Recurrent intussusception in children.

Twenty-eight children with 35 recurrent intussusceptions were collected and analyzed from a series of 600 intussusceptions over 17 yr. The overall recurrence rate in the entire series was 5% with 11% recurring after hydrostatic barium enema reduction, and 3% after operative reduction. Twenty-three children had one recurrence each, four children had two recurrences, and one child had four recurrent intussusceptions. More than two-thirds of the patients had a recurrence within 6 mo of their first intussusception, and half of these presented earlier and with fewer signs and symptoms than the previous attack had manifested. Twenty-one of 30 recurrences were reduced with barium enema. Sixteen were operated on, reducing nine manually and resecting four others. Only two leading points were found, and in both instances resection was required. All but two of the intussusceptions were ileocolic. The previous mode of reduction of each intussusception did not set a trend for future treatment of recurrent intussusceptions in the same child. While operative reduction diminishes the chances of a recurrent intussusception and ileocolic resection eliminates it, there does not seem to be any indication for surgery as long as barium enema reduction is successful. We have never observed the hydrostatic reduction of an intussusception caused by a leading point.     

Conservative treatment for small intestinal intussusception associated with Henoch-Schönlein's purpura

Purpose: Emergency laparotomy is generally considered the appropriate course of action for small bowel intussusception associated with Henoch-Sch?nlein's purpura (HSP). In this paper, we define a conservative approach after witnessing spontaneous reduction of ileoileal invagination at laparotomy in a patient with HSP who had been on steroid therapy for renal involvement. Methods: HSP was diagnosed by the appearance of a purpuric rash without thrombocytopenia. Intussusception was diagnosed by ultrasonography (USG) and plain abdominographs, which showed signs of obstruction, and clinical examination. Barium enema was used to treat ileocolic intussusceptions, and conservative therapy, consisting of nasogastric drainage, steroids, and intravenous fluid administration, was used to treat ileoileal intussusceptions. Emergency laparotomy was performed for the patients unresponsive to therapy within 24 h, those with peritonitis, and those with ileocolic invagination not able to be reduced by barium enema. Results: Six children with an ileoileal intussusception and one with an ileocecal intussusception were studied. The average age was 6 years old. Apart from the initial patient in whom spontaneous reduction was seen at laparotomy, three others required emergency laparotomy; for ileocolic intussusception unable to be reduced by barium enema in one, for ileoileal invagination with peritonitis on admission in one, and for ileoileal intussusception unresponsive to conservative therapy in one. The other three patients were successfully treated by conservative therapy. Conclusion: Conservative therapy is feasible for HSP patients with small bowel intussusception as long as the time of onset is known, an ultrasonographic and X-ray diagnosis is confirmed, emergency operating facilities are available, and an experienced pediatric surgical team follows up the patients. Received: December 7, 2001 / Accepted: July 2, 2002 Reprint requests to: K. S?nmez, 46. Sokak 28/3, Bahcelievler, 06510 Ankara, Turkey     

Intussusception due to lymphoma

Over 1,200 infants and children with an intussusception were treated at our hospital over the last 40 years and from this group, only 11 were found to have a lymphoma as a leading point for the intussusception. This number represents 17% of the 65 pathologic lesions that have caused an intussusception. Three children were under 41/2 years of age. All the children except two were chronically ill with pain for at least 1 week and usually for several months; weight loss and an abdominal mass in many instances provided the suspicion of a possible malignancy. When barium studies were done, there was almost always an ileocolic intussusception present with some obstruction. Reduction of the intussusception was accomplished with hydrostatic barium enema in 10 of the 11 patients; the one reduction, however, had a residual filling defect. Surgery confirmed the above findings and a resection of the leading point lymphoma was carried out in all of the children. In spite of all forms of treatment, death followed in all but three, usually within several months. One of these three survivors was treated with radiotherapy and steroids (after surgical excision) and is alive after 30 years; the second was also given chemotherapy and is alive and well after 6 years, and the third has not had radiotherapy and is alive after 10 months.     

