Sonographic detection of lymph nodes in the intussusception of infants and young children: clinical evaluation and hydrostatic reduction

Impact of a 6-12-h delay between ileocolic intussusception diagnostic US and fluoroscopic reduction on patients' outcomes

BACKGROUND

Image-guided reduction of intussusception is considered a radiologic urgency requiring 24-h radiologist and technologist availability.

OBJECTIVE

To assess whether a delay of 6-12 h between US diagnosis and fluoroscopic reduction of ileocolic intussusception affects the success frequency of fluoroscopic reduction.

MATERIALS AND METHODS

Retrospective review of 0-5-year-olds undergoing fluoroscopic reduction for ileocolic intussusception from 2013 to 2023. Exclusions were small bowel intussusception, self-reduced intussusception, first fluoroscopic reduction attempt>12 h after US, prior bowel surgery, inpatient status, and patient transferred for recurrent intussusception. Data collected included demographics, symptoms, air/contrast enema selection, radiation dose, reduction failure, 48-h recurrence, surgery, length of stay, and complications. Comparisons between<6-h and 6-12-h delays after ultrasound diagnosis were made using chi-square, Fisher's exact test, and Mann-Whitney U tests (P< 0.05 considered significant).

RESULTS

Of 438 included patients, 387 (88.4%) were reduced in <6 h (median age 1.4 years) and 51 (11.7%) were reduced between 6 and 12 h (median age 2.05 years), with median reduction times of 1:42 and 7:07 h, respectively. There were no significant differences between the groups for reduction success (<6 h 87.3% vs. 6-12 h 94.1%; P-value = 0.16), need for surgery (<6 h 11.1% vs. 6-12 h 3.9%; P-value=0.112), recurrence of intussusception within 48 h after reduction (<6 h 9.3% vs. 6-12 h 15.7%; P-value=0.154), or length of hospitalization (<6 h 21:07 h vs. 6-12 h 20:03 h; P-value=0.662).

CONCLUSION

A delay of 6-12 h between diagnosis and fluoroscopic reduction of ileocolic intussusception is not associated with reduced fluoroscopic reduction success, need for surgical intervention after attempted reduction, recurrence of intussusception following successful reduction, or hospitalization duration after reduction.

Ultrasound-guided pneumatic reduction of intussusception in children: 15-year experience in a tertiary children's hospital

BACKGROUND

International practice regarding the method used to nonoperatively reduce pediatric intussusception is variable.

OBJECTIVE

To provide an overview of ultrasound-guided pneumatic intussusception reduction and assess its safety and effectiveness.

MATERIALS AND METHODS

A single-center prospective study was conducted in a tertiary referral pediatric hospital during the 15-year period between January 2008 and February 2023. All patients with ileocolic intussusception underwent abdominal sonographic examination for diagnosis. An ultrasound-guided pneumatic reduction of intussusception was then attempted. Children who were hemodynamically unstable, with signs of peritonitis or bowel perforation and those with sonographically detected pathologic lead points were excluded.

RESULTS

A total of 131 children (age range 2 months to 6 years) were enrolled in this study. Pneumatic intussusception reduction was successful in 128 patients (overall success rate 97.7%). In 117 patients, the intussusception was reduced on the first attempt and in the remaining on the second. In three cases, after three consecutive attempts, the intussusception was only partially reduced. As subsequently surgically proven, two of them were idiopathic and the third was secondary to an ileal polyp. No bowel perforation occurred during the reduction attempts. There was recurrence of intussusception in three patients within 24 h after initial reduction which were again reduced by the same method.

CONCLUSION

Ultrasound-guided pneumatic intussusception reduction is a well-tolerated, simple, safe and effective technique with a high success rate, no complications and no ionizing radiation exposure. It may be adopted as the first-line nonsurgical treatment of pediatric intussusception.

Factors associated with in-hospital recurrence of intestinal intussusception in children

BACKGROUND

A minority of children experience in-hospital recurrence of intestinal intussusception after treatment. This study investigated the factors associated with in-hospital recurrence of intussusception in pediatric patients in China.

METHODS

This retrospective study included patients aged 0-18 years-old with intestinal intussusception treated at Hainan Women and Children's Medical Center between January 2019 and December 2019. Demographic and clinical characteristics were extracted from the medical records. Factors associated with in-hospital recurrence of intussusception were identified by logistic regression analysis.

