Intussusception: 354 cases in 10 years

Rising Incidence of Childhood Intussusception in Ontario: A Population-Based Study From 1997-2016

BACKGROUND

Intussusception is the most common cause of bowel obstruction in children aged 3 months to 6 years of age. We sought to describe patterns of incident childhood intussusception.

METHODS

A retrospective longitudinal cohort study utilizing population-based health administrative data and a validated case definition was used to identify patients <18 years of age treated for intussusception between January 1, 1997 and December 31, 2016 in Ontario, Canada. Descriptive statistics, graphical analyses, and a Poisson regression model were performed for trend analysis.

RESULTS

The overall incidence of intussusception in Ontario children (<18 years) was 3.3 cases/100,000 child years (cyrs), 95% CI [3.2.3.5]. The overall incidence increased from .9 cases/100,000 cyrs to 2.3 cases/100,000 cyrs. The highest incidence was in children aged 6-12 months at 28.9 cases/100,000 cyrs, 95% CI [26.2.31.9]. Incidence increased in all age-groups between 6 months and 5 years (at a rate of 5% to 16% per year; all P < .05). Month of year did not predict intussusception counts in a log-linear Poisson models, nor did rotavirus immunization implementation in 2011. There was a 3-fold variability across geographic areas in the province. There was a high rate of readmission for recurrence within 1 year (10.7%).

CONCLUSION

The incidence of intussusception more than doubled in Ontario from 1997 to 2016. The incidence increased for children aged between 6 months and 5 years at a rate of 5-16% per year, suggesting that an increased rate of idiopathic intussusception is responsible for the increase in the province.

An Unusual Neurological Form of Acute Intussusception in an Infant: Late Diagnosis and Management

Acute intussusception is one of the most common causes of intestinal obstruction in infants and small children and involves the invagination of one bowel segment into another. The clinical signs can be deceptively misleading when there is only one symptom or when an unusual symptom is in the foreground, especially in infants less than 1-year-old. We report a case of an infant with an acute intussusception where the neurological symptoms are predominant. The neurological form is the expression of major vascular narrowing of the collar of the intestinal intussusception; this form is rare and misleading and can be responsible for a delayed diagnosis.

Intussusception:

Intussusception, the invagination of one portion of the intestine into another, is considered a true emergency, which most commonly affects pediatric patients. It occurs when bowel (small or large) telescopes within itself, creating an obstructive mass. Peristalsis exacerbates the more proximal bowel into the lesion, causing the intussusception to have a “sleeve”-like shape. The lesion propagates distally, with obstructive ischemia and possible necrosis occurring over time. With the improvement of technology in diagnostic imaging, sonography has become the initial imaging modality of choice. The authors present a case study and current review of the literature regarding intussusception from a sonographer's viewpoint.

Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission

BACKGROUND

Controversy persists about the need to admit patients after successful reduction of intussusception. Our hypothesis is that pediatric intussusception can be managed with discharge from the emergency department (ED) after reduction without increasing morbidity, yielding significant cost savings.

METHODS

A chart review over 10 years was performed at two Canadian institutions. Data abstracted included: demographics, length of stay (LOS), initial and recurrence management. Primary outcome was early recurrence and resultant management, including LOS and need for operative intervention. Costs were calculated using hospital-specific data.

RESULTS

584 patient records were assessed: 329 patients were managed with admission after reduction, 239 as outpatients. In the admission group, 28 patients had at least one recurrence (8.5%), with 8 after discharge. In the outpatient group, 21 patients had at least one recurrence (8.8%), with 19 after discharge. The difference post-discharge was significant (p=0.004). Outcomes of recurrence did not differ, with 2 patients in each group requiring operative intervention. Average LOS in the admission group was 90 h, with additional average cost of $1771 per non-operated patient.

CONCLUSIONS

Pediatric intussusception can be safely managed as an outpatient with reliable follow up. Discharge from the ED reduces hospital charges without increasing morbidity. This approach should be considered in managing patients with intussusception.

Postoperative intussusceptions in children and infants: a systematic review

BACKGROUND

Postoperative intussusception (POI) is an unusual complication in children and infants who underwent various kinds of surgery. The early recognition was difficult for its rarity and atypical presentations. This study evaluates the clinical features of POI through a literature review.

METHODS

MEDLINE database was searched for relevant articles that reported the children and infants with POI since 1990 in English-language using the key word "postoperative intussusception". All published studies containing clinical data for POI in children and infants were included. Reference lists of retrieved articles were reviewed for additional cases. Detailed data of the included cases were extracted and analyzed.

