Transient small-bowel intussusception in children on CT

OBJECTIVE: To determine the frequency and significance of small-bowel intussusception identified in children on CT. MATERIALS AND METHODS: All abdomen CT reports between July 1995 and April 2002 were reviewed to identify patients with small-bowel intussusception. Intussusceptions were identified as an intraluminal mass with a characteristic layered appearance and/or continuity with adjacent mesenteric fat. Ileocolic intussusceptions and intussusceptions related to feeding tubes were excluded. Imaging studies and medical records were reviewed. RESULTS: Twenty-five pediatric patients (16 boys, 9 girls; mean age 11.2 years) were identified with small-bowel intussusception on CT. No patient had a persistent intussusception requiring surgery. Fourteen had limited immediate repeat CT images as part of the same examination, ten of which demonstrated resolution of the CT abnormality. Follow-up CT [ n=13 (6 within 24 h)], ultrasound ( n=3), small-bowel follow-through ( n=4) and surgery ( n=3) showed no intussusception. In four patients with persistent symptoms, underlying pathology was identified requiring treatment (giardiasis, 2; small-bowel inflammation/strictures, 1; abscess and partial small-bowel obstruction after perforated appendicitis, 1). In 21 other patients, direct correlation of symptoms to CT abnormality was absent or questionable, no treatment was required, and there was no clinical or imaging evidence of persistence or recurrence. CONCLUSION: Most small-bowel intussusceptions identified in children by CT are transient and of no clinical significance.     

小儿剖腹手术后粘连性肠梗阻99例分析

目的 探讨小儿剖腹术后粘连性肠梗阻的发生原因与防范措施.方法 回顾性分析我院小儿外科近10年来收治的99例剖腹术后粘连性肠梗阻患儿的病例资料.结果 剖腹术后粘连性肠梗阻99例(占同期收治小儿肠梗阻病人总数的32.25%),其中,62例为本院小儿外科剖腹术后发生的粘连性肠梗阻(占同期剖腹手术总数的5.72%).引起粘连的原发病前3位依次为先天性巨结肠、肠套叠、阑尾炎.65例采取手术治疗,34例采取保守治疗,两组出院后肠粘连复发情况比较,差异无统计学意义(P＞0.05).结论 小儿剖腹术后腹膜粘连在临床中并不少见,预防研究应进一步深入,严格遵守手术操作规范,并积极开展腹腔镜等微创手术.     

婴儿阑尾盲肠多重套叠并急性阑尾炎一例并文献复习

目的 探讨婴儿期阑尾盲肠多重套叠并急性阑尾炎的临床病理和诊治方法.方法 回顾性分析1例阑尾盲肠多重套叠并急性阑尾炎8月龄婴儿的临床资料,并通过PubMed、ProQuest、中国知网(CNKI)、万方和维普数据库中检索2016年5月前的报道并复习相关文献资料,对各类儿童阑尾套叠进行系统性综述.结果 本例阑尾盲肠多重套叠并急性阑尾炎经手术诊断,整复套叠后切除阑尾并经病理证实,术后顺利康复.共检索到215例阑尾套叠中儿童52例,阑尾盲肠套叠136例,仅3例阑尾自身套叠中有2例为儿童;检索到肠套叠并阑尾炎66例,儿童59例,其中小于1岁的患儿27例,回结型肠套叠43例,此外,检索到回肠盲肠型套叠7例和盲肠盲肠型套叠并阑尾炎1例均为成人患者,所有病例均行手术治疗而痊愈.儿童阑尾盲肠多重套叠并急性阑尾炎者未见报道.结论 婴儿阑尾盲肠多重套叠并急性阑尾炎罕见,如套叠未导致回盲瓣排空完全梗阻则无典型症状体征,诊断困难,易误、漏诊.因此,对经保守治疗不能解除肠梗阻且不能解释其原因时,只要B型超声提示“同心圆征”或“套筒征”就应果断行手术探查以明确诊断并及时治疗.     

Use of ultrasound in diagnosing postoperative small-bowel intussusception in pediatric surgical oncology patients: a single-center retrospective review

Background

Postoperative intussusception can be a complication of abdominal surgery and often poses a diagnostic dilemma.

