Intussusception in Western Nigeria

An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital

Background

Intussusception in adults is considered rare in surgical practice. It is the causative lesion in a small proportion of cases of intestinal obstruction and lower gastrointestinal bleeding. In the last decade, the incidence of adult intussusception appears to be increasing at our centre.

Aims

This study aims to document the pattern of presentation and management outcome of adult intussusception at our institution during the last decade. We also observed the occurring trends of this lesion.

Patients and Methods

This was a 10-year retrospective study of consecutive adult patients with intussusception seen at our institution from July 2008 to June 2018. Information on biodata, clinicopathological features and management outcome retrieved from case notes and pathology records were analysed on a personal computer using SPSS version 23.

Results

Twenty adult patients who had intussusception were seen during this period. There were 9 (45%) males and 11 (55%) females giving a male-to-female ratio of 1:1.2. The mean age of presentation was 45 (range 18-66) years. Clinical features were abdominal pain (85%), abdominal distension (80%), vomiting (70%), rectal bleeding (70%) and palpable abdominal mass (35%). Majority of patients (70%) presented with features of intestinal obstruction. Idiopathic intussusception (55%) accounted for more than half of the cases with the jejunoileal variety (30%) as the most common pathological type. One patient who had intussusception in the postoperative period was treated with manual reduction at laparotomy. Bowel resections were performed in the remaining 19 (95%) patients.

Conclusion

Adult intussusception is still uncommon in our general surgical practice. Bowel resection is the mainstay of treatment.

Childhood intussusceptions at a tertiary care hospital in northwestern Tanzania: a diagnostic and therapeutic challenge in resource-limited setting

BACKGROUND

Intussusception remains a common cause of bowel obstruction in children and results in significant morbidity and mortality if not promptly treated. There is a paucity of prospective studies regarding childhood intussusception in Tanzania and particularly the study area. This study describes the pattern, clinical presentations and management outcomes of childhood intussusception in our setting and highlights the challenging problems in the management of this disease.

METHODS

This was a prospective descriptive study of patients aged < 10 years operated for intussusception at Bugando Medical Centre. Ethical approval to conduct the study was obtained from relevant authorities. Data was analyzed using SPSS version 17.0.

RESULTS

A total of 56 patients were studied. The male to female ratio was 3.3: 1. The median age was 6 months. Three-quarter of patients were < 1 year. Etiology was mainly idiopathic in 91.1% of cases. The classic triad of bloody stool, vomiting and abdominal distention/abdominal pain was found in 24 (42.5%) patients. The diagnosis of intussusception was mainly clinically in 71.4% of cases. All patients were treated surgically. Ileo-colic was the most frequent type of intussusception (67.9%). Twenty-six (46.4%) patients required bowel resection. The rate of bowel resection was significantly associated with late presentation > 24 hour (p = 0.001). Complication rate was 32.1% and surgical site infection (37.5%) was the most frequent complication. The median length of hospital stay was 7 days. Patients who had bowel resection and those who developed complications stayed longer in the hospital and this was statistically significant (p < 0.001). Mortality rate was 14.3%. Age < 1 year, delayed presentation, associated peritonitis, bowel resection and surgical site infection were the main predictors of mortality (p < 0.001). The follow up of patients was generally poor

CONCLUSION

Intussusception in our setting is characterized by late presentation, lack of specialized facilities and trained personnel for nonsurgical reduction. Therefore, surgery remains the main stay of treatment in our centre. A high index of suspicion and proper evaluation of patients is essential for an early diagnosis and timely definitive treatment, in order to decrease the morbidity and mortality associated with this disease.

Childhood intussusception: a 9-year review

Sixty-four consecutive cases of intussusception in 48 infants and 16 older children managed at Jos University Teaching Hospital between January 1990 and December 1998 are reviewed. The age range was between 3 months and 15 years (mean 2.2 years) and the male to female ratio was 3.6:1. The quartet of abdominal pain, bloody mucoid stools, abdominal mass and palpable rectal mass was present in 70% compared with the classical triad (abdominal pain, bloody mucoid stools and abdominal mass) which occurred in only 32%. All the children had surgery. In 26 (41%) of the children, no associated cause was found, in three polyps formed the lead point and in five children a buried appendicectomy stump formed the lead point. In 30 (47%) other children, mesenteric lymphadenopathy and inflamed Peyer's patches were noted. Ileo-colic intussusception occurred in 32 (50%) children. Manual reduction was successful in 67%. Bowel resection for gangrene, irreducibility and an iatrogenic colonic tear was done in 30% of patients. Two (3%) had spontaneous reductions. There were four deaths. The commonest complications were wound infection and adhesive intestinal obstruction.