Intussusception in the 1970s: Indications for operation

Eighty-one patients with proven intussusception were treated at the Cincinnati Children's Hospital from 1970–1974. One died. Seven of these had ileo-ileal intussusception, all treated surgically. Seventy-four had colonic components of their intussusceptions. In 58 of these patients (78%), reduction was attempted at barium enema, successfully in 32. Hydrostatic reduction was abandoned and the patient operated upon when the intussusception was not pushed out of the colon, when barium failed to reflux into several loops of ileum, or when there was a large persistent filling defect in the cecum or terminal ileum. Primary operation without barium enema was done in 16 patients. The appearance of intestinal obstruction by abdominal x-ray seemed to give the best warning about the complicated, incarcerated, or gangrenous intussusception. Primary operation is, therefore, advised for the patient with intussusception if there is x-ray evidence of intestinal obstruction. The age of the patient and the duration of his symptoms do not seem important in this regard, except as they correlate with peritonitis or obstruction. For the patient without peritonitis or intestinal obstruction, attempted reduction of the intussusception at barium enema seems safe and effective, regardless of the patient's age or duration of his symptoms.     

The use of glucagon in the diagnosis and management of illeocolic intussusception

Twenty-one of 25 episodes of ileocolic intussusception were successfully reduced by the barium enema hydrostatic technique supplemented by glucagon. No apparent serious complications occurred from the use of this drug. The comfort of the children and the ease of filling the colon and small bowel seemed enhanced by the glucagon.     

Idiopathic intussusception: the role of laparoscopy

BACKGROUND: The use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical complete reduction of the intussusception, which must be proven by adequate reflux of barium into the distal ileum. If this does not occur, it is assumed that the intussusception has not been reduced, and the infant is taken straight to the operating room for laparotomy and surgical treatment. The aim of this study is to limit unnecessary surgical explorations by the diagnostic and the therapeutic policy of laparoscopy with assisted hydrostatic saline reduction under general anesthesia. METHODS: Over a period of 3 years, 90 patients with intussusception were treated. Twenty patients in whom hydrostatic reduction was contraindicated were treated initially by surgery. In the remaining 70 patients, hydrostatic reduction was successful in 50 (71%), and laparoscopy was performed in 20 patients before laparotomy. Hydrostatic saline reduction was used when there was failure of reduction seen by laparoscopy. RESULTS: In 20 patients, laparoscopy showed reduction of intussusception in eight patients (40%), and saline hydrostatic reduction was successful in six patients (30%), with failure of reduction in six patients (30%) necessitating laparotomy. CONCLUSION: The use of laparoscopy for diagnosis of failure of reduction of intussusception and the hydrostatic reduction by saline enema during laparoscopy saved 14 patients from unnecessary laparotomy.     

Heterotopic gastric mucosa leading to recurrent intussusceptions: Report of a case

Although most cases of intussusception during childhood are caused by viral enlargement of the Peyer’s patches, the remainder of the cases may be due to congenital anomalies, such as heterotopic gastric mucosa (HGM). This report presents a case of HGM in a 4-year-old boy. The patient presented with acute abdominal signs with a right lower quadrant mass. His medical history indicated three episodes of recurrent intussusceptions. The abdominal ultrasound examination detected an intussusception. A laparotomy revealed an ileocolic intussusception and reduction was accomplished. During exploration, an intraluminal mass in the ileum, which was the lead point, was discovered by palpation. An enterotomy showed a 2-cm-diameter crater-shaped mucosal thickening. An ileal resection and anastomosis was performed. The histopathological examination revealed HGM. Heterotopic gastric mucosa is supposed to be of vitellointestinal tract origin and may cause intussusception as being a lead point in the ileum. Despite its rarity, HGM should be considered in cases of recurrent intussusceptions and diagnostic studies should be performed. A laparotomy is required for the diagnosis and treatment in complicated cases. Surgical management should include reduction of the intussusception and careful manual examination of the ileum which may expose such pathology. An intestinal resection and anastomosis is sufficient to prevent complications.     