Objective

The purpose of this study was to evaluate the utility of ultrasonography in the diagnosis of intussusception in children who had recently undergone resection of a primary solid tumor.

Materials and methods

We performed a retrospective review of all pediatric surgical oncology patients undergoing laparotomy for excision of an abdominal tumor at our institution from 1995 to 2015. We reviewed those with documented postoperative intussusception. In addition we searched the radiology database for all ultrasound examinations requested to rule out postoperative intussusception during our study interval. We analyzed demographics, primary diagnosis, surgical procedure, presentation, diagnostic investigations and definitive treatment.

Results

At our institution 852 laparotomies for abdominal tumor resection were performed during the study period, resulting in 10 postoperative intussusceptions (1.2% of cases), of which half were following neuroblastoma resection and the other half following nephrectomy for Wilms tumor. Postoperative intussusception was suspected if the patient had increasing nasogastric output, abdominal distension or feeding intolerance. Ultrasound was used to diagnose intussusception in 9/10 cases, on postoperative day 6 (standard deviation [SD] 5.6 days) on average, with a sensitivity of 89% (8/9; one false negative; 95% confidence interval [CI] 0.52, 1.00) and a specificity of 100% (no false positives; 95% CI 0.96, 1.00).

Conclusion

Ultrasound was highly accurate in diagnosing postoperative intussusception in children who underwent resection of retroperitoneal tumors.

     

Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception

Background

The contemporary management of children with ileocolic intussusception often includes pneumatic reduction. While failure of the procedure or recurrence after reduction can result in the need for surgical treatment, more serious adverse sequelae can occur including perforation and, rarely, tension pneumoperitoneum. During the last year, four cases of perforation during attempted pneumatic reductions complicated by tense pneumoperitoneum have occurred in our center.

Objective

We have elected to report our patient experience, describe methods of management and review available literature on this uncommon but serious complication.

Materials and methods

Using ICD-9 diagnosis codes, we reviewed the records of children with intussusception during 2011. Demographic and therapeutic clinical data were collected and summarized.

Results

During the study period, 101 children with intussusception were treated at our institution, with 19% (19/101) of them requiring surgical intervention. Four children (4%) experienced a tense pneumoperitoneum during air enema reduction, prompting urgent needle decompression in the fluoroscopy suite. These children required bowel resection during subsequent laparotomy. No deaths occurred.

Conclusion

Pneumoperitoneum is a real and life-threatening complication of pneumatic enemas. It requires immediate intervention and definitive surgical management. Caution should be exercised by practitioners performing this procedure at institutions where pediatric radiology experience is limited and immediate pediatric surgical support is not available.     

Intussusception--the forgotten postoperative obstruction.

Ten children developed intussusception after laparotomy. The bowel obstruction caused by the intussusception was evident within 8 days of major laparotomy in 8 children and within 39 days in the other two. It developed after the usual postoperative laparotomy ileus, and did not respond to normal non-operative treatment not even to a barium enema. There was one palpable abdominal mass and no rectal bleeding. Only at surgery was the correct diagnosis made. Eight of 10 intussusceptions affected only the small-bowel; most of them were ileoileal, but 2 were ileocolic. Seven of the 10 intussusceptions needed only manual reduction. Postoperative recovery was uneventful.     

Small-bowel intussusception around a gastrojejunostomy tube resulting in ischemic necrosis of the intestine

Gastrojejunostomy (GJ) tube feeding has made a significant difference in the lives of children with oropharyngeal motor problems and severe gastroesophageal reflux disease. It may, however, also lead to small-bowel intussusception. Previously, these intussusceptions have been reported as intermittent, self limiting, and innocuous. We report a case of a GJ-tube-related small-bowel intussusception that resulted in ischemic necrosis of the bowel. This case suggests that close monitoring and confirmation of successful reduction is necessary in the treatment of GJ-tube-related small-bowel intussusception.     

Ileoileal intussusception caused by a Ewing sarcoma tumour. An unusual case report.