RESULTS

The analysis included 624 children (400 boys) with a median age of 1.8 years (range, 2 months and 6 days to 9 years). Seventy-three children (11.7%) had in-hospital recurrence of intussusception after successful reduction with air enema. Multivariate logistic regression analysis identified age > 1 year-old (odds ratio [OR]: 7.65; 95% confidence interval [95%CI]: 2.70-21.71; P < 0.001), secondary intestinal intussusception (OR: 14.40; 95%CI: 4.31-48.14; P < 0.001) and mesenteric lymph node enlargement (OR: 1.90; 95%CI: 1.13-3.18; P = 0.015) as factors independently associated with in-hospital recurrence of intussusception.

CONCLUSIONS

Age > 1 year-old, secondary intussusception and mesenteric lymph node enlargement were independently associated with increased odds of in-hospital recurrence of intussusception after successful reduction with air enema.

Evolving Concepts in Ultrasonography of Pediatric Intussusceptions: Unequivocal Differentiation of Ileocolic, Obstructive and Transient Small-Bowel Intussusceptions

The main aim of the study was to elaborate on the various ultrasonographic parameters that can be used for definite differentiation of ileocolic, obstructive small-bowel and transient small-bowel intussusceptions (SBI). In this study, 90 children (63 boys and 27 girls) with suspected intussusception were evaluated. Of these, 54 cases were diagnosed as obstructive intussusceptions (33 ileocolic and 21 ileoileal), 15 cases were classified as transient SBIs and 21 cases were negative for intussusception. The mean fat core diameter was 1.45 ± 0.32 cm for ileocolic versus 0.37 ± 0.06 cm for obstructive SBI versus 0.29 ± 0.08 cm for transient SBI (p < 0.001). The mean lesion diameter was 3.23 ± 0.08 cm for ileocolic intussusceptions and 2.12 ± 0.038 cm for SBI (p < 0.001), and the ratio of inner fat core to outer wall thickness was greater than 1 for ileocolic intussusceptions and less than 1 for SBI. A statistically significant difference was found between segmental invagination of transient versus obstructive SBIs with mean values of 1.93 ± 0.39 cm and 3.17 ± 0.25 cm, respectively, and an "optimal" threshold at 2.5 cm.

Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception

OBJECTIVES

The aim of this study was to evaluate whether point-of-care ultrasound (POCUS) for intussusception screening streamlines the workflow of clinically nonspecific intussusception (CNI), an intussusception presenting with only 1 manifestation of the classic triad, and/or vomiting.

METHODS

We reviewed 274 consecutive children with intussusception, aged 6 years or younger, who visited a tertiary care hospital emergency department between May 2012 and April 2016. This period was dichotomized by May 2014 (the "PRE" and "POST" groups), starting point of implementation of the POCUS protocol for intussusception screening. All children with CNI who had positive results on or forwent POCUS underwent radiologist-performed ultrasound (US). We measured and compared emergency department length of stay (EDLOS), the sum of door-to-reduction and observation times, and the frequency of POCUS and positive US results between the 2 groups.

RESULTS

Of 160 children with CNI, 93 visited the emergency department since May 2014. The POST group showed a shorter median EDLOS (856 vs 630 minutes, P < 0.001), door-to-reduction time (137 vs 111 minutes, P = 0.002), and observation time (700 vs 532 minutes, P < 0.001). The POST group had a higher frequency of POCUS (12% vs 60%, P < 0.001) with positive US results (33% vs 59%, P < 0.001). The PRE group had a higher frequency of severe bowel edema (16% vs 1%, P < 0.001). No significant differences were found in the severity, recurrence, admission, and surgery. One child had a false-negative result on POCUS.

CONCLUSIONS

Point-of-care ultrasound could streamline the workflow of CNI via decrease in EDLOS and unnecessary referrals for US.

Current Views in the Diagnosis and Treatment of Intestinal Intussusception

Intestinal intussusceptions most often occur in young dogs and cats. Common locations for intestinal intussusceptions include enterocolic, eneteroenteric or colocolic. Ultrasonography is highly reliable for diagnosing of intussusception and for prediction of its reducibility. Abdominal structures that may mimic intussuception can be seen ultrasonographically. Intussusceptions is a surgical emergency. Immediate stabilization of the animal followed by manual reduction or intestinal excision of the affected intestine through midline celiotomy are required. Recurrence is a common postsurgical complication. Enteroplication may be considered for recurrence prevention but is not without complications. Prognosis is good in uncomplicated cases.

High prevalence of obesity among infants presenting with intussusception: Findings in an Egyptian cohort

BACKGROUND AND STUDY AIMS

Intussusception is a life-threatening illness, with incompletely understood aetiology, although some predisposing factors are known. Intussusception frequently occurs in well-nourished chubby infants. We aimed to determine whether patients presenting with intussusception have a high prevalence of obesity.