Intussusception: barium or air?

At The Hospital For Sick Children, the use of air has recently replaced the use of barium in the reduction of intussusceptions. The purpose of this study was to review the results from 200 consecutive patients with intussusceptions, 100 patients treated with barium enema and 100 patients treated with air enema. The groups were similar with regard to sex, average and median ages, and presenting symptoms and signs. Successful reduction was achieved in 75% of episodes of intussusception treated with barium enema and 76% treated with air enema. Failure of either modality showed a high association with the presence of either a lead point or an ileoileal or ileoileocolic intussusception. Among those cases of unsuccessful reduction, operation was performed in all 59 cases; resection in 30 cases, manual reduction in 19, and spontaneous reduction was found in 10. There were three perforations during attempted reduction with barium and two with air. All perforations were treated by resection and primary anastomosis. There were 18 recurrent intussusceptions following barium enema reduction and nine following air enema reduction. Therefore, with the lower absorption of x-rays by air and the relatively inert nature of air (compared with barium in the event of a perforation), we feel that air enema is the treatment of choice in the initial management of intussusception.     

Forshal type IE appendiceal intussusception: A case report

IntroductionAppendiceal intussusception is a rare condition. Clinical features are not specific for it. Patients may present with abdominal pain and vomiting. These symptoms represent a variety of abdominal pathology. Preoperative diagnosis is difficult because of the non-specific clinical features. We present a case report of a child who initially presented with ileocolic intussusception.Case presentationThis is a case report of a 5-years-old boy with abdominal pain and vomiting. He had an ileocolic intussusception 2 days back, and was successfully managed by hydrostatic reduction and discharged. On ultrasonography, an intussusception was identified in the ileocaecal region. Hydrostatic reduction failed this time and laparotomy was performed. On laparotomy, there was complete intussusception of the appendix with normal ileocaecal junction. Appendectomy was performed. Post-operative period was uneventful.DiscussionAppendiceal intussusceptions are mostly diagnosed intra-operatively. The clinical features may mimic various other acute and chronic abdominal conditions. Type IE appendiceal intussusception, as described by Forshal, is a rare condition. Appendectomy with a rim of the caecum is the procedure of choice.ConclusionThough ileocaecal intussusceptions are common in children, appendiceal intussusceptions are rare and are usually diagnosed during the operative procedure. Radiologists and pediatric surgeons should be aware of this rare entity. Appendectomy is the treatment of choice in most of the appendiceal intussusceptions.     

Role of surgery in the era of highly successful air enema reduction of intussusception

BACKGROUND: Despite routine use of air enema reduction in childhood intussusceptions, some still require operative management. This study evaluated the role of surgery and identified factors associated with failed air enema reduction and bowel resection. METHODS: We reviewed 24 patients who underwent laparotomies for intussusception between 1 July 1999 and 31 July 2002. Demographic data, clinical presentations, investigations, surgical interventions and their outcomes were reviewed. RESULTS: Twenty-four (14.5%) of 166 patients treated for intussusceptions between 1 July 1999 and 31 July 2002 underwent laparotomies. A significant proportion (45.8%) was younger than 3 months and older than 36 months of age. Intussusception was diagnosed on ultrasonography in 21 patients. Eighteen underwent attempted air enema reduction. Ileocolic intussusceptions occurred in 54.2% of patients. Five patients had small bowel intussusceptions, all of whom required bowel resection. Seven patients (29.2%) had pathological lead points. Presence of pathological lead points and intussusceptions occurring outside the ileocolic region strongly predicted the need for bowel resection. CONCLUSION: Air enema reductions are less likely to succeed in patients less than 3 months old and those more than 3 years old. Bowel resection is most likely required when pathological lead points are present and when intussusceptions occur outside the ileocolic region. Early surgical intervention may obviate the need for bowel resection in selected patients, thereby reducing surgical morbidity.     

