Ileoileocolic Intussusception Research Articles

Ileoileocolic intussusception secondary to isolated ectopic pancreatic tissue: An uncommon case

Ileoileocolic intussusception secondary to isolated ectopic pancreatic tissue: An uncommon case

Small bowel intussusception together with appendicitis in childhood: A case report

Simultaneous diagnosis of intussusception and appendicitis in the same patient have rarely been described in the pediatric population. We reported a small bowel intussusception case together with acute suppurative appendicitis. A 9 years old boy had abdominal colic pain and he had vomit frequently. On physical examination, he was awake, active and uncomfortable. Abdominal ultrasound (US) suggested ileoileocolic intussusception. Laparotomy was performed and an ileoileocolic intussusception was visualized. Ileoileocolic intussusception was reducted manually. After reduction appendix was visualized and it was acute suppurative appendicitis. Appendectomy was performed. Neither medical nor surgical problem occurred during long term follow-up. In conclusion, we though that it is important to examine the other pathologic conditions such as leading points, bowel complications and even appendicitis in case of intussusception.

Delayed presentation of intussusception in childrena surgical audit

Background The preferred modality of treatment of intussusception is radiologic reduction; however, the situation is different in our setup, in which surgery is the only possible treatment modality to salvage patients. This study presents the management of patients of intussusception in our setup with delayed presentation, in which surgery becomes necessary to save life.Patients and methods This retrospective study included reviewing the records of all patients having intussusception. The patients were evaluated for their age of presentation, sex, duration of symptoms before presenting to the hospital, type of intussusception, complications of surgery, mortality, and follow-up.Results The study duration was 9 years and included 95 patients. The male-to-female ratio was approximately 2.5 : 1. The mean age at presentation was 3.24 ± 2.49 years. The mean duration of symptoms before presenting to the hospital was 6.08± 1.38 days. The presenting features were vomiting in 95 patients (100%), distension of theabdomen in 67 patients (70.5%), lump in the abdomen in 61 patients (64%), and bleeding per rectum in 10 patients (10.5%). Eighty-six patients (90.5%) had ileocolic or ileoileocolic intussusception. Resection was required in 75 patients (79%). The mortality rate in this study was 10.5%.Conclusion Despite the advances in the diagnosis and treatment of intussusception, a large number of children in the developing world still present very late. Hence, the treating surgeon must be ready to manage this entity effectively. Proper clinical evaluation, resuscitation, and treatment as per the condition of the patients yield good results.Keywords: bowel obstruction, children, delayed presentation, intussusceptions, surgery

Delayed presentation of intussusception in children–a surgical audit

Background The preferred modality of treatment of intussusception is radiologic reduction; however, the situation is different in our setup, in which surgery is the only possible treatment modality to salvage patients. This study presents the management of patients of intussusception in our setup with delayed presentation, in which surgery becomes necessary to save life. Patients and methods This retrospective study included reviewing the records of all patients having intussusception. The patients were evaluated for their age of presentation, sex, duration of symptoms before presenting to the hospital, type of intussusception, complications of surgery, mortality, and follow-up. Results The study duration was 9 years and included 95 patients. The male-to-female ratio was approximately 2.5 : 1. The mean age at presentation was 3.24 ± 2.49 years. The mean duration of symptoms before presenting to the hospital was 6.08± 1.38 days. The presenting features were vomiting in 95 patients (100%), distension of theabdomen in 67 patients (70.5%), lump in the abdomen in 61 patients (64%), and bleeding per rectum in 10 patients (10.5%). Eighty-six patients (90.5%) had ileocolic or ileoileocolic intussusception. Resection was required in 75 patients (79%). The mortality rate in this study was 10.5%. Conclusion Despite the advances in the diagnosis and treatment of intussusception, a large number of children in the developing world still present very late. Hence, the treating surgeon must be ready to manage this entity effectively. Proper clinical evaluation, resuscitation, and treatment as per the condition of the patients yield good results. Keywords: bowel obstruction, children, delayed presentation, intussusceptions, surgery

