Intussusception: evolution of current management

The records of 583 children who were treated for intussusception at the Children's Hospital of Buffalo in the period 1930-1985 were reviewed. Following a change in management in 1970 from operative treatment to hydrostatic reduction of the intussusception by barium enema, two main groups are defined. In earlier years 95% of patients underwent operative reduction whereas in the latter period 92% had barium reduction attempted. The remaining 8% in this group had clinical contraindications for hydrostatic enema attempt. Ten percent had pathological lead points. Recurrent intussusception occurred in 50 cases (8.5%), 66% following barium enema reduction and 33% after surgery. The mortality in the earlier group was 3.9% and 1.3% in the latter group. No deaths occurred in patients treated successfully with barium enema reduction, and there were no deaths in the children with simple uncomplicated intussusception requiring surgery.     

Is barium enema reduction safe and effective in patients with a long duration of intussusception?

The aim of this study was to determine whether barium enema reduction (BER) is safe and effective in patients with a long duration of intussusception. Over the last 17 years, 104 patients were admitted to our hospital with a diagnosis of intussusception. All except 1 with peritonitis underwent BER primarily. Of the 103 intussusceptions treated primarily by BER, 84 (82%) were reduced by the enema alone, whereas 19 (18%) underwent surgical reduction. There were no differences in mean duration of disease between the patients with successful and failed enema reduction (successful: 15 ± 14 h; failures: 14 ± 11 h, P = 0.6). The success rate of BER was 85% within 12 h of symptoms, 76% for 12–24 h, and 71% for more than 24 h. Of 8 cases with a second trial, 4 (50%) were reduced by repeated barium enema. There were no deaths and no intestinal perforations. The success rate of more than 70% even in patients with a long duration of intussusception suggests that BER is safe and effective regardless of the duration of the disease. Accepted: 4 September 1998     

Intussusception in children of school age

BACKGROUND: There are only a few reports discussing the characteristics of intussusception developing in school-age children. The characteristics of these cases are discussed, with reference to previous literature. METHODS: The present study included eight cases of intussusception in school-age children among 143 intussusception patients treated on an inpatient basis at Nihon University Itabashi Hospital, during the 11 year period from 1993 to 2003. The remaining 135 patients were assigned to the infant group as controls. The clinical characteristics of intussusception in school-age children were compared with those of the condition developing in infants. RESULTS: The eight children of school age with intussusception ranged in age from 8 to 15 years (mean, 11.6 years), and consisted of five boys and three girls. The major symptom was abdominal pain, occurring in 100% (8/8). Bloody stools and vomiting were reported in two patients each (25%) from this group. The triad of abdominal pain, bloody stools and vomiting was recognized in only one child (12.5%) of this group. Two children (25.0%) had a palpable abdominal mass, and one child (12.5%) complained of diarrhea. None of the school-age children with intussusception had any antecedent infection; five, two and one patients had the ileo-colic type, ileo-ileo-colic type and ileo-ileal type of intussusception, respectively. Four underwent enema reduction and four underwent surgical reduction. One of the eight children (12.5%) had underlying organic abnormality; in the remaining children the condition was labeled idiopathic. One child developed recurrences. CONCLUSIONS: In school-age children intussusception is generally believed to be commonly secondary to underlying organic abnormality, but in the present study only one of eight school-age children had underlying organic abnormality; in the remaining children, the condition was labeled idiopathic. The major symptom in school-age intussusception was abdominal pain. Therefore this may need to be differentiated from appendicitis in children of school age. It is considered that abdominal ultrasonography (USG) is a simple and useful method for making the diagnosis of intussusception, and that diagnostic USG should be conducted in all school-age children presenting with acute abdominal pain.     

Air reduction of intussusception.

AIM: To show that intussusception in children is reducible in most cases, using air. METHODS: Initially we used a barium enema to treat paediatric intussusception. Now we use an air enema. We consider the latter reduction technique to be the method of choice in the treatment of intussusception in childhood. RESULTS: Over a period of 21 years, we have treated 151 patients presenting with intussusception. In a group of 130 children treated with barium enema we managed to reduce the intussusception in 110 cases (84.6 %). We used air pressure to treat a second group of 21 children; the success rate in this group was 100 %. CONCLUSIONS: In order to avoid a surgical operation this technique must become more generally known. We are of the opinion that if the method is applied correctly, it is almost always possible to correct intussusception using air.     