A simple and safe technique for pneumatic reduction of intussusception

BACKGROUND: Pneumatic reduction has a higher success rate and lower incidence of complications compared to barium enema and hydrostatic reductions. What is deterrent to its common use is the cumbersome technique. Our aim is to develop a simple technique that can be used in any hospital with locally available facilities. METHODS: An intercostal drainage bottle and an enema can were used to pass air into the rectum at a controlled pressure determined by the height of the enema can. Water running in from the enema can displaces the air in the intercostal drainage bottle into the rectum effecting the reduction of intussusception. RESULTS: This system was tried in 12 patients. Successful air delivery was obtained in all cases. In two cases, the intussusception could not be reduced. Laparotomy revealed these to be ileoileal intussusceptions. CONCLUSION: The technique described is easy to assemble, safe and effective. We recommend it for regular use in pneumatic reduction of intussusception.     

Leading points in childhood intussusception.

Children whose intussusception is caused by a specific pathologic lesion are harder to diagnose and have a higher morbidity than those with the idiopathic variety. We have collected and analyzed 31 such cases found in a series of over 500 intussusceptions. The average age of these children was greater than is usually found in most cases, and the duration of the signs and symptoms was also longer than is usually seen. Almost 50% presented with a picture of advanced small bowel obstruction. Fewer barium enemas were done (50%) and none was successful in reducing the intussusception. There was a higher number of ileo-ideal intussusceptions in this group. The commonest leading points were Meckel's diverticula, polyps, and duplications. All patients with leading points required operation; three-fourths had a bowel resection performed. This study of 569 cases suggests that older children with intussusception and children with recurrent intussusception do not necessarily have leading points causing their intussusceptions.     

Contrast enema for pediatric intussusception: is reflux into the terminal ileum necessary for complete reduction?

Purpose

Complete contrast enema reduction of intussusception is traditionally considered confirmed when contrast is seen refluxing into the terminal ileum. Operative intervention is typically indicated when the intussusception is not completely reduced. This study reviews the outcomes after symptomatic reduction of intussusception without requiring reflux of contrast into the terminal ileum.

Methods

A retrospective review of all pediatric patients treated for intussusception between 1996 and 2006 was performed. Diagnostic modality, operative reports, and hospital records were reviewed.

Results

One hundred sixty-eight patients were treated for intussusception during the study period. Median age was 9.9 months (59 days to 16.7 years). One hundred thirty-seven (81.5%) patients underwent contrast enema as the initial diagnostic/therapeutic modality. On contrast enema, 15 (10.9%) patients demonstrated reduction of the intussusception but without contrast refluxing into the terminal ileum. All 15 patients had improvement of symptoms. Six (40%) patients underwent operative intervention and were found to have a completely reduced intussusception. Two (13.3%) patients had repeat contrast enema the next day confirming complete reduction. The remaining 7 (46.7%) patients were observed without further radiographic studies, and all 7 patients were discharged the following day tolerating full feedings. There were no recurrent intussusceptions.

Conclusion

Nonoperative management may be used in patients with reduced intussusception despite lack of contrast refluxing into the terminal ileum if symptoms resolve.     

The incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception in children: A retrospective analysis

Background

There is a lack of studies addressing the occurrence of negative intraoperative findings (that is the absence of intussusception) after an unsuccessful hydrostatic reduction of an ileocolic intussusception. The aim of this study is to determine the incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception.

Failure of enema reduction for ileocolic intussusception at a referring hospital does not preclude repeat attempts at a children's hospital

Background

Some children with intussusception undergo attempted enema reduction at a hospital without pediatric radiology expertise and are transferred to a children's hospital (CH) if this is unsuccessful. We sought to determine whether a failed reduction (FR) at a referring hospital predicted failure of repeated attempts by a pediatric radiologist at a CH.

Methods

A retrospective review of all children with ileocolic intussusception admitted to a large CH over 9 years was performed. Differences in outcome between those who initially presented to the CH and those who had a FR elsewhere before transfer (FR → CH) were assessed.