Paediatric intussusception

Intussusception is one of the commonest causes of intestinal obstruction in infants and accounts for about 700 hospital admissions each year in England and Wales. Improved results of treatment have followed recent technological developments, which include ultrasonographic imaging and pneumatic reduction techniques. Most intussusceptions can be reduced successfully without the need for operation but close cooperation between surgeon and radiologist is essential. Mortality and morbidity rates from the condition have progressively declined in recent decades but avoidable deaths still occur.

The changing pattern of infantile intussusception in northern Nigeria: a report of 47 cases

Infantile intussusception is not rare in Africa, but was reported to be relatively uncommon. This retrospective review of 47 infants with the diagnosis of intussusception included 38 boys and nine girls. Surprisingly, the clinical presentation is at variance with previous reports and beliefs about intussusception in tropical Africa, but is similar to those from Europe and North America. Contrary to expectation, about 70% of infants presented with the classical clinical picture of intussusception with the complete features of vomiting, 'colicky abdominal pain', blood mucoid stools and palpable abdominal mass. The other 30% presented with various combinations of the components of the tetrad. The small bowel was the leading point in 30 infants and the colon in 17. Of the small bowel variety, the two main types were the ileo-ileal and the ileocolic, while the ileocaecal and the various types of colo-colic intussusception were of large bowel origin. Morbidity was minimal. There were four deaths. Intussusception in this series differs in many respects from previous experience in Zaria.

Childhood intussusception in Ile-Ife, Nigeria

A retrospective review of 41 intussusceptions encountered in 39 children seen over an 8-year period in Ile-Ife, Nigeria is presented. Most cases (61.5%) occurred in infancy. This contrasts with previous reports from Nigeria where intussusception has been presented as being commoner in older children. Vomiting, abdominal pain, excessive crying and passage of bloodstained stools were the main presenting symptoms. An abdominal mass was palpable in only 28.2% of patients. Generally, patients presented late in hospital with only two (5.1%) arriving within 24 hours of the onset of illness. Hydrostatic reduction with barium enema was attempted in these two patients, and it successfully reduced the intussusception in one and caused partial reduction in the other. Nineteen patients (46.3%) required bowel resection. There were nine deaths, giving a mortality rate of 23.1%. The relatively high bowel resection and mortality rates were attributed to the delay in seeking medical treatment.

The computed tomographic appearances and clinical significance of intussusception in adults with malignant neoplasms

The computed tomography (CT) appearances of intussusception in 14 patients and the clinical follow-up of this condition in 17 adults with known primary malignant neoplasms were retrospectively reviewed. The ages of the 11 men and six women ranged from 25 to 83 years. Nine patients had been treated for malignant melanoma and the others for various primary neoplasms. Intussusception on CT was characterized by thickening of the affected bowel segment in all 14 patients and by the presence of intraluminal fat density material in 13, a concentric ring or "target" lesion in four, and an intra-luminal soft-tissue mass in nine. Five patients had intussusception, without other evidence of disease, caused by metastases in three patients, lipoma in one and idiopathic in one. Eleven of the other 12 patients had extensive disease, and one had small bowel cytomegalovirus infection. Five of these patients had more than one site of bowel involvement. Ten of the 12 patients had progression of disease on follow-up CT examinations and six died between 26 days and 7 months after diagnosis of intussusception. Intussusception may occur as the first indication of tumour recurrence or metastasis, but is more commonly a manifestation of widespread disease. However, even in patients with malignant neoplasms, it may be idiopathic or a result of benign neoplasm.

Intussusception in infants and older children: a comparison

The clinical features and operative findings in 37 infants and 29 older children with intussusception seen over a 10-year period were compared and contrasted. While most of the children presented acutely, 28% of older children had chronic intussusception compared with 5% in infants. Only about a third of all children had the four classical features of abdominal pain, vomiting, abdominal mass and bloody stool; the rest had two or three of the above features. Pain and palpable abdominal mass were more common features in older children while abdominal distension, constipation and diarrhoea were more prominent in infants. Fifty-four per cent of intussusceptions in infants were entero-colic while in older children 69% were colonic. All the intussusceptions in infants were idiopathic while in 14% of older children there were predisposing causes. Resection for gangrene/perforation was required in 30% of infants compared with 7% of older children.

