Childhood intussusception: ultrasound-guided Hartmann's solution hydrostatic reduction or barium enema reduction?

Current diagnosis and image-guided reduction for intussusception in children

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

Sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception: 20 year experience

BACKGROUND

Ileocolic intussusception is a common abdominal emergency in children, diagnosed routinely with ultrasound and treated most frequently with fluoroscopic pneumatic reduction without sedation. Alternatively, ultrasound can also be used to obviate ionizing radiation and sedation can be used to avoid discomfort from the procedure. The purpose of this study was to present our experience with sedation using saline enema under ultrasound guided control to reduce ileocolic intussusception.

MATERIALS AND METHODS

This is a retrospective study of patients with ileocolic intussusception presenting to a tertiary care hospital between 1998 and 2018. We excluded the data of patients that underwent either fluoroscopic guided reduction with barium enema or primary surgery. All patients received sedation with propofol and subsequently underwent our sedated ultrasound guided saline reduction (SUR) protocol until reduction was confirmed.

RESULTS

414 total reductions were performed in the 338 children who underwent our SUR protocol, of which 86.0% were successful. Zero perforations occurred during attempted reduction. 58 patients required surgery after a failed reduction (14.0%). There were 76 recurrent episodes that underwent our SUR protocol, of which 93.4% had a successful reduction.

CONCLUSION

The success rate of reduction was high and compared similarly to techniques that either use pneumatic reduction under radiation or refrain from administering a sedative prior to enema.

LEVEL OF EVIDENCE

Treatment study level III.

Sonographic guided hydrostatic saline enema reduction of childhood intussusception: a prospective study

Background

The management of childhood intussusception in our sub-region is still via surgical intervention. Currently, the gold standard of treatment is non-operative reduction. We sought to assess the suitability of hydrostatic (saline) reduction of intussusception in children in our institution.

Materials and methods

A prospective study was conducted between January 2016 and June 2017 in all children with ultrasound confirmed intussusception at a tertiary teaching hospital in Nigeria. All children excluding those with signs of peritonitis, bowel gangrene and intestinal prolapse were selected for ultrasound-guided hydrostatic reduction (USGHR). We allowed a maximum of three attempts at reduction.

Results

The age range was 3 months to 48 months with a mean of 10.8 ± 9.1 months. Forty percent (N = 18) presented after 24 h of onset of symptoms. The success rate of hydrostatic reduction with saline enema was 84.4% (N = 38). Two (4.4%) perforations occurred during the procedure. Three (7.5%) patients had recurrent intussusception within six months. The duration of symptoms greater than 24 h, age and sex of patients did not influence successful reduction p > 0.05. The duration of admission between those who had successful non-operative reduction and those who subsequently had operative reduction and or resection attained statistical significant difference, p = 0.001. There was no mortality. We achieved a 68% decrease in the operative reduction of intussusception using USGHR as the primary modality of treatment.

Conclusion

Our study found out that USGHR is a suitable alternative for the treatment of childhood intussusception.

Utility of hospital admission for pediatric intussusceptions

PURPOSE

The standard practice in pediatric patients diagnosed with intussusception has been reduction via enema and admission for a period of nil per os and observation. Little data exists to support this practice. The objective of this study was to examine whether post-reduction admission to hospital is required.

METHODS

A retrospective chart review was performed on all patients aged 0-18 years old with intussusception over a span of 20 years. Study included children treated for intussusception on first encounter with enema and subsequently admitted for observation. Study excluded those readmitted for recurrence after 48 h, patients whose intussusception did not reduce on first try, those lost to follow-up, and those who went to the operating room. Early recurrence was defined as recurrence within 48 h post-reduction.

RESULTS

Out of 171 patients admitted, only one experienced an early recurrence (0.6 %). Median length of stay for all patients was 2 days. Average cost incurred per day for intussusception admission was $404.

CONCLUSION

Intussusception in a child that is successfully reduced via enema has a low recurrence rate and is usually followed by prompt resolution of symptoms. An abbreviated period of observation in the emergency department post-reduction may result in healthcare savings.

Twenty years' experience for reduction of ileocolic intussusceptions by saline enema under sonography control

BACKGROUND

Ultrasonography is a well-established efficient diagnostic tool for ileocolic intussusceptions in children. It can also be used to control hydrostatic reduction by saline enemas. This reduction method presents the advantage of avoiding radiations. Parents can even stay with their children during the procedure, which is comforting for both. The purpose of this study was to present our 20 years' experience in intussusception reductions using saline enema under ultrasound control and to assess its efficiency and safety.

MATERIAL AND METHODS

This retrospective single center study included patients with ileocolic intussusceptions diagnosed by ultrasound between June 1993 and July 2013. We excluded the data of patients with spontaneous reduction or who underwent primary surgery because of contraindications to hydrostatic reduction (peritonitis, medium or huge abdominal effusion, ischemia on Doppler, bowel perforation). A saline enema was infused into the colon until the reduction was sonographically confirmed. The procedure was repeated if not efficient. Light sedation was practiced in some children.

