Intussusception presenting as profound lethargy

High risk and low incidence diseases: Pediatric intussusception

INTRODUCTION

Pediatric intussusception is a serious condition that carries with it a high risk of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric intussusception, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Intussusception is one of the most common pediatric abdominal emergencies. This is associated with one part of the intestine telescoping into another, resulting in bowel edema. If the intussusception remains untreated, obstruction, ischemia, necrosis, and perforation may result. Most cases are idiopathic, with 10-25 % associated with a pathologic mass or lead point. The most common age group affected includes those between 3 months to 5 years. The triad of intermittent abdominal pain, currant jelly stool, and sausage-shaped mass is uncommon, though most patients will present with intermittent abdominal pain. Nonbilious emesis and bloody stools (gross blood or guaiac positive) are also common. Younger patients can present atypically, including altered mental status or lethargy. Thus, intussusception should be considered in pediatric patients with abdominal pain, emesis, and a sausage-shaped mass, as well as those with atypical presentations such as altered mental status or lethargy if there is no other etiology found on testing. The diagnostic modality of choice is ultrasound. Plain radiography may assist in evaluating for obstruction and perforation. Treatment includes prompt reduction of the intussusception. In patients who are stable and have no evidence of perforation, non-operative reduction with hydrostatic or pneumatic reduction should be attempted. Operative intervention is necessary in those who are unstable, peritonitic, or have a focal lead point. Discharge may be appropriate for patients following successful non-operative reduction if the patient is able to tolerate clear fluids, is asymptomatic, and can return for any recurrence of symptoms.

CONCLUSION

An understanding of pediatric intussusception and its many potential mimics can assist emergency clinicians in diagnosing and managing this high risk disease.

Fluoroscopy-guided hydrostatic reduction of intussusception in infancy: role of pharmacological premedication

PURPOSE

Intussusception is one of the most common causes of paediatric emergency. Fluoroscopy-guided hydrostatic reduction is a common nonoperative management strategy for the treatment of intussusception. The role of pharmacological premedication in increasing the success rate of hydrostatic reduction is still controversial. The purpose of this study was to verify the presence of a possible correlation between pharmacological premedication and the percentage of hydrostatic reduction of intussusception in paediatric patients.

MATERIALS AND METHODS

This study considered children with a diagnosis of idiopathic intussusception treated at our hospital between January 2007 and June 2013. One group of patients underwent hydrostatic reduction by barium enema without any preliminary therapy. A second group of patients received pharmacological premedication with both a sedative and an anti-oedematous agent before the procedure.

RESULTS

A total of 398 patients were treated with barium enema for therapeutic purposes. In the group of patients who received no premedication (n = 254), 165 (65 %) children achieved hydrostatic reduction of the intussusception. Among the patients who received pharmacological premedication prior to barium enema (n = 144), 122 (85 %) children achieved resolution of the intussusception.

CONCLUSIONS

Our study shows that the use of pharmacological premedication is effective for the reduction of the intussusception, as its limit patient stress, fluoroscopic time and radiation dose.

[Neurological symptoms in children with intussusception]

INTRODUCTION

Intussusception is a potentially severe obstructive disease that occurs when a more proximal portion of bowel invaginates into a more distal part of the bowel. Patients with intussusception often present with a wide range of non-specific systemic symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. An acute change in level of consciousness could be the only clinical symptom of this disorder.

OBJECTIVES

To ascertain the frequency and nature of the neurological symptoms in children with intussusception, and to describe the characteristics of the patients presenting in this atypical way.

PATIENTS AND METHODS

We retrospectively reviewed the records of 351 children presenting with intussusception from 2000 to 2012. General epidemiological data, abdominal and neurological signs and symptoms, duration of symptoms and effectiveness of treatment, were analysed in all patients.

RESULTS

Of the 351 patients studied, 15 (4.27%) had one or more neurological symptoms recorded at presentation, with lethargy being the most frequent (66.66%), followed by hypotonia, generalized weakness, paroxysmal events, and fluctuating consciousness. Sixty per cent of these fifteen patients showed isolated neurological symptomatology, and eleven of them (73.3%) needed a laparotomy to reduce the intussusception.

CONCLUSIONS

Intussusception should be considered in the differential diagnosis in infants and young children presenting as a pediatric emergency with lethargy, hypotonia, generalized weakness, paroxysmal events and/or sudden changes in consciousness, even in the absence of the classical symptoms of intussusception. An early recognition of intussusception may improve the global prognosis and avoid ischaemic intestinal sequelae.

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

Intussusception is the most common cause of intestinal obstruction in children between 3 months and 6 years. Intussusception occurs when a more proximal portion of bowel invaginates into more distal bowel. These patients often present with a wide range of non-specific symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. Thus, the diagnosis continues to rely on clinical suspicion. This review article discusses the clinical presentation of intussusception and the state-of-the art diagnostic and treatment options, as well as a review of the pertinent literature.

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.

Altered consciousness and lethargy from compromised intestinal blood flow in children

Altered state of consciousness and lethargy could be early and cardinal complaints in diseases that actually originate within the abdomen. Thirteen children were seen at our departments in whom impairment of the individual's mental state preceded the appearance of common gastrointestinal symptoms. Whereas in infants with intussusception of childhood neurological signs and symptoms have been rarely mentioned, references to an altered state of consciousness and lethargy in volvulus, strangulation or bowel incarceration have not been previously reported. Recognition of this possibility, however, should be taken into account in the diagnostic work-up of children presenting with inexplicable alterations of their mental state.