Intussusception typically occurs in childhood, presenting with a well-known medical history and clinical symptoms. Pathologically, a "leading point" may be attributed to lymphadenomatosis, polyps, or a tumour. In older patients and adolescents, the diagnosis can be complicated due to the lower incidence and variable subacute symptoms. We report on an 18-year-old patient with increasing abdominal discomfort over several weeks. External diagnostics showed no pathological signs or were misinterpreted as a malfunction of intestinal motility. The patient experienced increasing colics, recurrent vomiting, dehydration and weight loss. Finally he was transferred to our paediatric surgical department and laparotomy had to be performed for the clinical and radiological signs of an ileus. An ileoilealic intussusception was found, caused by a small bowel tumour, which almost completely obstructed the intestinal lumen. It was resected and bowel continuity was re-established. Histopathology revealed a very rare, highly malignant mesenchymal Ewing sarcoma, infiltrating the complete bowel wall. After the postoperative course, the patient was transferred to our oncological department for chemotherapy. In older children or young adults, intestinal malignancies are extremely rare. Nevertheless, if these patients suffer from unspecific complaints of chronic intestinal obstruction, a tumour must be ruled out. A Ewing sarcoma may be responsible for an intussusception.     

6例小儿肠道多发憩室、肠重复畸形的诊治分析

目的 探讨小儿肠道多发憩室 、肠重复畸形的临床特点 、诊断及治疗方法 .方法 收集湖南省儿童医院2010年1月1日至2018年12月30日收治的梅克尔憩室、肠重复畸形患者546例作为研究对象,其中6例为肠道多发憩室、憩室合并肠重复畸形,对该6例患者的临床资料、辅助检查、治疗经过进行回顾性分析.结果 6例患者以消化道出血...     

Management and surgical treatment for focal nodular hyperplasia in children

Focal nodular hyperplasia (FNH) is rare in pediatric liver tumor. To investigate the experience in the appropriate management of pediatric FNH, the records of consecutive children who were managed at our institute from 2000 to 2007were reviewed for FNH. There were four males and nine females whose ages ranged from 26 months to 18 years with a mean of 11.7 years. FNH in most children was detected by medical examination for abdominal pain (61.5%) or other symptoms. All the 13 pediatric patients underwent liver resection. There was no operative death or postoperative complications. The children were regularly followed up ranging from 2 to 85 months and they were healthy without recurrence. For pediatric FNH patients with clinical symptoms or indefinite diagnosis, it is suggested that active surgical treatment by hepatectomy should be performed.     

2037例小儿急性肠套叠的诊治体会

目的 对小儿急性肠套叠病例的临床特点、诊断和空气灌肠治疗方法进行探讨。方法 分析总结2037例小儿急性肠套叠的临床表现和X线下空气灌肠复位的诊治效果。结果 2037例均以肠套叠四大症状(阵发性哭闹、呕吐、血便和腹部包块)中两个或以上为主要表现,X线监视下低压空气灌肠诊断、空气灌肠治疗和手法推挤按摩整复成功1972例,成功率为96．8％,未复位65例(占3．2％)。穿孔2例(占0．98‰)。结论 早期正确诊断、空气灌肠及手法按摩整复治疗明显提高小儿急性肠套叠整复率;空气灌肠是肠套叠诊疗的首选方法。     

Clinical case definition for the diagnosis of acute intussusception

OBJECTIVE: Because of the reported association between intussusception and a rotavirus vaccine, future clinical trials of rotavirus vaccines will need to include intussusception surveillance in the evaluation of vaccine safety. The aim of this study is to develop and validate a clinical case definition for the diagnosis of acute intussusception. METHODS: A clinical case definition for the diagnosis of acute intussusception was developed by analysis of an extensive literature review that defined the clinical presentation of intussusception in 70 developed and developing countries. The clinical case definition was then assessed for sensitivity and specificity using a retrospective chart review of hospital admissions. Sensitivity of the clinical case definition was assessed in children diagnosed with intussusception over a 6.5-year period. Specificity was assessed in patients aged <2 years admitted with bowel obstruction and in patients aged <19 years presenting with symptoms that may occur in intussusception. RESULTS: The clinical case definition accurately identified 185 of 191 assessable cases as "probable" intussusception and six cases as "possible" intussusception (sensitivity, 97%). No case of radiologic or surgically proven intussusception failed to be identified by the clinical case definition. The specificity of the definition in correctly identifying patients who did not have intussusception ranged from 87% to 91%. CONCLUSIONS: The clinical case definition for intussusception may assist in the prompt identification of patients with intussusception and may provide an important tool for the future trials of enteric vaccines.     