Results

A total of 152 subjects were identified. There was no difference in the frequency of successful enema reduction at the CH for those who initially presented at the CH (60.5%) and those who were transferred after a FR elsewhere (60.7%). The only predictor of successful reduction was anatomy, whereby 64% of intussusceptions proximal to the splenic flexure were reduced, but only 35% of those distal to that point (P < .01).

Conclusions

Children who are transferred to a CH after failed enema reduction elsewhere should undergo a repeat hydrostatic or pneumatic enema reduction in the absence of other contraindications.     

Early laparoscopy for ileocolic intussusception with multiple recurrences in children

Background  The risks of subsequent episodes and a lead point are common problems in ileocolic intussusception with more than two recurrences. To decrease subsequent recurrence and to detect a lead point, an early laparoscopy was performed for children with ileocolic intussusception. Methods  This study enrolled six children with multiple recurrences of ileocolic intussusception from January 2004 to August 2007. Using a 5-mm laparoscope and two additional transabdominal wall stab incisions, an appendectomy and an ileocolonic pixie with nonabsorbable sutures were performed simultaneously for all the children after the last successful hydrostatic reduction. Results  The mean operating time was 68.8 ± 12.6 min (range, 55–86 min). There was no operative morbidity, and no lead point was found in any child. The mean follow-up period was 10.8 ± 6.7 months (range, 2–20 months). No recurrence was observed during this period. Conclusion  The authors suggest that early intervention should be undertaken for ileocolic intussusception with multiple recurrences in children after the last nonsurgical reduction has been attempted successfully. Under this strategy, laparoscopy is an acceptable approach. It allows differentiation of a specific etiologic lesion, the possibility of incomplete reduction, and additional proximal invaginations. Later complications, such as repeat recurrence and associated surgical morbidity, also can be avoided.     

General anaesthesia may improve the success rate of hydrostatic reductions of intussusception

Intussusception is the most common cause of intestinal obstruction in young children. Hydrostatic enemas result in a successful reduction of intussusception in 50% to 80% of patients. Failure to achieve reduction with hydrostatic enema results in laparotomy, although a frequent finding upon exploration is complete reduction of the intussusception, presumably due to induction of general anaesthesia. Recent paediatric literature suggests that induction of general anaesthesia may improve the success rate of therapeutic hydrostatic enema. We report a difficult case of recurrent intussusception where the induction of general anaesthesia alone did not result in reduction of intussusception, but successful reduction by enema was achieved while the patient was anaesthetized.     

Management of intussusception in children: A systematic review

ObjectiveThe 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.MethodsThe 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.ResultsA 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.ConclusionsRegarding 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 EvidenceLevel 3–5 (mainly level 3–4)Type of studySystematic Review of level 1–4 studies     

Laparoscopic management of delayed recurrent intussusception in an older child.

BACKGROUND: Intussusception is the most common cause of bowel obstruction in infants and children. Although early recurrence is not uncommon, recurrence years later is rare. METHODS: A 13-year-old male with a history of recurrent intussusception at ages 2 and 5 presented with recurrent intussusception 8 years later. The diagnosis was made using computed tomography, and the patient underwent a laparoscopic ileocecectomy with an uneventful postoperative course. RESULTS: The specimen was remarkable for findings of multiple enlarged lymph nodes over the serosal surface of the ileum and the terminal ileum with focal edema, prominent lymphoid hyperplasia and large hemorrhagic areas. CONCLUSION: This case highlights the fact that in a child with a delayed recurrence of intussusception, the presence of a lead point should be suspected, and operative therapy should be strongly considered over hydrostatic reduction. The current management of recurrent intussusception is reviewed and applied to this case.     

Conservative treatment of intestinal invagination in children

A new method of the conservative treatment of intussusceptions in children by hydrostatic disinvagination with the help of barium enema is described. The durability of the colon was shown to change proportionally to its tone. To make the conservative treatment more efficient and to prevent a perforation of the colon the hydrostatic pressure should depend on the colon tone. Out of 48 patients with acute intestinal invagination 46 children were cured by this method including 2 children with small intestine invagination. In this group of patients there were neither complications nor lethal outcomes.