某市级医院儿童急性肠套叠流行病学特征及分析

目的通过分析珠海市10年间儿童急性肠套叠病例,探讨儿童急性肠套叠的流行病学特点及一般规律,为预防、诊断和治疗提供理论依据。方法对2004——2013年本院收治的儿童肠套叠病例进行回顾性研究,并结合珠海地区的气候、卫生条件等对患儿的临床资料、治疗方法、治疗效果、复发特点进行分析。结果 10年间本院共收治儿童肠套叠患儿1 045例,其中男性706例,女性339例,男:女=2.08:1。生后12~4个月为发病高峰年龄。全部病例均予空气灌肠治疗,获成功829例,需手术治疗216例,空气灌肠成功率79.33%。复发133例。术中发现继发性肠套叠23例。年龄2岁以上的15例。结论珠海地区儿童肠套叠好发于秋冬季,2岁以内儿童高发。多为原发性,2岁以上患儿需警惕继发性的可能。6个月内是肠套叠空气灌肠复位成功后复发的高发期。彩超是重要的诊断手段,空气灌肠是较有效的治疗方法,也是复发性肠套叠首选的治疗手段。     

高频彩超及全控式水压复位器诊治幼儿肠套叠

目的总结彩超下水灌肠诊治急性肠套叠的经验。方法采用高频超声定位并诊断肠套叠,用彩色多谱勒显像（CDFI）确定套叠部血流动力学改变,判断是否适宜灌肠复位,并用自制全控式水压复位器于高频彩超监测下灌肠复位。同期设立临床诊断70例肠套叠患儿为对照组,经低频（3．5MHz）B超诊断、监测并分次注水灌肠复位。结果72例拟诊幼儿肠套叠病例中明确诊断68例,判断不宜灌肠3例（经手术证实为难复性肠套叠,肠缺血严重。65例以全控式水压复位器于高频彩超监测下灌肠复位全部成功。对照组70例临床诊断幼儿肠套叠病例在低频B超监测下分次注水灌肠复位治疗56例,44例成功。结论全控式水压复位器结合高频彩超治疗幼儿肠套叠较之低频B超分次注水复位法,指征更明确,治疗更安全快速,效果更好,便于基层医院推广。     

The efficiency and limitations of barium enema in the treatment of intussusception in infancy and childhood

Sixty-one children with intussusception were treated during a period of 7 years. A barium enema was routinely performed for diagnosis and treatment unless signs of gangrenous bowel were present. Hydrostatic reduction was successful in 50% of attempts in the idiopathic cases. There were no complications from this procedure and no recurrence of intussusception. At surgery the intussusception was found to be reduced in 6 of 32 patients; 19 underwent operative reduction; and resection was performed in 7. A higher failure rate of hydrostatic reduction was associated with older patient age, longer duration of symptoms, and the presence of a pathological leading point.     

Intussusception in children: 11-year experience in Vladivostok

Idiopathic intussusception is an important abdominal emergency in infancy and childhood. The nonoperative management by air enema has always been the standard of care in Russia. Our purpose is to assess our reduction rate and the rate of complications. We performed a retrospective analysis of all intussusception cases seen at the Department of Paediatric Surgery from 1994 to 2005. The data obtained included age, sex, clinical presentation, diagnostic procedures, mode of treatment, and results. Patients included 280 children from 1 month to 14 years of age. Eighty-one percent of children were under age 1 year old, 61% were boys. The duration of symptoms before treatment was less than 18 h in 65%, 18–24 h in 21%, and more than 24 h in 14% of patients. The successful reduction rate was 86.1%. One patient with a duration of symptoms more than 24 h experienced colon perforation. Thirty-nine patients underwent surgery and, among these, abnormalities in the intestinal wall required resection in 12 cases. An association between the duration of symptoms and the outcome of the non-surgical treatment was present; non-surgical reduction was successful in 97.3% in the group with the duration of symptoms less than 18 h, 86.4% in 12–24 h, and 33.3% in more than 24 h. Air enema is a safe and effective approach for uncomplicated intussusception reduction with a high success rate, but the duration of symptoms directly increases the complication rate.     

Ultrasound guided hydrostatic reduction in the management of intussusception

Objective: A case series study was conducted for two years from 01 June 2002 to 01 June 2004 to study the efficiency of ultrasound guided hydrostatic reduction in the management of intussusception in children.Methods: A total of 25 patients who underwent the procedure were evaluated. All the patients were diagnosed by High Resolution Ultrasonography (HRUSG). Continuous monitoring of the progress of reduction during the procedure was done by HRUSG. 500–1000 ml (average 600 ml) of normal saline was used.Results: 24 out of 25 (96%) intussusceptions were successfully reduced. Average time taken was 15 minutes. All the patients were reviewed after 24 hrs for recurrence. None of them showed recurrence within 24 hrs. No complications were observed.Conclusion: The study concludes that ultrasound guided hydrostatic reduction is a safe, simple and effective method for treatment of intussusception in children.     