PATIENTS AND METHODS

This cross sectional study was conducted in 100 infants presenting with intussusception aged ≤2 years at the Paediatric Surgery Department. Anthropometric measures, history of recent upper respiratory tract infection, timing and type of intervention were recorded. A near median split divided the population into younger (aged < 8 months, N = 47) and older (8-24 months, N = 53) groups. Obesity was defined as having a body weight for length ≥ 97.7th centile on WHO growth charts.

RESULTS

The study comprised 58 boys and 42 girls, 31% of whom had upper respiratory infection in the preceding month. Obesity was present in 18% of patients, based on WHO growth charts. There was a trend towards higher percentage of obese infants within the younger (25%) compared to older age groups (12%, P = 0.085), but no gender difference. Obesity did not influence the rate of success of hydrostatic reduction. Based on Egypt-specific growth charts, the percentage of infants with a weight-for-age centile ≥ 85th was 42%, of whom 7% were ≥ 97.7th centile. The corresponding percentages for the weight-for-length were 29% and 15% of patients respectively.

CONCLUSION

There is a high prevalence of obesity in infants presenting with intussusception, particularly under 8 months of age. The mechanistic link between obesity and the pathogenesis of intussusception deserves investigation.

Point-of-care ultrasound identification of pneumatosis intestinalis in pediatric abdominal pain: a case report

We describe a case report of an infant with intussusception who presented to a pediatric emergency department with diarrhea and increased irritability. Pneumatosis intestinalis (intra-mural air) detected on point-of-care ultrasonography (but not apparent on plain abdominal radiographs) alerted the emergency physicians towards the severity of disease process.

Risk factors associated with failed sonographically guided saline hydrostatic intussusception reduction in children

OBJECTIVES

The aim of this study was to explore the risk factors associated with failed sonographically guided saline hydrostatic intussusception reduction in children.

METHODS

We retrospectively reviewed the medical records and sonograms of 288 cases of intussusception over a 3-year period. Logistic regression was used for the analysis of the clinical data (sex, age, duration of symptoms, and presence or absence of emesis or bloody stool) and sonographic features (initial location and intussusception length, presence or absence of free peritoneal fluid, and trapped fluid in the intussusception).

RESULTS

The sex, age, and duration of symptoms showed no significant impact on the hydrostatic reducibility. The success rate became significantly lower for the intussusception cases with the presence of bloody stool, free peritoneal fluid, and trapped fluid in the intussusception (P < .05). The success rate was also lower when the intussusceptions were located in the left side of the abdomen (P < .05). For the above risk factors, the odds ratios from multivariate logistic regression analysis were 174.68 for initial intussusception location in the descending colon/rectum, 36.06 for the presence of peritoneal fluid, 13.22 for trapped fluid in the intussusception, and 9.27 for the presence of bloody stool.

CONCLUSIONS

An initial intussusception location in the descending colon/rectum, the presence of peritoneal fluid, trapped fluid in the intussusception, and bloody stool are the most important risk factors for failure of sonographically guided saline hydrostatic intussusception reduction.

External manual reduction of paediatric idiopathic ileocolic intussusception with US assistance: a new, standardised, effective and safe manoeuvre

BACKGROUND

The ultimate goal in the management of paediatric ileocolic intussusception is to achieve non-operative reduction and therefore patient cure. The standard non-surgical treatment consists of enema (air or liquid media).

OBJECTIVE

The purpose of this study is to present external manual reduction for paediatric ileocolic intussusception. We present a new manoeuvre that is standardised, simple, safe and effective for the radiologist in the non-surgical management of this pathology.

MATERIALS AND METHODS

External manual reduction is performed under sedation. Execution of the manoeuvre is detailed and illustrated. The procedure was carried out 15 times in 13 paediatric patients with idiopathic ileocolic intussusception.

RESULTS

Complete reduction exclusively by external manual reduction was accomplished on 12 occasions (80%). In the remaining three procedures, partial reduction to the cecum was obtained. Subsequent enema achieved complete reduction in two. Overall non-surgical reduction rate was 93%.

CONCLUSION

External manual reduction is a radiation-free, safe and effective procedure. In case of incomplete reduction, it facilitates enema performance. External manual reduction incorporates and additional initial step in the non-surgical reduction of intussusception and should be considered a first-line procedure.

Interloop fluid in intussusception: what is its significance?

BACKGROUND

Sonography has been used to predict pneumatic reduction outcome in children with intussusception.

