aged 4 to 81 years (mean, 49 ± 16.2 years); 44 were women (mean, 51.8 ± 14.3 years) and 41 were men (mean, 46 ± 17.5 years). According to the location of the IFP, ileal intussusception was found in 63 patients, while 17 had jejunal, three had colonic, and two had ileojejunal intussusception.

CONCLUSION

Although IFPs are rare and benign, surgery is the only solution in case of intestinal obstruction. Differential diagnosis should be made via immunohistochemical examination.

Abdominal computed tomography in refractory coeliac disease and enteropathy associated T-cell lymphoma

AIM: To evaluate computed tomography (CT) findings, useful to suggest the presence of refractory celiac disease (RCD) and enteropathy associated T cell lymphoma (EATL).

METHODS: Coeliac disease (CD) patients were divided into two groups. GroupI: uncomplicated CD (n = 14) and RCD typeI(n = 10). Group II: RCD type II (n = 15) and EATL (n = 7).

RESULTS: Both groups showed classic signs of CD on CT. Intussusception was seen in 1 patient in groupIvs 5 in group II (P = 0.06). Lymphadenopathy was seen in 5 patients in group II vs no patients in groupI(P = 0.01). Increased number of small mesenteric vessels was noted in 20 patients in groupIvs 11 in group II (P = 0.02). Eleven patients (50%) in group II had a splenic volume < 122 cm³vs 4 in groupI(14%), 10 patients in groupI had a splenic volume > 196 cm³ (66.7%) vs 5 in group II (33.3%) P = 0.028.

CONCLUSION: CT scan is a useful tool in discriminating between CD and (Pre) EATL. RCD II and EATL showed more bowel wall thickening, lymphadenopathy and intussusception, less increase in number of small mesenteric vessels and a smaller splenic volume compared with CD and RCDI.

Twenty years' experience for reduction of ileocolic intussusceptions by saline enema under sonography control

BACKGROUND

Ultrasonography is a well-established efficient diagnostic tool for ileocolic intussusceptions in children. It can also be used to control hydrostatic reduction by saline enemas. This reduction method presents the advantage of avoiding radiations. Parents can even stay with their children during the procedure, which is comforting for both. The purpose of this study was to present our 20 years' experience in intussusception reductions using saline enema under ultrasound control and to assess its efficiency and safety.

MATERIAL AND METHODS

This retrospective single center study included patients with ileocolic intussusceptions diagnosed by ultrasound between June 1993 and July 2013. We excluded the data of patients with spontaneous reduction or who underwent primary surgery because of contraindications to hydrostatic reduction (peritonitis, medium or huge abdominal effusion, ischemia on Doppler, bowel perforation). A saline enema was infused into the colon until the reduction was sonographically confirmed. The procedure was repeated if not efficient. Light sedation was practiced in some children.

RESULTS

Eighty-tree percent of the reductions were successful with a median of 1 attempt. Reduction success decreased with the number of attempts but was still by 16% after 4 attempts. The early recurrence rates were 14.5%, and 61.2% of those had a successful second complete reduction. Forty-six patients needed surgery (11 of them had a secondary intussusception). Sedation multiplies success by 10. In this period, only one complication is described.

CONCLUSION

Ultrasound guided intussusception reduction by saline enema is an efficient and safe procedure. It prevents exposure of a young child to a significant amount of radiation, with similar success rate. We had very low complication rate (1/270 cases or 3‰). The success rate could be increased by standardized procedures including: systematic sedation, trained radiologists, accurate pressure measurement, and number and duration of attempts.

A randomized trial of pneumatic reduction versus hydrostatic reduction for intussusception in pediatric patients

OBJECTIVES

Data of randomly controlled trials comparing the hydrostatic and pneumatic reduction for intussusception in pediatric patients as initial therapy are lacking. The aim of this study was to conduct a randomly controlled trial to compare the effectiveness and safety of the hydrostatic and pneumatic reduction techniques.

STUDY DESIGN

All intussusception patients who visited West China Hospital of Sichuan University from January 2014 to December 2015 were enrolled in this study in which they underwent pneumatic reduction or hydrostatic reduction. Patients were randomized into ultrasound-guided hydrostatic or X-ray-guided pneumatic reduction group. The data collected includes demographic data, symptoms, signs, and investigations. The primary outcome of the study was the success rate of reduction. And the secondary outcomes of the study were the rates of intestinal perforations and recurrence.