RESULTS

Twenty-six studies with total 127 cases of POI were included. According to the extracted data, the median age was 19 months with the male-to-female ratio 1.5:1. There were 65 operations (51.2 %) that involved gastrointestinal system, 26 cases (20.5 %) of retroperitoneal tumor resection, 12 operations (9.4 %) involved diaphragm, 8 operations (6.3 %) involved urinary system, 5 cases (3.9 %) of partial pancreatectomy, 11 cases (8.7 %) of non-abdominal operations. 75.5 % presented symptoms in the first 7 days after surgery. The prominent symptom was bilious vomiting or increased nasogastric output (87.1 % of 101 patients), following abdominal distention (74.3 %), abdominal pain (35.6 %). Six cases (5.0 %) of ileocolic POI were reduced successfully by air enema. The small bowel intussusception attributed 85.6 % of POI (95 patients). Laparotomy and manual reduction were performed in 104 cases (86.0 %). Nine patients (7.4 %) underwent intestinal resection and anastomosis.

CONCLUSIONS

POI should be suspected in pediatric surgical patients who showed signs of intestinal obstruction in the early postoperative period. Early recognition and prompt management are important.

An institutional analysis and systematic review with meta-analysis of pneumatic versus hydrostatic reduction for pediatric intussusception

BACKGROUND

Intussusception remains a frequent cause of bowel obstruction in children and typically is treated by reduction via enema. Controversy persists regarding the optimal reduction technique to maximize success while minimizing morbidity.

METHODS

We reviewed our institutional data comparing outcomes of enema reduction that use contrast medium versus air. A systematic review also was undertaken of comparative studies evaluating pneumatic (oxygen or air) versus hydrostatic (any contrast medium) reduction. Critical appraisal was performed with the Methodological Index for Non Randomized Studies scale for observational studies, Jadad score for randomized trials. Meta-analysis was performed with REVMAN 5.1.

RESULTS

Institutional data revealed a failed reduction rate of 20.4% (20/98) with air and 29.6% (8/27) with contrast reduction. Nineteen studies were included in the systematic review. The cumulative failure rate favored pneumatic reduction (odds ratio [OR] 0.45; 95% confidence interval [95% CI] 0.34-0.60); sensitivity analysis of prospective studies demonstrated similar results (OR 0.39; 95% CI 0.24-0.63). The number needed to treat to eliminate one failed reduction was nine pneumatic reductions. No difference was noted in reported perforations (OR 0.98; 95% CI 0.48-2.03).

CONCLUSION

Pneumatic reduction is more likely to successfully reduce intussusception in children without evidence of increased morbidity. In the context of available expertise, pneumatic reduction should be the method of choice for the treatment of intussusception barring an indication for immediate operative intervention.

Laparoscopic versus open reduction of intussusception in children: experience over a decade

BACKGROUND

Intussusception is a common cause of bowel obstruction in children, which sometimes necessitates operative reduction and or resection. We report our series of patients with intussusception who were treated laparoscopically (LAP group) compared with exploratory laparotomy (OPEN group).

SUBJECTS AND METHODS

After institutional review board approval, a retrospective review was performed evaluating outcomes for patients requiring surgical reduction of intussusception over a 10-year period. Analysis was based on intent to treat, and technique of exploration was surgeon's choice. Data were analyzed with the Wilcoxon rank sum test and chi-squared test where appropriate. P≤.05 was considered significant.

RESULTS

During the time period studied, there were 92 patients treated surgically for intussusception: 65 LAP and 27 OPEN. Conversion to the open procedure was required for 21 patients in the LAP group, and of those, 6 required bowel resection. Seven of the patients who were started in the OPEN group ultimately required bowel resection. Operative time, length of hospital stay, time to full feeds, and total days of narcotics were all significantly shorter for the LAP group compared with the OPEN group (P=.003, P=.001, P=.001, and P=.004, respectively). A pathologic lead point was found in 14% of LAP and 15% of OPEN cases. In a subset analysis, 33% of patients who were converted from the LAP group to the open procedure had a pathologic lead point. Complication rates between the LAP and OPEN groups were comparable.

CONCLUSIONS

Laparoscopy appears to be a safe and effective technique for reducing intussusception in children. The laparoscopic cases had shorter operative time, shorter time to full feeds, lower requirement for intravenous narcotics, and earlier discharges.

Adult intussusception: diagnostic pitfalls, morbidity and mortality in a developing country

OBJECTIVE

To study diagnostic pitfalls, morbidity and mortality of adult intussusception.

PATIENTS AND METHODS

Retrospective study of adult patients records operated between 1979 and 2007 with the diagnosis of adult intussusception.

RESULTS

We found 41 cases of adult intussusception. The mean age was 35.2 years (standard deviation (SD)=7.1). The delay between onset and medical consultation was 15 days. The diagnosis was made pre-operatively in 11 cases. Abdominal ultrasound showed an abdominal mass in 11 cases. Ileo-ileal intussusception was most frequent (16 cases). Intussusception was secondary in 24 cases. There were seven instances of intestinal necrosis. Intestinal resection was performed in 34 cases. Surgical site infection occurred in four patients, three patients died.

