小儿急性肠套叠细菌移位的相关研究

目的 探讨小儿急性肠套叠细菌移位及机制.方法 应用聚合酶链反应(PCR)定性检测细菌共有的16 SrRNA和大肠杆菌特异性β半乳糖苷酶基因BG;肠系膜淋巴结细菌培养;免疫组织化学方法检测组织Bcl-2、Bax的表达.结果 正常对照组全血16SrRNA、大肠杆菌BG未检出,空气灌肠复位组16SrRNA阳性率30%,BG阳性率20%;手术复位组16SrRNA阳性率50%,BG阳性率60%,肠系膜淋巴结培养阳性率为50%;肠坏死肠切除组16SrRNA阳性率60%,BG阳性率70%,肠系膜淋巴结培养阳性率为60%;与对照组相比,肠套叠手术组凋亡调控基因Bcl-2、Bax表达明显升高,Bcl-2/Bax比值变小.结论 小儿急性肠套叠应用PCR技术早期可诊断细菌移位,而肠套叠肠缺血再灌注损伤诱导Bcl-2、Bax蛋白表达,是引起肠黏膜细胞凋亡最终发生细菌移位可能的机制.     

Ileoileal intussusception in children: ultrasonographic differentiation from ileocolic intussusception

Background The treatment of ileoileal intussusception in children differs from that of ileocolic intussusception. Objective To differentiate ileoileal intussusception from ileocolic intussusception using ultrasonography. Materials and methods We reviewed the clinical and ultrasonographic findings in 27 patients with intussusception between September 2003 and July 2005. For statistical analysis the Mann-Whitney test was applied. Results Regarding ileoileal intussusceptions, 11 were documented in ten patients (seven boys, three girls; mean age 3.1 years). Symptoms suggestive of intussusception were present in nine patients. The mean diameter was 1.5 cm (range 1.1–2.5 cm) and length 2.5 cm (range 1.5–6.0 cm). The intussusceptions were located in the paraumbilical region (n=6), the right upper quadrant (n=2), the right lower quadrant (n=2), and the left lower quadrant (n=1). Regarding ileocolic intussusceptions, 16 were documented in 14 patients (13 boys, 1 girl; mean age 1.9 years). All patients had symptoms suggestive of intussusception. The mean diameter was 3.7 cm (range 3.0–5.5 cm) and mean length was 8.2 cm (range 5.0–12.5 cm). All intussusceptions were located in the right side of the abdomen. The difference in diameter and length between ileoileal and ileocolic intussusceptions was statistically significant (P<0.05). Conclusion Unlike clinical symptoms, ultrasonography can differentiate between ileoileal and ileocolic intussusception. The diameter and length of the intussusception are the main criteria.     

Recurrent ileocolic intussusception after different surgical procedures in children

Intussusception in children may recur after surgical correction. Ileopexy has popularly been used as a procedure to prevent recurrent intussusception, but its effect has not been well evaluated. The present study compared the incidence of recurrent intussusception after several different surgical procedures for intussusception in children. The charts of 278 children undergoing surgical reduction of ileocolic intussusception over 17 years were retrospectively reviewed. The incidence of recurrent intussusception was compared among the three surgical procedures: simple manual reduction, manual reduction plus ileopexy, and segmental resection. Simple manual reduction was performed in 67 (24.1%) of the 278 patients, manual reduction plus ileopexy in 186 (66.9%), and resection of the involved segment in 25 (9.0%). There were four episodes of recurrence in three (4%) patients who had had manual reduction, nine episodes in eight (4%) patients who had undergone ileopexy, and none after segmental resection. There was no statistical difference in recurrent rate among the three groups (reduction vs. ileopexy, P = 0.95; reduction vs. resection, P = 0.28; ileopexy vs. resection, P = 0.29). Ileopexy is not better than simple manual reduction in preventing recurrence of ileocolic intussusception in children.     