Enema reduction of intussusception with a small dose of iopamidol may have advantages over barium

Barium enema (B-enema) has been the standard method for hydrostatic reduction of intussusception, although recently air enema has been used due to the lower risk when perforation occurs. Recently, we have administered a small dose of iopamidol during enema reduction (I-enema) in children with intussusception. From November 1989 to December 1993, we treated 50 children with intussusception at Kiyama Hospital. Barium was used in the first half of the period, and iopamidol in the second half. Reduction was successful in 22 of 24 patients with barium (92%) and 23 of 26 with iopamidol (88%); 25 children had the ileocolic type and 25 the ileoileocolic (-cecal) type of intussusception. Operations were carried out in 3 patients from each group. I-enema avoids some of the drawbacks of barium and air enemas. It is a new method of enema reduction, as a contrast medium is injected first. It is possible to obtain a good image of the advanced portion with a small dose of contrast medium, which is important for treatment. For institutions performing B-enemas, I-enemas can be performed easily with the same equipment and technique. It causes less contamination upon leakage than a B-enema, and also has less influence on the intestinal membrane with very few risks if perforation occurs. Better images are obtained than with air. A large dose of contrast medium is not needed, thereby reducing medical expenses to a minimum. Iopamidol can be used safely for enema reduction of intussusception with an expected high success rate.     

Air enema for intussusception: Is predicting the outcome important?

Air enema is the treatment of choice for childhood intussusceptions. Although peritonitis is the established contraindication, studies have attempted to identify factors that affect the outcome of air enema. In our series we studied the impact of such factors on the clinical scenario to determine if it was important to predict the outcome of air enema. We retrospectively reviewed the records of 179 children who underwent air enema for intussusception at our institution over a 5-year period. Abdominal colic was present in 144 children, vomiting in 139 and rectal bleeding in 108 children. The duration of symptoms was less than 24 h in 131 children. An abdominal mass was present in 121 children, rectal prolapse of intussusception in 14, dehydration in 31 and small bowel obstruction in 27 children. The success rate of air enema was calculated. All clinical features were analyzed for impact on outcome using univariate and multivariate analysis. The extent of this impact on the clinical scenario was examined. Air enema was successful in 157 cases (89%). One child developed a perforation during the procedure (0.6%). The recurrence rate was 8%. Using χ² test, success of air enema was reduced in the presence of rectal bleeding, rectal prolapse of intussusception, dehydration, and small bowel obstruction. This reduction was statistically significant (P < 0.05). Using logistic regression analysis, the success of air enema was significantly reduced (P < 0.05) only in the presence of prolapsing rectal intussusception (57%) and small bowel obstruction (52%). Small bowel obstruction and prolapsing rectal intussusceptions merely reduce the success of air enema and do not increase the complications. Since the success of air enema is very high, it must be attempted in all children with the exception of peritonitis. Predicting the outcome is not crucial because of the high success rate and low complication rate.     

Air contrast enema reduction of single and recurrent ileocolic intussusceptions in children: patterns,management and outcomes

Background

There is no consensus as to when surgical intervention should be considered for recurrent ileocolic intussusceptions in a stable patient after previous successful air contrast enema.

Objective

To review the patterns of ileocolic intussusceptions, air contrast enema success rates, and pathologic lead point rates in patients with and without recurrence to evaluate whether treatment outcomes depend on the number and timing between episodes.

Materials and methods

We retrospectively reviewed 683 children with air contrast enema performed for ileocolic intussusception between January 2000 and May 2018. Recurrent intussusceptions were separated into mutually exclusive categories: short-term only (≤7 days between episodes) and long-term (>7 days between episodes) intussusceptions. Long-term recurrences included both long-term only and long- and short-term intussusceptions.

Results

Of the 683 patients, 606 (89%) had at least 1 successful air contrast enema. Of the 606, 115 (19%) had recurrent intussusceptions after successful reduction. The air contrast enema success rate for a single intussusception was 86% (491/568) and for recurrent intussusceptions was 96% (110/115) (P=0.004). Single and recurrent intussusceptions had similar pathologic lead point rates (3.5% vs. 4.3%; P=0.593). Short-term and long-term recurrences did not differ in air contrast enema success rates (96% vs. 95%). Long-term recurrences had higher pathologic lead point rate compared to short-term only (13% vs. 0%; P=0.003). Of short-term recurrences, 99% (76/77) were ≤5 intussusceptions; 92% had successful air contrast enema without surgery.