CONCLUSION

The pre-operative diagnosis of acute intestinal intussusception is difficult. Morbidity and mortality rates are high. Improved diagnostic investigations in developing countries could improve the prognosis of this condition.

Acquired ileal atresia complicating an ileocolic intussusception in a 4-month-old infant

We report a 4-month-old female infant who was apparently well before the onset of vomiting, abdominal distension, and the passage of red currant jelly stools. A clinical diagnosis of intussusception was made, and the infant was prepared for a laparotomy. Intraoperative findings were a gangrenous ileocolic intussusception with a proximal atretic ileal segment (similar to a type IIIa ileal atresia). An extended right hemicolectomy including the atretic ileal segment was done with an ileotransverse anastomosis to establish bowel continuity. The patient had a wound dehiscence on the fourth postoperative day that was repaired. She subsequently made satisfactory clinical recovery and was discharged on the 10th day.

Sociodemographic and dietary risk factors for natural infant intussusception in the United States

BACKGROUND

In 1999, a US case-control study demonstrated a strong association between intussusception and a rotavirus vaccine (Rotashield). However, because most (87%) cases were not temporally associated with vaccination, we reanalyzed these data to assess risk factors for intussusception cases unrelated to Rotashield.

PATIENTS AND METHODS

Case-patients were infants with intussusception between November 1998 and June 1999. Controls were matched by age and hospital of birth. Sociodemographic and feeding practice data were collected through parent and provider interviews. Conditional logistic regression was used to identify risk factors for intussusception, controlling for exposure to Rotashield <21 days before intussusception.

RESULTS

Four hundred twenty-nine cases and 1763 controls were enrolled. Among case-patients, 372 (87%) had not received Rotashield within 21 days before intussusception. After adjusting for recent Rotashield administration, factors associated with intussusception included male sex (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.3-2.2), Hispanic (OR 2.1; 95% CI 1.4-3.2) or black (OR 1.8; 95% CI 1.2-2.7) race/ethnicity, and Medicaid enrollment (OR 1.5; 95% CI 1.1-2.0). Feeding practices modified the risk of intussusception. Interaction was found between introduction of solid food (ISF) and type of formula consumption. Using breast milk as the referent group, infants with ISF for at least 5 weeks who consumed soy milk-based formula had a lower risk (OR 0.26; 95% CI 0.1-0.7) and infants without ISF who consumed cow's-milk formula had an increased risk (OR 2.33; 95% CI 1.4-3.9).

CONCLUSIONS

Risk of intussusception among US infants varies based on sociodemographic characteristics and feeding patterns.

Incidence of intussusception among children 0-5 years of age in Thailand, 2001-2006

To provide baseline incidence data of intussusception among Thai children under 5 years old, outpatient and inpatient records from 2001 to 2006 from five hospitals were reviewed. 112 cases of intussusception were identified, confirmed by either ultrasonography (65%), radiology procedure (32%) or surgery (3%). Common presenting symptoms were vomiting, mucous bloody stool and fever. 50% of intussusceptions were ileocolic in location and 49% underwent surgery. Male to female ratio was 1.7:1 and 86% of cases were under 1 year of age. No deaths were reported. 89 of 112 cases were resident in the study catchment area, for an annual incidence of 19.70-47.83 and 4.36-11.44 per 100,000 children under 1 and 5 years of age, respectively. This is somewhat lower than other regional studies emphasising need to continue and enhance surveillance prior to starting a universal rotavirus vaccine program.

Rotavirus infection and intussusception in Tunisian children: implications for use of attenuated rotavirus vaccines

BACKGROUND

A licensed rotavirus vaccine was withdrawn from use because of an increased risk of intussusception. The association of rotavirus vaccination with intussusception raised concerns about a potential link between natural rotavirus disease and intussusception. The objectives of the present study were to determine whether an epidemiological association with natural rotavirus infection existed.

METHODS

From 1984 to 2003, all children younger than 5 years with intussusception were retrospectively identified by medical charts, and from 1995 to 2003, a prospective surveillance study of rotavirus infection in children younger than 5 years was independently conducted. Epidemiological characteristics of intussusception and rotavirus infection were then compared.

RESULTS

A total of 533 cases of intussusception and 146 cases of rotavirus infection were identified. The incidence of intussusception for infants younger than 1 year was 62/100,000 child-years. The age distributions of intussusception and rotavirus gastroenteritis overlapped, and a masculine predominance was noted in both cases. No significant association was observed between the monthly distribution of intussusception and rotavirus infection.

CONCLUSION

The present study has not convincingly shown that rotavirus diarrhea plays a major role in intussusception. However, data about age and sex distributions supported the biologic plausibility of such an association.