Postoperative intussusception in childhood

Over a period of 10 years, five children developed postoperative intussusception after intra-abdominal procedures at the Department of Pediatric Surgery of the Johannes Gutenberg University Mainz. Two appendectomies, one ileal resection for a Meckel's diverticulum, one operative procedure for Hirschsprung's disease plus intestinal neuronal dysplasia type B, and one hiatoplasty with jejunostomy preceded the intussusception. Three of the five children were older than 2 years. The clinical symptoms consisted primarily of abdominal distension, diffuse abdominal pain, bilious vomiting, and rectal bleeding in one case. Preoperative diagnosis was achieved in four cases by abdominal ultrasound. Plain abdominal radiographs demonstrated dilated loops of small intestine with air-fluid levels in four of the five cases. In the case without radiographic findings, the jejunojejunal intussusception was missed even by a bowel follow-through. The intussusceptions were ileocolic (3), ileoileal (1), and jejunojejunal (1). A hydrostatic procedure to reduce an ileocolic intussusception was not successful. Operative treatment of the intussusception was performed in three cases within 5 days, once at 32 days, and once 3 months after the primary operation, in all cases by laparatomy and simple manual reduction without intestinal resection. In contrast to idiopathic intussusception, noninvasive hydrostatic procedures are not indicated in postoperative intussusception, since protection of intestinal anastomoses from hydrostatic pressure and exclusion of other causes of postoperative ileus are mandatory.     

小儿胃重复畸形的诊治

目的 探讨小儿胃重复畸形在临床表现、诊断及治疗上的特点,以期减少误诊,提高诊治水平.方法 回顾分析2010年3月至2015年3月我院收治的4例胃重复畸形患儿诊治过程.其中女3例,男1例.年龄9个月至11岁,术前B型超声或CT检查均发现上腹部囊性肿块,但不能明确肿块来源,经腹腔镜探查及开腹探查术中确诊.不同类型胃重复畸形可行不同方式切除.结果 腹腔镜辅助脐孔拖出切除2例,完全腹腔镜下切除1例,中转开腹手术切除1例.手术顺利,术后无并发症出现,分别随访1个月、1年、2年、3年,术前症状完全消失,恢复良好.结论 小儿胃重复畸形较为少见,无特异性临床表现.腹部B型超声及CT易于发现病变,常为上腹部囊性肿块,但难以分辨病变的来源,常误诊为胰腺囊肿、肠重复畸形等病变.外科手术探查是诊断胃重复畸形的有效手段,不复杂的囊状胃重复畸形可选择腹腔镜辅助或单纯腹腔镜切除,单纯重复畸形体切除能达到较好治疗效果.     

Infants with radiologic diagnosis of gastric volvulus: are they over-treated?

Gastric volvulus (GV) is a rare condition in infants. The aim of this study was to define the management strategies of infants with GV based on their clinical and radiologic features. The medical records of 13 infants with a radiologically confirmed diagnosis of GV were retrospectively reviewed. Patients were divided into two groups according to the type of treatment (surgical vs conservative). Abdominal radiographs and upper gastrointestinal contrast studies allowed an unequivocal diagnosis in both groups. Group 1 included 3 infants with acute GV and 2 with chronic, intermittent secondary GV. Three patients had associated diaphragmatic defects, 1 had an ileocolic intussusception, and 1 had hypertrophic pyloric stenosis. The main presenting symptoms were vomiting, dehydration, respiratory distress, and abdominal pain and distention in acute cases and vomiting and failure to thrive in chronic cases. A laparotomy was required in all 5 infants with no recurrence of symptoms. Group 2 included 8 infants with idiopathic chronic GV, who were managed nonoperatively with gradual improvement of symptoms over 12 months. Based on our study, we conclude that: (1) laparotomy can be reserved for patients with either acute or chronic secondary GV; (2) conservative treatment is both safe and effective in infants with chronic idiopathic GV; and (3) routine gastropexy for all patients with a radiologic diagnosis of GV appears to be overtreatment. Accepted: 6 November 2000     