RESULTS

A total of 124 children with intussusception who had met the inclusion criteria were enrolled. The overall success rate of this study was 90.32%. Univariable analysis showed that the success rate of hydrostatic reduction with normal saline (96.77%) was significantly higher than that of pneumatic reduction with air (83.87%) (p=0.015). Perforation after reduction was found in only one of the pneumatic reduction group. The recurrence rate of intussusception in the hydrostatic reduction group was 4.84% compared with 3.23% of pneumatic reduction group.

CONCLUSION

Our study found that ultrasound-guided hydrostatic reduction is a simple, safe and effective nonoperative treatment for pediatric patients suffering from intussusceptions, and should be firstly adopted in the treatment of qualified patients.

LEVEL OF EVIDENCE

Therapeutic study TYPE OF STUDY: Prospective study.

Intussusception in an infant as a manifestation of COVID-19

Gastrointestinal manifestations of COVID-19 are rare and have primarily been limited to diarrhea or vomiting. Intussusception is the most common cause of bowel obstruction in infants, with up to 30% of pediatric intussusception cases having a preceding viral illness. We present the rare case of intussusception in a SARS-CoV-2 positive infant. This is the first documented case of survival in a SARS-CoV-2 positive patient presenting with intussusception as the primary manifestation. As our knowledge of this disease evolves, surgeons need to remain suspicious for possible gastrointestinal manifestations of COVID-19.

Laparoscopic treatment of intussusception in children: a systematic review

BACKGROUND

Idiopathic intussusception is one of the most common causes of small bowel obstruction in children. In the event of failed radiological reduction, laparotomy remains the treatment of choice. There is still no agreement in pediatric surgery about safety and effectiveness of the use of minimally invasive surgery in this common pediatric condition. By reviewing available data we aimed to establish whether laparoscopy should be the primary technique in the surgical reduction of intussusception.

METHODS

A systematic review of all publications on the laparoscopic treatment of pediatric intussusception from January 1990 to April 2012 was performed. The following variables were analyzed: age, laparoscopic success rate, reason for conversion, enterotomy rate, operative time, complications, and length of stay (LOS).

RESULTS

Ten retrospective studies treating 276 cases of laparoscopically reduced intussusception were identified. A total of 80 conversions corresponded to a 71.0% laparoscopic success rate. Only one case of intraoperative iatrogenic intestinal perforation was reported (0.4%). Postoperative complications occurred in 8 patients (2.9%), and adhesive small bowel obstruction was reported in 1 case (0.4%). Recurrence rate after laparoscopy was 3.6%. Three of 10 papers compared results between laparoscopic and open reduction of intussusception showing a shorter mean LOS in the former group (4.0 vs. 7.1 days, p<0.01).

CONCLUSION

Laparoscopy is safe and effective in the treatment of pediatric intussusception. Tertiary centers with adequate minimally invasive skills should establish laparoscopy as the primary surgical technique in the treatment of this condition.

Update on the global epidemiology of intussusception: a systematic review of incidence rates, age distributions and case-fatality ratios among children aged <5 years, before the introduction of rotavirus vaccination

Background

In some countries that have introduced oral rotavirus vaccines, a small but elevated risk of intussusception—a rare bowel disorder—has been reported. Updated estimates on the global epidemiology of intussusception are needed to help predict the potential number of intussusception cases that could be caused by the vaccine in different settings.

Methods

We estimated incidence rates, age distributions and case-fatality ratios (CFRs) for intussusception hospital admissions among children aged <5 years, before the introduction of rotavirus vaccines. We included all articles identified in a systematic review between January 2002 and January 2018, and contacted authors for more granular unpublished data on age distributions.

Results

We identified 128 articles containing 227 country datasets (61 age distributions, 71 incidence rates and 95 CFRs). The median age of intussusception ranged from 29 weeks in Africa (83% of cases in the first year of life) to 70 weeks in the Western Pacific region (35% of cases in the first year of life). The median (range) annual incidence of intussusception hospital admissions per 100 000 aged <1 year ranged from 34 (13–56) in Africa to 90 (9–380) in the Western Pacific region. We found extreme differences between the CFRs in Africa (1 death in every 10 hospital admissions) and the rest of the world (fewer than 1 death in every 100–2000 hospital admissions).

Conclusion

Intussusception epidemiology varies by country and region. Understanding and recognizing these differences will be important when assessing the potential number of intussusception cases associated with rotavirus vaccines.

Intussusception incidence among infants in the UK and Republic of Ireland: a pre-rotavirus vaccine prospective surveillance study

•

The pre-rotavirus vaccine incidence of intussusception among UK and Irish infants was 24.8 and 24.2/100,000 live births.