OBJECTIVE

To assess the prognostic significance of fluid between the intussusceptum and intussuscepiens with respect to reduction outcome, lead point or necrosis.

MATERIALS AND METHODS

Sonograms of children with a discharge diagnosis of intussusception from four institutions were reviewed for interloop fluid and correlated with results of pneumatic reduction and surgical/pathological findings when available. Maximal dimension of interloop fluid on a transverse image and fluid complexity were evaluated.

RESULTS

Of 166 cases, 36 (21.7%) had interloop fluid. Pneumatic reduction was successful in 21 (58.3%) with fluid and 113 (87.6%) without. The average largest fluid dimension was 8.7 mm (range 5 mm-19 mm, median 8 mm) in cases with successful reduction and 12.8 mm (range 4 mm-26 mm, median 12.5 mm) in unsuccessful reduction (p < 0.05). Fluid dimension equal to or greater than 9 mm correlated with failed reduction (p < 0.0001;odds ratio 13:1). In 36 cases with interloop fluid that required surgery, there were four lead points and three necrosis. In cases without fluid with surgical reduction, there was one lead point and one necrosis. Interloop fluid correlated with lead point (p < 0.04) or necrosis (p < 0.03). Its significance increased with larger amounts of fluid (p < 0.0001). Patient age/fluid complexity did not correlate with reduction outcome (p = 0.9).

CONCLUSION

Interloop fluid was associated with increased failure of pneumatic reduction and increased likelihood of lead point or necrosis, particularly when the maximum dimension exceeded 9 mm.

Intramural and subserosal echogenic foci on US in large-bowel intussusceptions: prognostic indicator for reducibility?

BACKGROUND

In large-bowel intussusceptions, several US signs are known to indicate a lower likelihood of reducibility by enema. US can demonstrate echogenic dots or lines (foci) in the bowel wall, which might indicate an ischemic bowel.

OBJECTIVE

To determine the presence of echogenic intramural and subserosal foci in large-bowel intussusceptions and to evaluate the degree of correlation with reducibility.

MATERIALS AND METHODS

Between 2001 and 2008, 74 consecutive US examinations were retrospectively evaluated by two pediatric radiologists for intramural and subserosal echogenic foci, or trapped gas, in the intussusception. The degree of correlation between the sonographic findings and reducibility was evaluated.

RESULTS

Of 73 intussusceptions examined by US, 56 (76%) were reducible and 17 (23%) were not reducible. Out of 10 intussusceptions with intramural gas, 11 with subserosal gas, and 14 with intramural and subserosal gas, 8 (80%), 6 (56%), 9 (64%), respectively, were not reducible. The presence of intramural gas or subserosal gas or both predicted a lower chance of reduction, but with regard to the effect of these findings together, intramural gas was the only significant predictor.

CONCLUSION

Having intramural gas in large-bowel intussusception significantly decreases the chance of reduction.

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.

Sonographic Evaluation of the Child with Lower Abdominal or Pelvic Pain

At many centers, CT has become the primary imaging modality for children who have abdominal pain. CT, however, delivers a substantial radiation dose, which is of particular concern in the pediatric patient. In contrast, sonography does not expose the patient to ionizing radiation. Properly performed, sonography is capable of providing useful diagnostic information in the child who has lower abdominal or pelvic pain. In many children and with many disorders, sonography proves to be the only imaging modality that may be required. In this article, the usefulness of sonography in evaluating disorders producing lower abdominal or pelvic pain in a child is reviewed.

Intermittent sonographic guidance in air enemas for reduction of childhood intussusception

OBJECTIVE

The purpose of this study was to prospectively assess the value of intermittent sonographic guidance in nonsurgical air reduction of childhood intussusception.

METHODS

The study group included 86 consecutive childhood intussusceptions confirmed on sonography for which we designed an air enema. With intermittent sonographic guidance of our own method, air was gradually injected to the initial intracolonic pressure of 60 mm Hg, which we attempted for 30 seconds on the initial attempt. If the air enema reduction attempts were not successful at a given pressure setting, we repeated the technique at each pressure setting upgraded by increments of 20 mm Hg up to 120 mm Hg. Surgery was performed when even repeated reduction attempts at the maximum intracolonic pressure of 120 mm Hg were unsuccessful. We calculated the successful reduction rate for the intussusceptions at each pressure setting.

RESULTS

The overall success rate of sonographically guided air enema reductions was 95% (82/86). The success rates of air enema reductions at 60, 80, 100, and 120 mm Hg showed progressive increases of 53% (42/86), 67% (58/86), 78% (67/86), and 95% (82/86), respectively, with no immediate recurrence and no gross perforation.