Hereditary angioedema causing colocolic intussusception]

Hereditary angioedema is a rare, autosomal dominant disease inherited. The cause is a quantitative or qualitative congenital deficit in C1 inhibitor. Various clinical symptoms, in particular of sub-cutaneous, upper airways and digestive origin, have been described. Life threatening conditions may be observed. Little information is available on digestive tract localization corresponding to intestinal intussusception associated with hereditary angioedema in children. We report a case of hereditary angioedema observed in a 15-years-old girl who presented such features. We propose a review of the literature and discuss the curative treatment of digestive crisis in children with hereditary angioedema.     

小儿肠套叠合并肠坏死的超声表现及诊断价值

目的：肠套叠合并肠坏死是空气灌肠复位的绝对禁忌症,目前对小儿肠套叠合并肠坏死的超声检查表现及特点报道较少,该研究重点探讨其超声表现,及时指导临床医生正确选择复位方式。方法：回顾性分析2004~2006年手术复位的48例肠套叠合并肠坏死病例的超声图文资料。结果：①肠套叠的类型与肠坏死密切相关,回回结型最易导致肠坏死;②套叠部肠壁明显增厚,套叠中心部常伴有肿大的淋巴结、肿大的阑尾;③肠套叠内积液、套叠远端肠管扩张伴肠壁增厚、肠蠕动减弱或消失是肠壁大片坏死的表现;④继发性肠套叠也是导致肠坏死的一个重要因素,部分可探及原发病灶的声像;⑤腹腔积液是所有肠套叠伴肠坏死的共同表现。结论：当肠套叠伴肠坏死时有一些较为明显的声像图特征,可间接提示肠坏死的可能,掌握这些超声表现能及时指导临床医生正确选择复位方式。     

Intussusception in a premature neonate: A rare and often misdiagnosed clinical entity

Intussusception is a very rare cause of intestinal obstruction in neonates. It is of extremely rare occurrence among premature neonates. We present a case of 11-day-old premature neonate who presented with abdominal distension, intolerance to feeds, vomiting, significant bilious aspirate and bleeding per rectum. The initial diagnosis of necrotizing enterocolitis (NEC) led to a delay in the diagnosis. On exploratory laparotomy, it turned out to be a case of ileo-colic intussusception with Meckel''s diverticulum as a lead point. This site of intussusception (ileo-colic) and presence of a lead point among premature neonate is of exceedingly rare occurrence and very few such cases have been reported.In this article, the published work about clinical features and management on intussusceptions in premature neonates has been reviewed. The authors intend to highlight the difficulty in distinguishing the NEC and intussusception. Subtle clinical and radiological features which can help in differentiating the two conditions have been emphasized. This can avoid the delay in diagnosis and management which can prove critical. High index of suspicion with timely intervention is the key for optimizing outcome. A diagnosis of intussusception should always be considered in any preterm infant with suspected NEC.     

Unusual cases of neuronal intestinal dysplasia

Six children with isolated neuronal intestinal dysplasia (NID) and unusual complications are presented. Three had meconium peritonitis, one of them in association with a solid pyloric atresia, one midgut volvulus, one rectal stenosis, and one jejunojejunal intussusception. These cases show that patients with isolated NID may present with a heterologous pattern of symptoms very different from those generally reported, indicating that NID may not be a distinct clinical entity. The symptomatology of NID seems to be directly correlated with the degree of functional defect of gut motility. NID should be suspected in any case of functional small-bowel obstruction. Offprint requests to: P. Sacher     

Influenza A-associated rhabdomyolysis with acute renal failure

Rhabdomyolysis induced acute renal failure as a rare complication of influenza A infection has been mainly described in adults. Consideration of this potentially life-threatening complication in pediatric patients presenting with influenza is important as clinical symptoms may be unspecific and early diagnosis leading to prompt treatment is essential to decrease associated morbidity and mortality. We report a 9 year old girl who developed severe rhabdomyolysis with myoglobinuric renal failure associated with influenza A virus infection. Receiving supportive therapy including intensive care management the patient recovered renal function completely.