Delayed Repeat Enema in the Management of Intussusception

To describe the demographic and clinical characteristics of children with intussusception and failed initial air enema reduction who were managed by delayed repeat enema attempts and identify predictors associated with successful reduction. This is a retrospective cross-sectional study of children diagnosed with intussusception who received care at an urban 110-bed children's hospital. Patients who had failed initial enema reduction attempts under fluoroscopic guidance and had subsequent delayed (≥2 hours from the initial attempt) repeat enemas made up the study population. The primary outcome variable was success of delayed repeat enema reduction. Predictor variables included duration of presenting symptoms (≤1 day vs ≥2 days), gross bloody stools, dehydration, altered mental status, ileus per radiograph, time from initial to delayed repeat enema, and lack of partial reduction to the ileocecal valve with the first attempt. During a 74-month period, 20 patients with 21 intussusception events managed by delayed repeat air enemas were identified. Of the 20 patients, there were 12 boys (60%). Distribution of race was as follows: 9 white (45%), 7 African Americans (35%), and 4 Hispanics (20%). Of the 21 events, the mean (SD) age at the time of intussusception was 14.4 (12.8) months, with a median of 8 months and ranging from 2.5 to 43 months. Of the first 21 attempted delayed repeat enemas, 9 (43%) were successful. Of the 12 unsuccessful attempts, 4 had a second delayed repeat enema attempt and 3 were successful. Overall delayed repeat enemas were successful in 12 patient events (57%). For the total 25 delayed repeat enemas, 12 (48%) were successful.Surgical reduction was performed in 9 patient events (43%). Of these, manual reduction was performed in 7 and surgical incision was performed in 2, with resection of a portion of the distal ileum. There were 19 ileocolic (90%) and 2 ileoileocolic (10%) intussusceptions. There were no pathologic lead points and no patient deaths.In comparing the successful from the failed delayed repeat enema reduction groups, there was no significant difference in demographic characteristics, clinical characteristics, or time from initial enema to first repeat enema. However, there was a trend toward a significant difference regarding the failed group having a greater rate of bloody stools, dehydration, or altered mental status. There was a significant difference for the degree of partial reduction achieved on the initial enema. For the successful delayed repeat enema reduction group, the location of the lead point of the intussusceptum after the initial enema was at the ileocecal valve for 9 patients (90%) versus 3 patients (33%) in the failed group. Although not significantly different, the successful versus failed delayed repeat enema reduction group trended toward significance regarding more patients with clinical improvement after initial enema (82% vs 43%). With the coordinated care of emergency medicine, surgery, and radiology services, delayed repeat enema seems to be an option to consider in the management of clinically stable children who, on initial air enema, have partial reduction. Our study showed that the success rate of delayed repeat enemas was greatest when the intussusceptum was initially reduced to the ileocecal valve.

Endoscopic Pneumatic Reduction of a Pediatric Ileo‐ileocolic Intussusception During Diagnostic Colonoscopy

An 11-year-old girl presented with acute abdominal pain after a 5-month history of intermittent colicky abdominal pain associated with nonbilious vomiting and weight loss. An ileo-ileocolic intussusception was noted on ultrasound, but the barium enema was negative. During diagnostic colonoscopy, a spontaneous ileo-ileocolic intussusception occurred at the level of the hepatic flexure. Endoscopic air insufflation was used to successfully reduce the large mass down to the cecum, through the ileocecal valve, to a level proximal to the ileum. Subsequent Meckel's scan was negative and the patient was discharged home after close observation. Her symptoms recurred and a Meckel's diverticulum was found at laparotomy. Ileo-ileocolic intussusception due to Meckel's diverticulum is a rare occurrence. In the literature, there are only a handful of case reports, of both children and adults, that describe an intussusception due to Meckel's diverticulum (1). There are more than 1 dozen cases in the adult and pediatric literature in which colonoscopy was instrumental in the diagnosis and/or reduction of colonic intussusception (2). This case highlights the endoscopic findings.FIG. 1: Intussusception seen at hepatic flexure.FIG. 2: Advancing intussusception with ulcerated leading edge (transverse colon).FIG. 3: Reduction via endoscopic air insufflation (cecum).Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

Current success in the treatment of intussusception in children

Intussusception remains a common cause of bowel obstruction in young children and results in significant morbidity and mortality if not promptly treated. The goal of this study was to determine the current success rate of radiologic reduction, the requirements for operative intervention, and the effect of delay in presentation on outcome. Children treated for intussusception over a 15-year period were reviewed after treatment at a tertiary children's hospital. Records were reviewed for patient outcomes from radiologic evaluation and surgical intervention. Two hundred forty-four children with intussusception were identified. Median age was 8.2 months (range, 16 days to 12.7 years). Eighty-seven percent of patients had ileocolic or ileoileocolic intussusception. The most common presenting symptoms were emesis (81%), hematochezia (61%), and abdominal pain (59%). Contrasted enemas were performed in 190 children, with successful reduction in 46%. Air-contrasted enema reduction was more successful than liquid-contrasted techniques (54% vs 34%; P = .017). Success in reduction was greater if symptom duration was <24 hours compared with >24 hours (59% vs 36%; P = .001). Despite failed prior attempts at reduction, 48% were reduced on reattempted enema reduction. One hundred forty children required surgical intervention for intussusception with 50% requiring bowel resection. Children with symptom duration >24 hours had a greater risk of requiring surgery (73% vs 45%; P < .001) and bowel resection (39% vs 17%; P = .001) than those with symptoms for <24 hours. Pathologic lead points were encountered in 14%. There were 2 deaths and complications occurred in 19%. Length of stay after surgical reduction was 3.9 days, but 6.1 days if bowel resection was required. Success of intussusception reduction is improved with air-contrasted techniques and is not affected by previously failed, outside attempts. Delay in presentation decreases success in radiologic reduction and increases risk of operative intervention and bowel resection.