Transanal protrusion of intussusception in infants is associated with high morbidity and mortality

BACKGROUND

Although anal protrusion of intussusception in infants is well recognised, it is rarely reported and confusion with rectal prolapse often results in delayed diagnosis and treatment. This report highlights the problems of diagnosis and the morbidity and mortality associated with this condition.

METHOD

A retrospective case series of five infants presenting to Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria with anal protrusion of intussusception over a period of 5 years. During that time, 17 children were treated for intussusception at ABUTH.

RESULTS

The anal protrusion rate of intussusception was 29%. The five infants were three girls and two boys aged 4-18 months (median 8). The duration of symptoms was between 6 and 28 days (median 21). The features were mainly protruding anal mass, diarrhoea and vomiting. Abdominal pain and passage of bloody stools occurred late. There was delay in referral and treatment owing to misdiagnosis as rectal prolapse. The intussusception was ileocolic in four patients and in one the type could not be ascertained before death. Two patients had perforation of the involved intestine and another had gangrene of the intestine, necessitating intestinal resection. In one patient, there was no bowel compromise and only open reduction was necessary. Two patients died from overwhelming infection, one before surgery and another after surgery.

CONCLUSION

The risk of morbidity and mortality in anal protruding intussusception is high. As early features might not be typical of intussusception, a high index of suspicion is necessary to avoid confusion with rectal prolapse so as not to delay diagnosis and treatment.

Abdominal tuberculosis presenting as ileocolic intussusception in an infant

Intussusception is the most common cause of intestinal obstruction in children, with a peak in children 5 to 7 months of age. Identifiable causes are found in 90% of adults, whereas in infants and young children the majority are idiopathic. We report a case of abdominal tuberculosis (ATB) presenting as an ileocolic intussusception in an infant. A 6-month-old infant presented with features of acute intestinal obstruction. Peroperatively, ileocolic intussusception was found. Histological examination revealed caseating epitheloid cell granulomas with positivity for acid-fast bacilli. Only 3 cases of ATB presenting as intussusception have been previously reported in the literature, with only 1 case presenting in a child. This appears to be the 2nd case of ATB presenting as an intussusception in a child and also in an infant. Tuberculosis should also be kept in the differential diagnosis of lead point of intussusception, even in the age group in which most cases are idiopathic, especially in endemic areas.

[Ultrasonography in the diagnosis of hypertrophic pyloric stenosis and intussusception--emergency conditions in pediatric gastroenterology]

Hypertrophic pyloric stenosis (HPS) is the most common abdominal surgical condition in newborns and infants, while intussusception is the most frequent problem in children between the ages of 6 months and 2 years. The aim of this study was to show the advantages of ultrasonography in diagnosis of hypertrophic pyloric stenosis and intussusception and also to point out the efficiency of ultrasound guided hydrostatic reduction of childhood intussusception, as a nonoperative therapeutic option.

MATERIAL AND METHODS

This study had a prospective design and included 208 patients in a 2-year period (2004-2005). Both US examinations were done using a linear 7.5 MHz probe, and the main ultrasound criteria for HPS were increased pyloric muscle thickness of 3 mm and over, as well as pyloric length over 15 mm, typical ultrasonic findings of intussusception included a target sign or a pseudokidney sign. Sonographically guided hydrostatic reduction of intussusceptions was also performed.

RESULTS

HPS was predominant in male infants, and the mean age was 40 days. The mean pyloric muscle thickness was 4.95 mm in infants with HPS, and the average length of the antroplyloric canal was 19.26 mm. In patients with intussusception, male predominance was also observed and the mean age was 1 year and 79 days. The intussusceptum was most often located in the cecoascending (53.6%) and transverse colon (21.4%). US-guided hydrostatic reduction of intussusception was successful in 82.14% of all cases.

DISCUSSION

Our findings are in absolute agreement with literature data regarding the average age of patients, both with HPS and intussusception, thickness of the muscular layer, length of the antropyloric canal, and extremely successfid US-guided hydrostatic reduction of intussusceptions.

CONCLUSION

Ultrasonography has proved to be a remarkably precise diagnostic modality in diagnosing HPS and intussusception, but also makes nonoperative treatment of intussusceptions possible in extremely high percentage.

Current radiological management of intussusception in children

Intussusception is the most common abdominal emergency situation in infants and small children. There has been great progress in diagnostic and therapeutic management of intussusception. Ultrasound (US) has been shown to be the first-choice imaging technique in diagnosing intussusception for reasons of high accuracy, simultaneous exclusion of differential diagnoses, and disclosure of additional pathologies. Controversial opinions exist worldwide concerning the nonoperative treatment of intussusception in infants and children. Pneumatic reduction under fluoroscopic guidance and hydrostatic reduction under US monitoring are the preferred techniques. The aim should be a success rate of at least 90% in idiopathic intussusception. This review summarizes different types of intussusception and outlines diagnostic aspects as well as several treatment concepts.