Adult intussusception in the tropics

Thirty-two cases are reported of intussusception occurring in patients over the age of 12 years, diagnosed in Papua New Guinea in the 8 years from March 1973. Malignant disease was found in only 2 patients (6.3 per cent), and in 21 cases (65.5 per cent) no associated pathology was detectable. Benign inflammatory polypi were encountered in 7 patients (22 per cent). A high proportion of primary intussusceptions is characteristic of series reported from tropical countries. Many may be due to the abnormal motility associated with acute diarrhoeal illnesses. Due to the rarity of associated malignancy a policy of conservative operative management is justifiable in a tropical environment.

Tropical paediatric intussusception--is it a different disease entity?

The presentation of intussusception in children in Zaria, Nigeria has been studied with the aim of identifying any features that may differentiate it from that which obtains in temperate countries. Our data reveal no difference in age of peak incidence, sex ratio, absence of preceding upper respiratory infection or lack of significant seasonal variation. However, there is an unusually high incidence (41%) of caecocolic intussusception. It is believed that this may account for other observed features, such as the low occurrence of constipation and other evidence of intestinal obstruction, and the relatively high incidence of "painless" intussusception and sub-acute or chronic intussusception. Twenty-nine per cent of the patients had only one or two of the usual diagnostic features of the disease and this contributed to delayed diagnosis. In all but two patients the condition was idiopathic and there was no evidence to implicate bacterial enteritis or parasitic infestation in the aetiology of the disease.

Mechanical bowel obstruction. Review of 316 cases in Benin City

A retrospective study of 316 patients with a diagnosis of intestinal obstruction admitted to the University of Benin Teaching Hospital over a 5 year period is presented. The overall mortality was 10.6 percent. Attention is called to the unacceptably high morbidity and mortality associated with volvulus in this and other series. Because the most common cause of intestinal obstruction in Africa is strangulation, a preventable complication of inguinal hernia, the clinician has a unique opportunity to significantly decrease the incidence of intestinal obstruction in Africa. Finally, our study confirms that the single most important antecedent of a grave prognosis in intestinal obstruction is late presentation of the patient.

Recurrent intussusception due to a primary colloid carcinoma of the large bowel in a child

A case of recurrent colo-colic intussusception due to a primary colloid carcinoma of descending colon with widespread lymphatic involvement in a child, is reported. The unusual mode of presentation and lack of awareness were responsible for a delay of 6 months before the final diagnosis was made. Two years after the operation the patient is well and there is no evidence of clinically detectable secondaries.

Intestinal obstruction in Nigerian children

A 10-yr review of acute intestinal obstruction in 280 Nigerian children reveals that the condition is the major cause of surgical emergencies in Nigerian children, as in children of other developing countries. These are significant differences of pediatric intestinal obstruction in developing countries, as compared with the pattern in other parts of the world. Intussuscaption was the leading cause followed by incarcerated or strangulated hernia. Lateness in presentation was common, with a resulting high morbidity and prolonged hospital stay. The overall mortality was 16%, but mortality of 33% was recorded in the neonatal group.

Tropical intussusception in adults

In contrast with the incidence in Britain and the United States, about 50% of intussusceptions in Sri Lanka occur in adults, the maximum age incidence being in the fourth decade. Seventy-six cases of intussusception in adults are analysed in this paper, 62 of which were of the caecocolic type, which though only rarely described in the West, have also been frequently reported from other tropical countries. The clinical picture was characteristic, and a mass was palpable in 90% of the patients, facilitating diagnosis without ancillary investigations. On the basis of the histological examination of resected specimens it is concluded that amoebic granulomatous formation in the dependent "diverticulum" of the caecum is the predisposing cause of the caecocolic intussusception, accounting for the chronicity of a large number of cases. Irrespective of the duration of the illness, gangrene did not occur in any of the cases if this type, although resection was occasionally required on account of irreducibility. In view of the proliferation of fibrous tissue in the wall of the caecum, complete evagination of the intussusception can only be achieved by surgical exploration and manipulation, the results of which are excellent.

The position, length, and content of the vermiform appendix in Nigerians

The position, length, and content of 78 appendices from perinates and of 125 from children and adults were studied at autopsy. The retrocaecal appendix was commonest among the children and adults, and the pelvic appendix among the perinates. The average length of the appendix of the perinate was 4.2 cm. and that of the children and adults was 9.6 cm. Extreme mobility of the caecum was noted in about 62 per cent of the cadavers in both groups of subjects. Parasitic infection of the appendix was high in the children and adults group.