RESULTS

Eighty-tree percent of the reductions were successful with a median of 1 attempt. Reduction success decreased with the number of attempts but was still by 16% after 4 attempts. The early recurrence rates were 14.5%, and 61.2% of those had a successful second complete reduction. Forty-six patients needed surgery (11 of them had a secondary intussusception). Sedation multiplies success by 10. In this period, only one complication is described.

CONCLUSION

Ultrasound guided intussusception reduction by saline enema is an efficient and safe procedure. It prevents exposure of a young child to a significant amount of radiation, with similar success rate. We had very low complication rate (1/270 cases or 3‰). The success rate could be increased by standardized procedures including: systematic sedation, trained radiologists, accurate pressure measurement, and number and duration of attempts.

Ultrasound-guided hydrostatic reduction of intussusception with saline: Safe and effective

PURPOSE

The study was undertaken to assess the efficacy of ultrasound-guided saline enema in reducing intussusception and to determine the role of age and duration of symptoms on this event.

METHODS

The case records of patients who were treated for intussusception at our institutions over the past 10 years were retrospectively analyzed. A total of 419 patients were treated for intussusception and 375 of them were included into the study. Patients were excluded if they had symptoms and signs of acute abdominal disease and required surgery as an initial treatment.

RESULTS

Hydrostatic reduction was successful in 313 of the 375 patients (83.46%). The procedure-related complication rate was nil. There were 29 episodes of recurrences in 23 patients, and recurrence rates did not differ between patients who responded to hydrostatic reduction and those who required surgery. Younger age [median (range); 11 months (3-108 months) vs. 20 months (1-180 months); p<0.05], rectal bleeding (p<0.01) and long duration of symptoms [mean (range); 1.95 days (1-7 days) vs. 1.44 days (1-10 days); p<0.01] were significantly associated with failed hydrostatic reduction.

CONCLUSION

Ultrasound-guided hydrostatic reduction is an easy, safe and effective method for the treatment of intussusception in the absence of acute abdominal findings.

Recurrence rates after intussusception enema reduction: a meta-analysis

BACKGROUND AND OBJECTIVE

Reported rates of recurrence after enema reduction for intussusception are variable. Concerns for recurrence influence postreduction management. The objective of this study was to conduct a systematic review and meta-analysis to estimate overall, 24-hour, and 48-hour recurrence rates after enema reduction in children.

METHODS

PubMed, Cochrane Database, and OVID Medline were searched from 1946 through December 2011 using the search terms: intussusception, recurrence, and enema. Sixty-nine studies of patients age 0 to 18 years with radiographically proven intussusception reduced by enema that report the number of enema reductions and the number of recurrences were included. Extraction was done by the primary author (M.P.G.) with 10% of included studies independently audited to ensure concordance.

RESULTS

Overall recurrence rates were 12.7% (95% confidence interval [CI]: 11.1%-14.4%, I2 = 28.8%) for contrast enema (CE), 7.5% (95% CI: 5.7%-9.8%, I2 = 52.4%) for ultrasound-guided noncontrast enema (UGNCE), and 8.5% (95% CI: 6.9%-10.4%, I2 = 50.1%) for fluoroscopy-guided air enema (FGAE). Recurrence rates within 24 hours were 3.9% (95% CI: 2.2%-6.7%, I2 = 47.0%) for CE, 3.9% (95% CI: 1.5%-10.1%, I2 = 0.0%) for UGNCE, and 2.2% (95% CI: 0.7%-6.5%, I2 = 59.8%) for FGAE. Recurrence rates within 48 hours were 5.4% (95% CI 3.7%-7.8%, I2 = 32.3%) for CE, 6.6% (95% CI: 4.0%-10.7%, I2 = 0.0%) for UGNCE, and 2.7% (95% CI: 1.2%-6.5%, I2 = 73.8%) for FGAE. Most included studies are retrospective and vary in quality of reporting. Few studies reported detailed patient characteristics including timing of recurrences.

CONCLUSIONS

The risk of early (within 48 hours) recurrence after enema reduction is low, suggesting outpatient management of well-appearing patients should be considered.

Ultrasound guided reduction of an ileocolic intussusception by a hydrostatic method by using normal saline enema in paediatric patients: a study of 30 cases

INTRODUCTION

The conventional hydrostatic reduction of an intussusception with barium enema or the pneumatic reduction of an intussusception is associated with considerable ionizing radiations and a risk of perforation; while the hydrostatic reduction of an intussusception under ultrasound guidance is a very safe method because the whole procedure is visualized with real time ultrasound. Also, being a non-invasive method with a high success rate, this procedure has emerged as a useful alternative to a surgical intervention.

AIM

The aim of this study was to evaluate the role of ultrasound and colour Doppler studies for the guidance of the hydrostatic reduction of a childhood intussusception by using normal saline.