Laparoscopic vs open surgical approach for intussusception requiring operative intervention

PURPOSE

Laparoscopy has recently been used to treat intussusception that cannot be reduced radiologically. The effectiveness and practical nature of this approach has been questioned.

METHODS

This study retrospectively analyzed the authors' experience with this laparoscopic approach and compared this to the conventional open laparotomy procedure.

RESULTS

Sixteen patients were treated via laparoscopy, with 2 of these requiring conversions to an open procedure (12.5%). Twenty-five patients underwent an open reduction. Operative time was not significantly different (P = .698) between the laparoscopic (49.56 +/- 26.40 minutes) and open groups (45.00 +/- 24.74). Length of stay, however, was significantly reduced (P = .005) in the laparoscopic group (3.00 +/- 1.31 days) compared to the open group (4.52 +/- 1.98). Total hospital charges were lower in the laparoscopic group ($8171 +/- 2595) compared to the open group ($11,672 +/- 5466); this difference was not significant (P = .088). There were no significant differences in intra- or postoperative complication rates (P = .637) between the 2 approaches.

CONCLUSIONS

Although there remains a group who will require a conversion to an open procedure, the laparoscopic approach should be considered a safe and effective option for all children who do not respond to a radiological reduction.

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.

Natural rotavirus infection is not associated to intussusception in Mexican children

AIMS

To determine whether natural rotavirus infection or infection by another enteropathogen is associated to intussusception (IS); and to describe the seasonality of IS compared with severe diarrhea (SD) and rotavirus SD in Mexican children.

METHODS

A prospective, observational, multicenter and case-control study was conducted in Mexico City from December 1999 to February 2001. Cases were children younger than 1 year old hospitalized for IS; diagnosis was made by clinical features, radiologic and/or surgery findings. Controls were children younger than 1 year old hospitalized for another disease than a gastrointestinal illness (NGI). Cases and controls were paired by age and date of admission (+/-3 months; for both), in a 1:2 ratio. A surveillance of IS cases, SD and rotavirus SD episodes was conducted during the study period. Stool samples collected soon after IS resolution or at admission were tested for rotavirus, adenovirus, astrovirus, bacteria and parasites.

RESULTS

Thirty cases of IS and 60 controls with NGI were studied. Rotavirus was not detected in any case of IS. Adenovirus (17%) was the only enteropathogen detected in IS. Rotavirus (8%), adenovirus (2%), astrovirus (2%) and bacteria (2%) were detected in NGI. Rotavirus infection was not associated with IS (odds ratio, 0; 95% confidence interval, 0-2.9), whereas adenovirus infection was strongly associated as risk factor for IS (odds ratio undefined; P = 0.003), compared with NGI. Seasonal variation in admissions for IS was small, whereas admissions for SD and rotavirus SD showed a marked seasonal increase during fall-winter.

CONCLUSIONS

In Mexican children, rotavirus infection was not associated to IS; whereas a significant association was observed between adenovirus and IS. Also there was no increase in IS cases during the sharply defined fall-winter rotavirus outbreak. Observations from this controlled study suggest that natural rotavirus infection is not a risk factor for IS. This information may have implications for development of a safer and effective rotavirus vaccine.

Feeding Intolerance as a Result of Small-Intestine Intussusception in a Child With Major Burns

Feeding intolerance is common in critically ill children. We present an unusual case of jejunojejunal intussusception causing feeding intolerance in a child with major burns. An 18-month-old female was admitted to the intensive care unit after sustaining a 65% TBSA burn. Following a decompressive laparotomy for abdominal compartment syndrome, nasojejunal feeds were started immediately after surgery, which she did not tolerate. A plain abdominal radiograph revealed a collection of intraluminal air and an abdominal CT revealed a proximal jejunojejunal intussusception. The patient underwent laparotomy and an uncomplicated reduction of the small-bowel intussusception (SBI). Successful enteral feedings were commenced on hospital day 24, and the patient was discharged to home after approximately a 4.5-month hospitalization. The major learning point is that SBI can cause feeding intolerance in the child with major burns. Despite the low incidence of SBI in critically ill children, arriving at a timely diagnosis is essential because the consequences of a missed or delayed diagnosis include intestinal ischemia, necrosis, or perforation. Because SBI defies diagnosis by techniques traditionally used to diagnose intussusception involving the colon, clinical suspicion for intussusception is needed to facilitate the urgent diagnosis and correction of feeding intolerance caused by mechanical obstruction.