腹腔镜手术治疗小儿急性肠套叠82例

目的：总结腹腔镜治疗小儿急性肠套叠的临床经验。方法2008年8月至2013年5月,我们对82例急性肠套叠患儿实施腹腔镜手术治疗。在腹腔镜直视下行肠套叠整复术,对于难复性肠套叠,术中辅助空气灌肠,复位后观察套叠肠管生机,探查末端回肠1 m以上及肠系膜淋巴结肿大情况,对有肠坏死或器质性病变者,扩大脐孔提出病变肠管,行肠切除肠吻合术,在腹腔镜下切除阑尾或淋巴结活检,对合并腹股沟斜疝者同时手术。结果82例中,77例腹腔镜下复位成功,5例因发现肠坏死或套叠过紧而中转开腹手术。术中发现13例有肠管器质性病变,75例非小肠套叠者予以阑尾切除术,平均手术时间6 min,5例合并腹股沟斜疝者同时行腹腔镜下疝囊高位结扎术,平均单侧手术时间5 min,总手术时间平均为52 min。术后平均随访时间2年9个月,无一例复发。结论腹腔镜治疗小儿急性肠套叠安全可靠,可清楚探查有无肠管器质性病变,对合并腹股沟斜疝可酌情同时手术治疗,效果满意,但应严格把握手术指征,熟练掌握操作流程。     

急性肠套叠患儿术后血浆白蛋白浓度的变化及意义

目的：探讨急性肠套叠患儿术后血浆白蛋白浓度的变化及意义。方法：用全自动生化分析仪分别测定32例轻症、21例重症急性肠套叠患儿术后第1天和治疗干预后术后第5天血浆白蛋白浓度及30例正常对照儿童血浆白蛋白浓度,并将轻重肠套叠两组患儿术后第1天的血浆白蛋白浓度与小儿危重评分进行相关性分析。结果：与正常对照组比较,轻症组与重症组血浆白蛋白浓度均下降,轻症组：（34.2±6.5）g/L vs （37.1±4.1）g/L,差异有显著性(P<0.05）;重症组：（25.8±7.5）g/L vs （37.1±4.1）g/L, P<0.01;重症组血浆白蛋白浓度明显低于轻症组,差异有显著性（P<0.05）。术后第5天,轻症组白蛋白浓度为（37.1±11.4）g/L高于术后第1天,差异有显著性（P<0.05）;重症组血浆白蛋白浓度术后第5天与术后第1天比较,差异无显著性（t=1.675,P＞0.05）。术后第1天血浆白蛋白浓度与小儿危重评分之间成正相关（r=0.879, P<0.01）。结论：急性肠套叠患儿术后第1天血浆白蛋白有不同程度的降低,并与急性肠套叠患儿术后严重程度相关;重症病例低白蛋白血症持续时间长,并与治疗干预无关。血浆白蛋白浓度测定可作为急性肠套叠患儿术后严重程度的预警指标。［中国当代儿科杂志,2009,11（4）：277-279］     

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。     

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.     

Infantile myofibromatosis: a rare presentation with intussusception

Infantile myofibromatosis (IM) is a distinct but rare clinicopathological entity occurring in neonates and infants. It probably represents a rare soft-tissue tumour made up of undifferentiated myofibroblasts. Its recognition is important since it can be mistaken for a malignancy when, in fact, it has a generally benign prognosis with spontaneous regression. We describe the first case of an infant with IM presenting with acute intussusception due to gastrointestinal as well as the typical skin involvement. Accepted: 1 May 1997     

Radiographic reduction of intussusception in patients with cystic fibrosis

Cystic fibrosis (CF) is a genetic disorder affecting approximately one in 2,500 births in the United States. Nearly 1% of patients with CF will develop intussusception, which is commonly ileocecal and felt to be secondary to inspissated feces. These patients generally present before the age of ten. Once the diagnosis of intussusception is confirmed on ultrasound or CT, surgery has been the mainstay of treatment in this patient group. We propose the use of air and contrast enemas as effective and beneficial non-operative approach in these patients. Clinical and imaging findings in four children with known CF who presented with intestinal intussusception, average age 13.25 +/- 5.3 years (range 8-18 years) were reviewed. Patients were diagnosed using ultrasound (n = 3) or abdominal CT (n = 1). All patients suffered from an ileocolic intussusception. Air and Gastrografin(R) enemas were used in an attempt to reduce the intussusception. There were six separate successful intussusception reductions in four patients. Three patients required multiple attempts (2.3 +/- 0.6). Air enemas were used initially in all cases. Gastrografin(R) was used successfully following the failure of air enema in one patient. One patient suffered three separate intussusceptions over a period of 18 months, which were all successfully reduced using air. There were no complications and the patients tolerated the procedure well. Intussusception is an uncommon but serious complication in children with CF. While surgical reduction has been the mainstay of treatment for these patients, we demonstrated that reduction of an intussusception using air or contrast can be accomplished safely, without anesthesia, and should be the initial treatment option.     