METHOD

Among 41 children who were evaluated with ultrasonography for the confirmation of the presence of intussusceptions, hydrostatic reduction of intussusception were performed under a sonographic guidance in 30 patients, whereas 11 patients were excluded due to clinical contraindications.

RESULTS

This disease was observed mostly at the ages of 6 months to 24 months. In 80% of the patients, there was a recent history of gastroenteritis and 40 % had a history of common cold. The most common site of the intussusception was the transverse colon near the hepatic flexor of the colon (90%), with a mean duration of 22.1±17.3 hours. The overall rate of a successful reduction was 87% and the mean reduction time was 14 minutes. None of the cases showed recurrence within 24 hrs. No complications were observed.

CONCLUSION

We conclude that ultrasound with colour Doppler study is very useful for the diagnosis of intussusceptions, as well as for guided hydrostatic reductions by using normal saline enema. This is an optimal, simple, and a safe procedure for the treatment of intussusceptions in paediatric patients.

Japanese guidelines for the management of intussusception in children, 2011

BACKGROUND

The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death.

METHODS

Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels.

RESULTS

Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable.

CONCLUSIONS

The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.

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.

Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: a review of 5218 cases in 17 years

BACKGROUND

The aim of this study was to evaluate the results of ultrasound (US)-guided hydrostatic reduction (UGSED) of intussusceptions in pediatric patients by saline enema.

METHODS

Five thousand two hundred eighteen pediatric patients with intussusceptions treated by UGSED from October 1985 to October 2002 were reviewed retrospectively.

RESULTS

The success rate of reduction in 5218 patients was 95.5%. Two hundred thirty-seven patients (4.5%) underwent surgery. Colonic perforation occurred in 9 patients (0.17%). Two infants suffered from milk aspiration because of vomiting during the hydrostatic enema reduction. There was no mortality.

CONCLUSIONS

UGSED of intussusceptions avoids radiation exposure. It is reliable and safe. It has high success rate and minimal complications. It is a perfect method for the nonoperative treatment of pediatric intussusception and can be widely used as routine therapy.

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Investigation in vomiting children

This article discusses how to investigate various surgical causes of vomiting. Particular emphasis is placed on plain radiographic, ultrasound, and contrast study findings. The article touches upon nineteen different diseases, and encompasses diseases found in neonates to adolescents.

Laparoscopic reduction of an ileoileal intussusception and resection of an inverted Meckel's diverticulum in an adult

Intussusception occurs commonly in children, but rarely is observed in adults. Whereas the hydrostatic pressure of a contrast enema often proves diagnostic as well as therapeutic in infants and children, resection usually is required for an underlying bowel pathology in older children and adults. Conventionally, the resection is accomplished at laparotomy. We report the case of a 20-year-old woman who presented with diarrhea and vomiting of 1 week duration. She was found unexpectedly to have intussusception on abdominal ultrasonography. The intussusception was laparoscopically reduced, and a segment of the middle small bowel that harbored an inverted Meckel's diverticulum was resected laparoscopically, after which an intracorporeal anastomosis was fashioned. The ileus resolved on postoperative day 4, and the patient was discharged from hospital on postoperative day 5. The role of the laparoscopic approach in the management of intussusception is discussed.

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.

Childhood intussusception: a comparative study of nonsurgical management

PURPOSE

A prospective study was conducted comparing air reduction, barium reduction under fluoroscopy, and saline reduction under ultrasound guidance for diagnosis and treatment of intussusception involved in 147 patients.

METHODS

Fifty children received air reduction (AR group), 50 received barium enema reduction (BE group) and 47 received saline reduction under ultrasound guidance (US group). Nonoperative management was attempted if there was a history of less than 48 hours; absence of general or abdominal signs of toxicity, peritonism, or peritonitis, and reasonable blood electrolyte levels (K, 3 to 5 mmol/L; Na, 130 to 150 mmol/L).

RESULTS

Group AR had successful outcome in 45 of 50 children (90%); BE had successful outcome in 35 of 50 children (70%), and US had successful outcome in 32 of 47 children (67%). This 20% to 23% success rate difference between air reduction and the other two techniques (BE and US) was statistically significant (P = .01). There was no significant difference between BE and US saline (P > or = .05). There were no perforations encountered in AR patients, three perforations in BE patients, and two perforations in US patients. There was no mortality.

CONCLUSIONS

Air reduction seems to be associated with fewer complications and the highest success rate. Proper selection of patients is crucial to achieve a high success rate and to minimise complications.

The approach to common abdominal diagnosis in infants and children

This article focuses on salient points in the evaluation of abdominal pain in infants and children. Specifically, the authors address appendicitis and abdominal pain associated with either vomiting, constipation, or gastrointestinal bleeding. A discussion of common abdominal masses, urologic, and gynecologic problems, and considerations in the evaluation of immunologically suppressed or neurologically impaired children, and children with recurrent abdominal pain is also presented. The authors establish logical, focused approaches to the initial evaluation and management of abdominal pain and suggest criteria for timely surgical referral.