Conclusion

The majority of recurrent intussusceptions were successfully treated by air contrast enema. Short-term recurrences have lower pathologic lead point rates, suggesting that a higher surgical threshold may be plausible relative to long-term recurrences. In the appropriate clinical context, repeat air contrast enemas are a safe option for short-term recurrences, which can be attempted at least five times, potentially precluding the need for surgical intervention.

     

Does the length of the history influence the outcome of pneumatic reduction of intussusception in children?

Purpose  

Intussusception is the most common cause of acute abdomen in infants and preschool children. Nonoperative reduction using air enema is an established treatment in children with intussusception. The aim of this study was to determine whether length of the history influences the outcome of pneumatic reduction of intussusception in children?     

Patterns of recurrence of intussusception in children: a 17-year review

Purpose. Patterns of recurrence of intussusception (INT) were reviewed to determine whether changes in management have affected the rate and patterns of recurrence as well as long-term outcome in children with multiple (i. e., 2 or more) recurrences. Materials and methods. Review was done of 763 children with 876 intussusceptions, including (1) recurrence rate, (2) patterns of recurrence (number of and interval between recurrences), (3) reducibility, (4) pathologic lead points (PLP), (5) operative findings and (6) long-term follow-up in those with multiple recurrences. Results. Above features (1)–(6) were the same in those managed with barium enema (1979–1985) and those managed with air enema (1985–1996). Overall recurrence rate was 9 %; 11 % with barium enema and 8 % with air enema. Sixty-nine patients had 113 recurrences: 47/69 (68 %) and 1 recurrence and 22/69 (32 %) had multiple recurrences. Multiple recurrences presented as isolated episodes or in clusters up to 8 years. Reducibility was 100 % for initial INT and 95 % for recurrent episodes; there were no perforations. Surgery, in 4 with irreducible recurrence, revealed no PLP. PLP were present in 5 (8 %): 2 (4 %) with 1 recurrence and 3 (14 %) with multiple recurrences. No pattern of recurrence was predictive for PLP. Long-term follow-up (up to 15 years) available in 11 with multiple recurrences revealed a favourable outcome. Conclusions. Rates and patterns of recurrence did not change with altered management. Because of the high reduction rate of recurrences, lack of perforation and favourable long-term follow-up, we recommend radiological reduction for recurrent INT. Multiple recurrences are not a contraindication. A careful search for PLP is mandatory. Surgery should be reserved for irreducible recurrences or for demonstrated PLP. Received: 30 December 1997 Accepted: 1 May 1998     

Can intussusceptions of small bowel and colon be transient? A prospective study

We performed a prospective study to explore a diagnosis and treatment protocol of transient intussusception in children (TIC). Totally, 143 children with intussusception who met the inclusion criteria were firstly divided into intussusception involving only the small bowel and intussusception involving the colon group. And in each group, they were further divided into short-segment (≤ 3.0 cm) and long-segment (> 3.0 cm) groups according to the length of intussusception. After a period of conservative treatment, the incidence of TIC, the incidence of surgery, and recurrence were collected and analyzed. Finally, we found that the incidence of TIC in the short-segment group of small bowel intussusception (96.29%) was significantly higher than that in other groups (P ≤ 0.001). Besides, the incidence of surgery and recurrence in this group was relatively low too. Therefore, we summarized the inclusion criteria and treatments to the short-segment group of small bowel intussusception as the suggested protocol to TIC.

Conclusion: For cases of small bowel intussusception with no identified pathologic lead point, a short duration of symptoms, a length of ≤ 3.0 cm, a relatively abundant vascular flow signal, and a stable general condition, the spontaneous reduction could be expected and a period of conservative treatment with careful monitoring is recommended.

Colo-colic intussusception in Henoch-Schönlein purpura

Intussusception is the commonest surgical complication of Henoch-Schönlein purpura (HSP), occurring in 1.3%–13.6% of affected children. Colo-colic intussusception is a rare occurrence in HSP, with only three other reported cases. Intussusception in HSP almost always originates in the ileum (90%) or jejunum (7%), and more than one-half of cases (58.4%) are confined to the small bowel. This is in contrast to idiopathic intussusception, where the majority (80%–90%) are ileo-colic and can be diagnosed and reduced by contrast enema.     