Postoperative intussusception

Postoperative intussusception is an uncommon complication of paediatric surgery. The diagnosis may be difficult because of its insidious onset in patients in whom there is already a cause of pain and vomiting. The condition must be considered in any patient who develops abdominal distension, pain, and vomiting after partial return of gastrointestinal function. Offprint requests to: S. W. Beasley     

原发性肠套叠血浆生长抑素测定及其临床意义

探讨血浆生长抑制含量在小儿原发性肠套叠发病及病理发展中的变化和作有和放射免疫测定法,测定４１例原发性肠套叠患儿血浆生长抑素含量值,并与６０例正常儿和１２例肠梗阻儿进行比较。结果血浆生长抑素含量在生后３个月达到峰值,之后逐渐下降。     

Cystic duplication of the cecum presenting with intussusception in a 7-day-old boy

A case of ileocolic intussusception due to cystic duplication of the gut near the ileocecal valve in a 7-day-old neonate is presented. A review of the literature on both intussusception and duplications of the intestine reveals the extreme rarity of this entity. Moreover, the very young age at clinical presentation is remarkable. The contribution of ultrasonography in the diagnostic work-up is emphasized. Correspondence to: T. De Backer     

儿童过敏性紫癜合并肠套叠临床分析

目的探讨过敏性紫癜合并肠套叠的临床特点及外科治疗方法。方法回顾性分析本院自2006年1月至2013年6月收治的19例过敏性紫癜合并肠套叠患儿的临床资料。结果19例中,空气灌肠复位成功4例,15例行手术治疗,手术整复4例,肠坏死11例,其中行肠吻合7例,肠造瘘4例。结论肠套叠病程在6 h 内者,行空气灌肠治疗是可行、有效的;发病时间在24 h 后者,应及时手术干预。     

Reactive lymphocytes and intussusception in childhood

The peripheral blood smears of 15 infants with idiopathic intussusception and 23 controls with acute gastroenteritis were examined. We found an increased absolute number of reactive lymphocytes in the infants with intussusception compared to the controls (0.14×10⁹/1 +/– 0.08 and 0.07×10⁹/l +/– 0.07, respectively). This finding could reflect the irritation and enlargement of the intestinal lymphatic system that is believed to act as the lead point in idiopathic intussusception. Another explanation could be adenovirus infection, often associated with idiopathic intussusception, which is known to provoke morphologic changes in lymphocytes. These changes in the peripheral blood smear are mainly of pathogenetic interest and do not have a significant diagnostic impact in infants presenting with the typical clinical picture. However, in a child with suspected intussusception lacking typical clinical signs, the finding of reactive lymphocytes will recommend careful supervision.     

Traumatic intussusception with intramural haematoma

Traumatic intussusception due to intramural haematoma as the lead point is rare. We present the CT findings of a large duodenojejunal intramural haematoma acting as the lead point of a jejunojejunal intussusception in a 12-year-old boy.     

Primary intussusception of the stomach in a neonate

A case of primary intussusception of the stomach is reported. Clinical, radiological, and pathological details are described and discussed. Offprint requests to: J. Bruce     

Prenatal and neonatal intussusception

Intussusception found in the 1st month of life is rare and usually discussed as one entity, neonatal intussusception, but in fact, includes the intussusceptions occurring both prenatally and neonatally, of which the clinical presentations and results are different. Four full-term babies with prenatal intussusception presenting as intestinal atresia (IA) and three premature babies with neonatal intussusception mimicking necrotizing enterocolitis (NEC) are presented. Prenatal intussusception, as one of the causes of IA produces prominent signs of intestinal obstruction immediately after birth. Preoperative evaluation usually fails to yield a definitive diagnosis, but surgery is usually performed in time and is successful. In neonatal intussusception, full-term infants usually have a pathological lead point and the colon is almost always involved. A barium enema is thus useful in diagnosis. Premature babies, on the other hand, rarely have a colonic component, and the clinical features are insidious and similar to NEC. This results in diagnostic confusion that may lead to a dangerous delay in appropriate surgical correction. A high level of suspicion about this condition in cases diagnosed presumptively with NEC is important. Serial abdominal sonograms may be helpful in the early diagnosis of neonatal intussusception.     