Fatal intussusception in infancy: an experience in forensic autopsy

Intussusception, although a common cause of pediatric surgical emergencies, is a rarely fatal condition. A 7-month-old infant who was discovered in her cot was unresponsive and pronounced dead after 2 h of uneventful cardiopulmonary resuscitation in an emergency hospital. Forensic autopsy which was performed in order to clarify the circumstances surrounding the death revealed intussusceptions at two sites of the ileum. Although morbidity and mortality rates from the condition have progressively declined in recent decades but avoidable deaths still occur as was experienced in the present case. The forensic pathology significance in this case was the occurrence of 'painless intussusception' whereby the affected child clinically exhibited no discomfort or characteristic features of acute abdomen until death. In summary, the present case has exhibited an uncommon fatal occurrence and demonstrated the importance of forensic autopsy in such unexpected sudden infant deaths.

Laparoscopic treatment of intestinal intussusception in the Peutz-Jeghers syndrome: case report and review of the literature

The hamartomatous polyps of Peutz-Jeghers Syndrome (PJS) can cause repeated episodes of rectal bleeding and intestinal subocclusion. Laparoscopic treatment of intussusception is rarely reported and must be considered for this clinical condition. We described a 35-year-old male with PJS who presented with rectal bleeding and abdominal pain. One duodenal polyp and two others in the jejunum, which caused intussusception, were visualized on preoperative investigation. Polyps were identified by laparoscopy and removed extracorporeally through enterotomies. All lesions were hamartomas. The patient was discharged on the third postoperative day and has been asymptomatic for more than 2 years. Laparoscopy allows an adequate access to explore and treat small bowel polyps and avoid the classic laparotomy.

Lack of association between rotavirus infection and intussusception: implications for use of attenuated rotavirus vaccines

BACKGROUND

Withdrawal of the tetravalent rhesus-human rotavirus vaccine Rotashield because of its association with intussusception raised concerns about a potential link between natural rotavirus disease and intussusception. Our objective was to determine whether such an association exists.

METHODS

In the Southern California Kaiser Permanente Health Care Plan, a large health maintenance organization, from October, 1992, to July, 1999, we retrospectively identified by computerized data and medical charts all children <3 years old with intussusception, and from 1997 to 1999 we independently identified by prospective clinical and laboratory evaluation children <3 years old with rotavirus diarrhea. We compared the epidemiologic characteristics of intussusception and rotavirus infection in our study population and evaluated for the presence of both diseases in individual patients.

RESULTS

Using computerized data we identified 124 cases of intussusception, 101 (81%) of which were confirmed by medical chart and radiologic reviews. The incidences for infants <1 year old and for children <3 years old were 41 (95% confidence interval, 32 to 55) and 17 (95% confidence interval, 13 to 20) per 100,000 child years, respectively. Between November 1997 and July 1999, we identified 470 cases of rotavirus diarrhea and none had intussusception. Although rotavirus diarrhea had a distinct peak incidence between December and February, intussusception had no apparent seasonality. The age distributions overlapped, but intussusception occurred at an earlier age than rotavirus disease.

CONCLUSIONS

We found no epidemiologic evidence for an association between intussusception and natural rotavirus infection, but our study was limited by an insufficient number of cases to definitively exclude a causal link. The dramatic winter peak of rotavirus disease had no discernable parallel in the incidence of intussusception. Our data suggest that the association between tetravalent rhesus-human rotavirus vaccine and intussusception may possibly result from the nonhuman rotavirus components of that vaccine.

Intussusception, infection, and immunization: summary of a workshop on rotavirus

This article summarizes the proceedings of a workshop sponsored by the National Institutes of Health and the National Vaccine Program Office, and held in Bethesda, Maryland, on January 21, 2000. The objective of the meeting was to focus research toward an understanding of the basis for the possible association between intussusception and the reassortant rhesus-human rotavirus vaccine tetravalent (RRV-TV). After numerous reports of intussusception after administration of RRV-TV, the manufacturers of this vaccine voluntarily withdrew it from the United States market. The American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians also withdrew their original recommendations for administration of RRV-TV to children at 2, 4, and 6 months of age. These actions will have global implications for the prevention of morbidity and mortality attributable to rotavirus infection. Benefit-cost ratios for the use of RRV-TV will be substantially different in developing countries compared with developed countries. Therefore, extensive research is needed in both of these settings, to further our understanding of the epidemiology, pathogenesis, and pathology of both rotavirus disease and intussusception to enable optimal prevention. The workshop reviewed the current understanding of the possible association between RRV-TV and intussusception, as well as the possible association between a variety of viral infections and intussusception. The workshop also identified critical areas of research regarding this possible association. This research will be essential not only for the development of safe and effective rotavirus vaccines, but for the development of other oral vaccines as well.

Sonographic features of small-bowel intussusception in pediatric patients

OBJECTIVE

Small-bowel intussusception (SBI) for pediatric patients is unusual and difficult to diagnose preoperatively. This study sought to determine the sonographic findings of pediatric SBI.