•

The highest incidence (50.3/100,000 live births) occurred in the fifth month of life (for England).

•

A seasonal trend in intussusception was observed with the incidence significantly increased during winter and spring.

•

Baseline rates will inform rotavirus vaccine-safety policy by enabling comparison with post-introduction incidence.

Introduction

Intussusception, an abdominal emergency in young children, has been linked to a previous vaccine used to prevent rotavirus gastroenteritis. Although this vaccine was withdrawn, recent studies have suggested a potential, very small increased risk of intussusception following the administration of newly developed rotavirus vaccines. We aimed to determine the baseline incidence of intussusception among infants in the UK and Republic of Ireland – prior to the imminent introduction of the rotavirus vaccine into the UK schedule this year.

Methods

Prospective, active surveillance via the established British Paediatric Surveillance Unit (BPSU) was carried out from March 2008 to March 2009. Clinicians across 101 National Health Service (and equivalent) hospitals, including 27 paediatric surgical centres, reported cases admitted for intussusception in the UK and Republic of Ireland. The standard Brighton Collaboration case definition was used with only definite cases included for incidence estimation.

Results

The study response rate was 94.5% (379 questionnaires received out of 401 case notifications). A total of 250 definite cases of intussusception were identified. The annual incidence among infants in the UK and Republic of Ireland was 24.8 (95% CI: 21.7–28.2) and 24.2 (95% CI: 15.0–37.0) per 100,000 live births. In the UK, the highest incidence occurred in Northern Ireland (40.6, 95% CI: 21.0–70.8), followed by Scotland (28.7, 95% CI: 17.5–44.3), England (24.2, 95% CI: 20.9–27.9), then Wales (16.9, 95% CI: 6.8–34.8). In England, regional incidence was highest in London and lowest in the West Midlands. By age, the highest incidence (50.3/100,000 live births, 95% CI: 33.4–72.7) occurred in the fifth month of life (for England). A seasonal trend in the presentation of intussusception was observed with the incidence significantly (p = 0.001) increased during winter and spring.

Conclusion

The baseline rates obtained in this study will inform rotavirus vaccine-safety policy by enabling comparison with post-introduction incidence.

Intussusception after Roux-en-Y gastric bypass

BACKGROUND

Jejuno-jejunal (J-J) intussusception is a rare complication after Roux-en-Y gastric bypass (RYGB). Prompt diagnosis is critical as it may lead to obstruction and bowel necrosis, but clinical presentation is nonspecific. A definitive treatment plan has not been established with intussusception after RYGB. The aim of our study was to describe clinical presentation and outcomes of treatment in patients with intussusception after RYGB.

METHODS

Out of 3022 patients who underwent laparoscopic RYGB between January 2003 and January 2013, 12 (0.4%) patients presented with intussusception after RYGB. A retrospective review of a prospectively collected database was performed.

RESULTS

Of the 12 patients, 11 (91.7%) presented with left or right upper quadrant abdominal pain as their chief complaint, and 1 (8.3%) presented with persistent nausea and vomiting. Diagnosis was made by computed tomographic scan (n = 1) or intraoperative findings (n = 11) at a mean period of 24.9 ± 26.0 months (range 3-85) after laparoscopic RYGB. Seven (58.3%) patients were treated only with reduction, 2 (16.7%) with resection and revision of J-J anastomosis, the remaining 3 (25.0%) underwent imbrication/plication of the J-J anastomosis. Only 1 (8.3%) patient, who was treated by reduction, returned with subsequent finding of recurrent intussusception at 9 months. All patients did well at a mean follow-up of 12.7 ± 16.4 months (range 1-47).

CONCLUSION

While reduction alone of the intussusception is safe and effective, there is a risk of recurrence, and imbrication of the J-J anastomosis may be a more effective means of treatment.

Clinical characteristics of intussusception secondary to pathologic lead points in children: a single-center experience with 65 cases

OBJECTIVE

Intussusception secondary to pathologic lead points (PLPs) is a challenging condition for pediatric surgeons, and few studies have been published on this subject. The aim of this study was to review and analyze clinical data on the diagnosis and management of intussusception secondary to PLPs in children.

METHODS

Between 2002 and 2016, a total of 65 pediatric patients with a diagnosis of intussusception secondary to PLPs were retrospectively reviewed.