Intussusception reduced by barium enema. Outcome and short-term follow-up

A retrospective study was performed of 88 consecutive cases of intussusception that occurred during a 3-year period. Forty-eight patients experienced hydrostatic reduction of intussusception with barium enema and 40 patients required surgical correction of intussusception when barium enema reduction was unsuccessful. Patients with fever or duration of symptoms greater than 24 hours, or ileo-ileocolic type of intussusception had a significantly greater rate of unsuccessful hydrostatic reduction (p less than 0.001). Of 48 cases of intussusception hydrostatically reduced by barium enema, 47 patients received repeat physical examination after reduction, 45 having normal findings. Oral feeding was tolerated in these 47 patients within 12 hours after reduction. All 41 hospitalized patients were discharged within 24 hours of reduction without developing complication; of seven non-hospitalized patients, six reported no complications during the initial 24 hour post-reduction period. The single complication that occurred was recurrence of intussusception (ileo-ileocolic type) in a patient 6 hours after initial reduction; this was the only case in which neither post-reduction physical examination nor trial of feeding had been performed. Children with intussusception hydrostatically reduced by barium enema are at low risk for complication during the subsequent 24 hour post-reduction period. When the pre-reduction course has been relatively uncomplicated, the post-reduction physical examination does not reveal abnormalities, and the patient is able to tolerate oral feeding, close outpatient monitoring appears to be safe.     

Idiopathic Intussusception Occurring in Father and Son, with a Post-operative Intussusception in the Son

Thomas, M. P. and McKay, D. G. (1979). Aust. Paediatr. J. , 15, 281–282. Idiopathic intussusception occurring in father and son, with a post-operative intussusception in the son. Idiopathic intussusception occurring in father and son is uncommon, as is the occurrence of an ileo-ileal intussusception following operative reduction of the ileo-caecal intussusception. The original ileo-caecal intussusception was treated operatively in both father and son, because of failure of attempted hydrostatic reduction. The father's post-operative convalescence was uneventful. The son developed a mechanical obstruction 36 hours after operation, due to an ileo-ileal intussusception which was easily reduced at a further laparotomy. Six weeks later he was re-admitted with a recurrent ileo-colic intussusception and this was successfully treated by hydrostatic reduction.     

Ultrasound-guided reduction of intussusception: a safe and effective method performed by pediatric surgeons

Objectives

Ultrasound has developed as the method of choice for diagnosing intussusception. Ultrasound-guided enema reduction is the standard method for treating intussusception. This retrospective study evaluates the efficacy and safety of ultrasound in diagnosis and treatment of intussusception performed solely by pediatric surgeons.

Methods

Charts were studied of all patients who were treatedfor intussusception in our unit from 2013 to 2015. Primary outcome measure was the completeness of reduction, and secondary outcome measure was the rate of complications and elapsed time until surgical treatment.

Results

We included 38 patients in this retrospective study. The mean age was 16.7 months (±15), and the female to male ratio was 1:2. Diagnosis was established by abdominal ultrasound. Thirty-five of thirty-eight patients underwent ultrasound-guided enema reduction at our institution. Three of thirty-eight patients were scheduled for immediate surgery due to signs of peritonitis or prolonged bowel obstruction. The overall rate of successful ultrasound enema reduction was 28/35 (80 %) patients. Seven of thirty-five patients underwent surgery after an unsuccessful enema reduction; 6/7 patients had a prolonged history of symptoms, and 6/7 patients had a specific pathological lead point. The length of hospitalization was less than 2 days for patients after enema reduction. Recurrence was observed in three cases (8.5 %). We did not observe any complications during enema reduction.

Conclusions

Ultrasound-guided enema reduction for intussusception is safe and effective when performed by pediatric surgeons.

     

B超引导下改良水压灌肠治疗小儿肠套叠

分析Ｂ超引导下改良水压灌肠治疗小儿肠套叠的疗效，介绍使用方法和意义。本组为１６８例小儿肠套叠，男１３０例，女３８例，全部采用Ｂ超引导下改良水压灌肠法治疗。灌肠特点是以自制密闭式手控加压灌肠器连接直径为０．６～０．８ｃｍ的肛管进行。１６８例患儿中，１５４例（９１．７％）为回结型肠套叠，１０３例病程不满４８小时。小儿的年龄为２．５月～４岁。１６１例复位成功，治愈率９５．８％（１６１／１６８）。７例非回结型套叠复位失败。我们认为，本灌肠技术简易、安全可靠。使用这种技术，监测压力方便，疗效满意。