METHODS

The sonographic features and surgical findings of 13 pediatric patients (7 boys, 6 girls; age range 4 months-15 years; average age 4 years and 2 months) with SBI encountered in the authors' hospital over a 12-year period were retrospectively reviewed.

RESULTS

Most of the patients presented with nonspecific symptoms, including vomiting, abdominal pain, and/or irritable crying. Sonographic screening in the emergency department revealed a doughnut or crescent-in-doughnut sign, or a multiple-concentric-rings sign for 11 of the 13 patients, and the lesions appeared short. Eight lesions were found in the paraumbilical or left abdominal regions. Sonographic measurement of the size of the lesions from these 11 patients ranged from 2 cm to 3.7 cm (average 2.77 cm). Subsequent barium enemas were performed for these 11 patients, none of which revealed colon lesions. Surgery revealed ileoileal intussusceptions for eight cases, jejunoileal for three, and jejunojejunal for the remaining two. Bowel ischemia or necrosis and pathologic lead points were demonstrated for seven and six patients, respectively, although none were recognized preoperatively.

CONCLUSIONS

Small-bowel intussusception is often over-looked due to nonspecific clinical presentations. Sonographic demonstration of a 2-3-cm sized, short, doughnut-like lesion, especially in the left abdomen or paraumbilical regions, should lead to strong suspicion of SBI.

Multipolypoid intussusceptum: a distinctive appearance of ileoileocolic intussusception at the ileocecal valve

Objective. To determine whether ileoileocolic intussusception can be diagnosed by a distinctive appearance during pneumatic reduction. Materials and methods. We reviewed the clinical, pathologic, and imaging findings of 11 patients with ileoileocolic intussusceptions seen in our hospital between January 1989 and July 1994. The patients ranged in age from 4 months to 4 years and 2 months. We specifically evaluated the appearance of these intussusceptions on air enemas performed in nine of these patients. Another 22 air enemas of all patients with surgically proven ileocolic intussusception seen during the same time period were also reviewed for comparison. Results. In seven of the nine patients with ileoileocolic intussusception who had air enemas, the intussusceptum clearly had two or more separate polypoid components once it was reduced to the cecum. This distinctive appearance was not seen until the intussusceptum was tethered at the ileocecal valve. The intussusceptum was also reduced to the cecum in 19 patients from the control group with ileocolic intussusception. In contrast to the ileoileocolic intussusceptums, these intussusceptums were either smoothly marginated (16 patients) or slightly lobular (three patients). Conclusion. In most patients with ileoileocolic intussusception, the intussusceptum has two or more polypoid components at the level of the ileocecal valve which are easily distinguished from the smoothly marginated or slightly lobular intussusceptum seen with ileocolic intussusception.

Intussusception: clinical and radiographic factors influencing reducibility

Hydrostatic reduction of intussusception by barium or air enema has been widely accepted. The five-year experience with this procedure at two children's hospitals is reviewed and the results compared to previous studies. Various clinical and radiographic factors are evaluated in relation to the reduction rate. The findings show that the more distal the intussusception is encountered, the lower the rate of reduction. However, 25% are reduced within the rectum with no evidence of increased complications. Small bowel obstruction and prolonged duration of signs and symptoms decreased the rate of reduction statistically but there is no significant increase in complication rate in those attempted, contrary to a previous report. The cresent sign (dissection sign) and age of the patient are not significant factors in reduction as reported by other studies.

Rotavirus infection and intussusception: a view from retrospect

A live orally-administrable rhesus rotavirus (RRV) tetravalent (TV) vaccine, licensed in the U.S.A. and the European Union, was recalled from the market because it was suspected to increase the risk of intussusception during the week following immunization. In contrast, natural rotavirus infection is generally believed not to cause intussusception. Because my experience contributed to the first paper that linked intussusception with rotavirus infection, I have re-examined our own data published 22 years ago and other studies on this issue. I also made a case study of adenovirus and intussusception as a paradigm to establish an etiological association of viral infection and intussusception. My hypothesis postulated in this review is that natural infection of susceptible (or predisposed) infants with some rotavirus strains, probably serotype G3 rotaviruses, will result in an appreciable fraction of idiopathic intussusception. Thus, the number of rotavirus-induced intussusception cases may change reflecting the relative frequency of G3 strains, which I believe was much higher in the 70s than during the last two decades. The epidemiological data indicate that the RRV-TV vaccine triggers intussusception at a rate significantly higher than the background incidence rate following the week of vaccination, particularly after the first dose. In contrast, the data do not suggest that the cumulative incidence among the vaccine recipients increases accordingly, implicating that the risk of intussusception attributable to the RRV-TV vaccine may be minimal.