RESULTS

The series comprised 47 males and 18 females. The average age of the patients was 4.9 years old. All patients had typical clinical manifestations, and intussusception was proven by ultrasound. Fifty-one patients had recurrent intussusception, of whom 21 had one, 14 had two, 10 had three, and 6 had more than three. There were 20 episodes of recurrence within 24 h (39.2%), 15 episodes were found between 24 and 72 h (29.4%), and the remaining 31.4% (16/51) of recurrences occurred after 72 h. All patients received surgical intussusception reduction. Meanwhile, enterectomy was the procedure of choice in 55 patients, polypectomy in 5 patients, and cystectomy in 3 patients. The types of intussusception secondary to PLPs included small intestinal (n = 25), ileocolic (n = 19), ileocecal (n = 11), ileo-ileocolic (n = 9) and cecalcolic (n = 1). The types of PLPs included Meckel diverticulum (n = 32), intestinal duplication (n = 14), benign polyps (n = 5), malignant lymphoma (n = 4), Peutz-Jeghers syndrome (n = 3), mesenteric cyst (n = 3), intestinal wall hematoma of hemophilia (n = 2), allergic purpura (n = 1), and hamartoma (n = 1). All patients recovered well with no relapse during follow-up, except for one patient who had an intestinal obstruction from adhesions that occurred approximately 3 months after discharge and who was curable after conservative treatment.

CONCLUSIONS

Intussusception secondary to PLPs tends to exhibit recurrence. There are various types of intussusception secondary to PLPs. It is necessary to improve auxiliary examinations to identify the etiology and avoid intraoperative omission. Surgical reduction of intussusception secondary to PLPs is the preferred clinical management.

Intestinal intussusception

Intussusception is defined as the invagination of one portion of the bowel into an immediately adjacent portion. Etiology, symptoms, diagnosis, and treatment are different in the pediatric and adult populations. In the pediatric population, most cases are idiopathic and result in the common scenario of ileocolic intussusception. Factors involved in causation include anatomic features of the developing gastrointestinal tract and infectious influences. In adults, the intussusceptum is typically the result of a mucosal, intramural, or extrinsic lead point that acts as a focal area of traction pulling the proximal portion of bowel into the peristalsing distal portion. The diagnosis and management in the pediatric population is relatively standardized with nonoperative reduction via air or contrast enemas attempted first. In the adult population, intussusception presents a preoperative diagnostic challenge; although surgical intervention is mandatory, intraoperative management remains controversial.

Update on imaging of Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant disease linked to a mutation of the STK 11 gene and is characterized by the development of benign hamartomatous polyps in the gastrointestinal tract in association with a hyperpigmentation on the lips and oral mucosa. Patients affected by PJS have an increased risk of developing gastrointestinal and extra-digestive cancer. Malignancy most commonly occurs in the small-bowel. Extra-intestinal malignancies are mostly breast cancer and gynecological tumors or, to a lesser extent, pancreatic cancer. These polyps are also at risk of acute gastrointestinal bleeding, intussusception and bowel obstruction. Recent guidelines recommend regular small-bowel surveillance to reduce these risks associated with PJS. Small-bowel surveillance allows for the detection of large polyps and the further referral of selected PJS patients for endoscopic enteroscopy or surgery. Video capsule endoscopy, double balloon pushed enteroscopy, multidetector computed tomography and magnetic resonance enteroclysis or enterography, all of which are relatively new techniques, have an important role in the management of patients suffering from PJS. This review illustrates the pathological, clinical and imaging features of small-bowel abnormalities as well as the role and performance of the most recent imaging modalities for the detection and follow-up of PJS patients.

Adverse events in patients with ulcerative colitis treated with indigo naturalis: a Japanese nationwide survey

BACKGROUND

Although indigo naturalis (IN) is effective for patients with active ulcerative colitis (UC), IN was associated with adverse events (AEs), including pulmonary arterial hypertension (PAH). Our aim was to evaluate the occurrence of IN-associated AEs and to evaluate any IN dose-effect on AEs.

METHODS

A nationwide survey, using questionnaires, was conducted by conducted by the research group funded by the Ministry of Health, Labour and Welfare of Japan, between June 2017 and September 2018. A first questionnaire determined the occurrence of AEs associated with the therapeutic use of IN or herbal medicines containing IN in patients with UC. A second survey identified the clinical characteristics of patients who developed IN-associated critical AEs, namely, liver dysfunction, PAH, and intussusception.