CONCLUSIONS

The use of intermittent sonographic guidance in air enemas is thought to help safely increase successful reductions of childhood intussusception even with sufficient air enema attempts.

Mimics of Appendicitis: Alternative Nonsurgical Diagnoses with Sonography and CT

OBJECTIVE

Our objective was to illustrate the imaging features of alternative nonsurgical disorders in patients presenting with clinical signs of appendicitis.

CONCLUSION

This article illustrates the sonographic and CT features of various appendicitis-mimicking conditions that are self-limiting or that can be treated conservatively. A correct imaging diagnosis of these disorders may prevent a nontherapeutic appendectomy and unnecessary hospitalization.

Ultrasound guided hydrostatic reduction in the management of intussusception

OBJECTIVE

A case series study was conducted for two years from 01 June 2002 to 01 June 2004 to study the efficiency of ultrasound guided hydrostatic reduction in the management of intussusception in children.

METHODS

A total of 25 patients who underwent the procedure were evaluated. All the patients were diagnosed by High Resolution Ultrasonography (HRUSG). Continuous monitoring of the progress of reduction during the procedure was done by HRUSG. 500-1000 ml (average 600 ml) of normal saline was used.

RESULTS

24 out of 25 (96%) intussusceptions were successfully reduced. Average time taken was 15 minutes. All the patients were reviewed after 24 hrs for recurrence. None of them showed recurrence within 24 hrs. No complications were observed.

CONCLUSION

The study concludes that ultrasound guided hydrostatic reduction is a safe, simple and effective method for treatment of intussusception in children.

COLOR DOPPLER ULTRASONOGRAPHY IN PREDICTION OF THE REDUCIBILITY OF INTUSSUSCEPTED BOWEL IN 15 YOUNG DOGS

Color Doppler ultrasonography was performed in 15 young dogs with intestinal intussusception to test the hypothesis that color Doppler findings can be used as a predictor of the manual reducibility of the intussusception at celiotomy. Color flow Doppler ultrasonography indicated blood flow within mesentery of the intussuscepted bowel in 12 of 15 dogs and reduction was achieved in nine of these 12 dogs (75%). In the remaining three dogs and in three dogs where no color Doppler signal were observed, an irreducible intussusception was confirmed at celiotomy. Color Doppler ultrasonography is a useful method for predicting the reducibility of intussusception in dogs.

Intestinal imaging of children with acute rotavirus gastroenteritis

OBJECTIVE

To examine the morphology and motility of the distal small bowel of infants with rotavirus gastroenteritis using non-invasive/non-ionizing imaging technology.

METHODS

Prospective, non-randomized observational study of five infants with symptomatic rotavirus infection. Infants were imaged by real-time magnetic resonance imaging (MRI) and ultrasound within 5 days of onset of gastroenteritis symptoms. Imaging studies were repeated in the convalescent period 5 to 9 weeks later.

RESULTS

Three of five infants had a significant increase in the ileal wall thickness visualized by ultrasound during acute rotavirus infection compared with convalescence. The number and size of mesenteric lymph nodes visualized by ultrasound appeared similar in the acute and convalescent phases, as did peristaltic activity assessed by MRI.

CONCLUSION

Abdominal ultrasound can detect changes in ileal wall thickness in infants with rotavirus infection. These changes may reflect ileal inflammation elicited by viral infection. Such studies may prove useful in evaluating morphologic response to attenuated rotavirus vaccines.

Ultrasound evaluation of acute abdominal emergencies in infants and children

Ultrasound is extremely beneficial in the evaluation of acute pediatric abdominal disease, such as HPS, intussusception, and acute appendicitis. As techniques and equipment improve, its role in the evaluation of infants and children continues to increase.

Sonography of the acute abdomen in the pediatric patient

OBJECTIVE

To review the causes and sonographic appearance of pathologic processes that result in abdominal pain in the pediatric patient and to understand the use and limitations of abdominal sonography in the acute pediatric abdomen.

METHODS

A pictorial review of cases is presented.

RESULTS

Sonography in conjunction with color and pulsed Doppler imaging is a valuable tool in the evaluation of the acute abdomen in the pediatric patient. This article reviews the use of sonography in the evaluation of the acute abdomen in the pediatric patient.

CONCLUSIONS

The causes of the acute abdomen in children vary depending on the ages of the children. Sonography is a noninvasive modality and is useful for assessing these patients.