Sudden death and intussusception in infancy and childhood--autopsy considerations

Search of the autopsy files of the Department of Histopathology at the Women's and Children's Hospital (WCH), Adelaide, Australia for cases of intussusception from January 1961 to December 1995 revealed two deaths due to intussusception out of a total of 4,384 autopsies (0.05%). Both cases occurred in infants (aged five months and six months respectively) who had only non-specific and apparently minor manifestations of illness, until precipitate deterioration occurred. The intussusceptions were ileo-ileal and ileocaecal in location, respectively. A total of 204 cases of intussusception were found in a search of 28,123 surgical pathology cases (0.73%) at the WCH over the 20-year period from 1976 to 1995. Mesenteric lymphadenopathy was found in 16 cases (including one with possible Yersinia infection), Meckels diverticulum in 14, isolated gastric/pancreatic heterotopia in two, cystic fibrosis in two and Henoch-Schonlein purpura in one. Although it has been shown that unexpected death is more likely to occur in older children with purely small intestinal intussusception, the current cases demonstrate that unexpected death may occur at any age, with intussusception at any level. The autopsy assessment of deaths due to intussusception requires careful evaluation of cases for evidence of local or systemic disease, particularly given the hereditary nature of certain predisposing conditions. Careful review of the presenting history is also required to assess the quality of care received by the child in the time preceding death.

Intussusception

Intussusception is the invagination of one portion of the intestine into another and is the most common form of intestinal obstruction in infants. This report reviews the clinical presentation and diagnostic and treatment options available for intussusception. The etiologies of childhood intussusception are discussed. Details and literature review are provided on the advantages and disadvantages of ultrasonography, barium enema, air contrast enema, and surgery in the diagnosis and treatment of intussusception.

Intussusception in a tropical country: comparison among patient populations in Jakarta, Jogyakarta, and Amsterdam

BACKGROUND

Intussusception is the most common cause of intestinal obstruction in young children, and high mortality rates remain a problem in developing countries. The purpose of this study was to describe and elucidate the differences in outcome between groups of children with intussusception in Indonesia, a developing country, and The Netherlands, a developed country.

METHODS

In this retrospective review, 176 patients were studied in three types of hospitals. A comparison was made among children treated at a primary care rural hospital in Indonesia, at a secondary care urban hospital in Indonesia, and at a tertiary care urban hospital in The Netherlands.

RESULTS

Children in the rural community hospital in Indonesia were more severely ill at arrival and had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality rate of 20%, in contrast to a mortality rate of 3% in the urban hospital in Indonesia and no deaths in the Dutch hospital.

CONCLUSIONS

The mortality of children with intussusception in rural Indonesia is much higher than in urban Indonesia or in The Netherlands, probably because of delayed treatment, which results in more patients undergoing surgery in worse physical condition.

Intussusception following a baby walker injury

Serious abdominal injury as a result of a fall in a baby walker has not been previously reported. We present the case of a 13-month-old boy who developed intussusception following a fall down five stairs in a baby walker. Attempted hydrostatic reduction was unsuccessful. At operation, a bowel wall hematoma, serving as a lead point, was identified. This case adds another type of injury to the list of those previously associated with baby walker use.

Viral etiology of intussusception in Taiwanese childhood

BACKGROUND

Adenovirus infection and lymphoid hyperplasia have been associated with childhood intussusception. However, the extent of other viruses involved in this condition remains unclear. This prospective study investigates the relationship between some lymphotropic viruses and current childhood intussusception.

METHODS

Patients with intussusception encountered in a pediatric emergency department in a recent 3-year period were studied. Healthy infants and toddlers of comparable age served as controls. Throat and rectal viral cultures were performed in patients and controls. Viral antibodies against adenovirus, cytomegalovirus, human herpesvirus (HHV)-6, HHV-7 and Epstein-Barr virus (EBV) were tested in paired sera from the patients. Acute stage serum from each patient and mesenteric lymph nodes from patients requiring surgery were studied for the presence of adenovirus genome by PCR.

RESULTS

Twenty-seven of 61 (44.3%) intussusception patients, but only 2 of 52 (3.8%) healthy controls shed nonenteric adenovirus in throat and rectal specimens (P < 0.001). Of the 27 (74.1%) patients who shed adenovirus, 20 were older than 1 year old, whereas only 1 of 15 (6.7%) similarly aged patients in a previous study from the same area three decades ago did so (P = 0.001). Among 43 patients with available paired sera, acute primary viral infection was found in 17 (39.5%) by adenovirus, 4 (9.3%) by HHV-6, 5 (11.6%) by HHV-7, 2 (4.7%) by EBV and none by cytomegalovirus. Multiple viral infections occurred in 6 patients. Adenovirus genome was detected in 4 of 9 mesenteric lymph nodes and in only 3 of 60 (5%) acute phase sera.

CONCLUSIONS

Primary nonenteric adenovirus infection contributes to current childhood intussusception. Acute primary HHV-6, HHV-7 and EBV infections also play etiologic roles.