RESULTS

Across 337 participating institutions, 49,320 patients with UC were identified, with IN used in 877 (1.8%). AEs were reported in 91 patients (107 events), including liver dysfunction (n = 40), gastrointestinal symptoms (n = 21), headache (n = 13), and PAH (n = 11). No dose-effect relationship between IN and AEs was identified. Liver dysfunction tended to be mild and reversible. Ten cases of intussusception were reported, with 40% of these patients requiring surgical resection. IN-induced PAH was recovered in patients who discontinued to use IN. No IN-associated deaths were reported.

CONCLUSIONS

IN-associated AEs were identified among patients with UC, with liver dysfunction often being reversible, while surgical resection was required in a high proportion of patients who developed intussusception. Both healthcare workers and patients should adequately recognize the potential for AEs with the use of IN.

Vanek's tumor of the small bowel in adults

Inflammatory fibroid polyps (IFPs), or Vanek's tumor, are one of the least common benign small bowel tumors. IFP affects both sexes and all age groups, with a peak of incidence in the fifth and seventh decades. They can be found throughout the gastrointestinal tract but most commonly in the gastric antrum or ileum. The underlying cause of IFPs is still unknown. Genetic study of IFP showed mutations in platelet derived growth factor alpha in some cases. At the time of diagnosis most IFPs have a diameter of 3 to 4 cm. The lesions have always been recorded as solitary polyps. Symptoms depend on the location and the size of the lesion, including abdominal pain, vomiting, altered small bowel movements, gastrointestinal bleeding and loss of weight. IFPs arising below the Treitz ligament can present with an acute abdomen, usually due to intussusceptions. Abdominal computed tomography is currently considered the most sensitive radiological method to show the polyp or to confirm intussusceptions. Most inflammatory fibroid polyps can be removed by endoscopy. Surgery is rarely needed. Exploratory laparoscopy or laparotomy is frequently recommended as the best treatment for intussusceptions caused by IFP. The operation should be performed as early as possible in order to prevent the intussusceptions from leading to ischemia, necrosis and subsequent perforation of the invaginated bowel segment. This report aims at reviewing the diagnosis, etiology, genetics, clinical presentation, endoscopy, radiology, and best treatment of IFP.

Risk factors for recurrence of intussusception in pediatric patients: A retrospective study

OBJECTIVES

The aim of this study was to explore the risk factors associated with recurrence of intussusception after operative or nonoperative reduction in children.

METHODS

Between January 2004 and December 2012, patients with intussusception treated with nonoperative and operative reduction were retrospectively analyzed. We included the patients who were diagnosed with intussusception from the age of 0 year to 18 years who received nonoperative and operative reduction as an initial treatment. The data collected included demographic data (sex, age, and bodyweight), symptoms (vomiting, abdominal pain, rectal bleeding, diarrhea, distention, constipation, and duration of symptoms), signs (temperature, palpable mass, and location of the mass), investigations (ultrasound findings) and the method of reduction.

RESULTS

The risk factors for recurrence of idiopathic intussusception were analyzed by the univariable analysis and multivariable analysis. In the univariable model, the significant risk factors for recurrence of intussusception analyzed were age, bodyweight, duration of symptoms, rectal bleeding, poor prognosis signs on ultrasound scans, location of mass, and pathological lead point. After multivariable analysis was done, we found that the significant risk factors for recurrence of intussusception were age ≥ 2 years (OR = 5.597, P = 0.044), duration of symptoms ≥48 h (OR = 91.664, P < 0.001), rectal bleeding (OR = 4.758, P = 0.009), location of mass (left over right side) (OR = 0.038, P < 0.001), pathological lead point (OR = 0.002, P < 0.001).

CONCLUSION

Our study found that age ≥ 2 years, duration of symptoms≥48 h, rectal bleeding, location of mass (left over right side) and pathological lead point were risk factors for recurrence of intussusception.

LEVEL OF EVIDENCE

Prognosis study.

TYPE OF STUDY

Retrospective study.

Rapunzel syndrome: The unsuspected culprit

Trichobezoar is a rare intriguing disorder in which swallowed hairs accumulates in the stomach. Being indigestible and slippery, it could not be propulsed and becomes entrapped within the stomach. Large amounts can thus accumulate over the years forming a hair ball. Rapunzel syndrome is a variant where hair accumulation reaches the small gut and beyond in some cases. Although the syndrome has been known for many years, only 24 cases have been reported in the literature and the discovery of a new case is always surprising. In this report, we present two cases discovered within a period of three months. One of them was pregnant and had small bowel intussusception and perforation, a very rare combination. We hereby add two more cases to the literature. To our knowledge, this is the first report on two cases of Rapunzel syndrome, the diagnosis of which demands a high index of suspicion.