Length of intussusception as a function of mesenteric anatomy

Ileocolic intussusception presents with an abdominal mass or, occasionally, there may be bowel palpable in the rectum or protruding from the anus. Various factors have been proposed for the variations in the length of bowel involved. We tested the theory that the length of mesentry available to the intussusception is one of the factors limiting the length of the process. A postmortem study was carried out in eight children who died without congenital or acquired gut abnormalities. The distal ileum was intussuscepted using a blunt, flexible introducer. In nearly all cases, the distance between the proximal end of the intussusceptum and the superior mesentric trunk was significantly less than normal distance fron the cecum to the trunk. The length of the artificial intussusceptum was found to be proportional to the length of mesentery available. Points proximal to the ileocecal valve had more mesentry available and yielded longer intussuscepta. The superior mesentric trunk, the hub of the mesentery, proved to be limiting factor in all experimental intussusceptions. Correspondence to: J. M. Hutson     

Presenting clinical features and outcome in intussusception

Objective  To evaluate if a correlation exists between the clinical and radiologic characteristics at presentation; and the success of conservative management, morbidity and outcome of patients with intussusception. Methods  All patients (total 179) treated for intussusception in our unit between 1993 and 2003, were retrospectively reviewed to find out the effects of physical examination (general appearence, consciousness, body temperature, abdominal distention and tenderness, blood on rectal examination), laborat (leukocyte count) and radiologic (air-fluid level on X-ray, free abdominal fluid on ultrasonography) findings on selection of first step therapeutic modality, conservative management (reduction with barium or air) success rate and surgical complication (serosal defect, intestinal perforation) rate. Additionally, the patients were subdivided into three subgroups as group A (patients for whom surgical management was performed primarily), group B (the ones who were operated after failure of reduction attempt with barium or air), group C (patients who had successful conservative reduction). These groups were compared within each other with regard to duration of nasogastric suction, antibiotic therapy; onset of oral feeding and duration of hospitalization. The chi-square, Kruskal-Wallis and ANOVA tests were used for the statistical analysis and p value less than 0.05 was considered to be significant. Results  Incidence of selecting conservative treatment primarily was lower in patients with toxic appearence (p=0.02) and with free fluid on ultrasonography (p=0.007). Success rate of conservative treatment was lower in patients with moderate general appearence (p=0.000), lethargy (p=0.011), blood on rectal examination (p=0.004), air-fluid level on X-ray (p=0.039), free fluid on ultrasonography (p=0.001). Surgical complication rate was higher in patients with moderate general appearence (p=0.000), lethargy (p=0.007), air-fluid level on radiograph (p=0.009). In group A; the duration of N/G suction, antibiotic therapy and hospitalization was longer; the onset of oral feeding was later than the other two groups (p=0.000). In group B; the duration of N/G suction, antibiotic therapy and hospitalization was longer; the onset of oral feeding was later than group C (p=0.000). Conclusion  Toxic appearence, lethargy and air-fluid level on radiograph not only decrease the success rate of conservative management, but increase the surgical complication rate as well. Thus, these parameters deserve more importance in the management scheme. Reduction with conservative management is the most important factor which decreases the morbidity. Morbidity is lower in cases who are operated after failure of conservative management than the ones for whom surgery is performed primarily. Thus, conservative management should be tried for all patients unless there is a clear cut contraindication such as peritonitis and/or pneumoperitoneum.     

Ileocolic intussusception: an unusual complication in a newborn with intestinal neuronal dysplasia

Intestinal neuronal dysplasia type B (IND B) represents a congenital malformation of the enteric nervous system causing disorders of intestinal motility, e. g., chronic constipation. We report a newborn who primarily suffered from intussusception and peritonitis. He required a subtotal colectomy for gangrene, but since IND B had not been expected at this time, no specific immunhistochemical workup for IND was initiated. Following recurrent episodes of ileus and subileus within the next years, colonic biopsies were taken and histotopochemical staining revealed IND B. The remaining colon required resection; an ileorectostomy was performed and the patient is now asymptomatic. This case report discusses the causality of IND B for intussusception and stresses that in newborn patients the clinical presentation may be misleading, and adequate histochemical evaluation is essential for early detection.