Intussusception. Part 2: An update on the evolution of management.

Children with symptomatic ileocolic or ileo-ileocolic intussusceptions can be successfully managed in one of a number of different ways. The nonoperative enema reduction technique has major advantages over surgical reduction and high success rates can be achieved using pneumatic or hydrostatic reduction techniques under fluoroscopic or sonographic guidance. This article highlights current concepts and some controversial issues related to management of intussusception, including patient selection for attempted enema reduction, the advantages and disadvantages of each technique, complications, the value of delayed, repeated reduction attempts, the role of imaging after attempted enema reduction, and recurrence of intussusception.

Ileoileocolic intussusception in children: diagnosis and significance.

The ileoileocolic type of childhood intussusception is difficult to diagnose pre-operatively and is associated with increased morbidity. This study describes the clinical and imaging features of 10 consecutive ileoileocolic intussusceptions diagnosed ultrasonically in 10 patients over a 36 month period. Ultrasound-guided hydrostatic reduction using Hartmann's solution was attempted in all 10 patients. Clinical and imaging features were compared with those of 28 ileocolic intussusceptions in 25 patients diagnosed and treated using the same methods during the same period. Most of the clinical and plain radiographic features of the patients with the ileoileocolic and ileocolic types of intussusception were similar. The two types of intussusception had the classical doughnut or pseudokidney, or both, signs on pre-reduction ultrasound scans. During the reduction process, when surrounded by fluid within the caecal lumen, the ileoileocolic type of intussusception had a typical complex appearance due to frond-like loops of intussuscepted small bowel. This finding was present in all cases. The hydrostatic reduction rate was only 10% (1/10) for ileoileocolic intussusception, compared with 92.9% (26/28) for the ileocolic type. All unsuccessfully-reduced cases underwent surgery, with surgical confirmation of the intussusception type in all cases. Only one patient was found to have a lead point, caused by a Meckel's diverticulum. In conclusion, the diagnosis of ileoileocolic intussusception can be made pre-operatively and these patients require surgical management.

Laparoscopic-assisted pneumatic reduction of intussusception

The nonoperative treatment of intussusception is done by fluoroscopy, however, false-positive and negative images may lead to unnecessary operations. The aim of this study was to evaluate the feasibility of laparoscopy in pneumatic reduction. Surgical ileoileocolic intussusception was performed in 27 dogs. Sixteen dogs were observed for 3 days (group A), and 11 were observed for 5 days (group B). Laparoscopy was performed in the intussuscepted dogs during pneumatic reduction. Under general anesthesia, a 10-mm trocar was inserted supraumblically in the midline, and the laparoscope was introduced. The intussuscepted bowel was observed on the video monitor. A 5-mm trocar was inserted in the right upper quadrant. The mesentery of the terminal ileum was manipulated using grasping forceps to assist reduction. CO 2 was insufflated into the rectum using a Foley catheter, and the reduction was observed on the video monitor. The success rate was 94% (mean reduction time, 2.5 minutes ± 1.0) for group A and 100% (mean reduction time, 3.7 minutes ± 0.8) for group B. Bowel perforation was observed in one dog, and recurrence of intussusception in another. The authors claim that observing the bowel on the video monitor may help in the differential diagnosis and reduction of difficult cases such as ileoileocolic and delayed intussusceptions. Therefore, unnecessary open surgery may be prevented.

Sonographically guided hydrostatic reduction of childhood intussusception using Hartmann's solution.

Currently, the standard methods for therapeutic reduction of intussusception in children involve considerable ionizing radiation. This study tested the effectiveness of sonographically guided hydrostatic reduction of intussusception using Hartmann's solution, a fluid with near-physiologic composition. Between March 1, 1994, and January 31, 1996, all children clinically suspected of having intussusception were evaluated by sonography. Those with positive findings on sonography were entered into the study and underwent confirmatory sonographically guided meglumine diatrizoate enema. During continuous sonographic monitoring, we used Hartmann's solution for attempted reduction of intussusception. Criteria for successful reduction were disappearance of the intussusceptum and passage of fluid through the ileocecal valve. Another sonographically guided meglumine diatrizoate enema was used to confirm successful reduction. We detected 25 consecutive intussusceptions in 22 patients. The patients were 12 girls and 10 boys, with a mean age of 14 months (range, 1-72 months). Sonograms revealed in all patients doughnut or pseudokidney signs or both. The sites of intussusception were the transverse colon (17 of 25), hepatic flexure (4 of 25), ascending colon (2 of 25), splenic flexure (1 of 25), and descending colon (1 of 25). Other findings were dilated fluid-filled small bowel (11 of 25) and free intraperitoneal fluid (9 of 25). The success rate of our sonographically guided attempts at hydrostatic reduction was 76% (19 of 25). Success was proven by meglumine diatrizoate enema in all 19 patients. The mean time of the reduction procedure was 18 min (range, 2-45 min). No complications occurred. All six patients in whom hydrostatic reduction was unsuccessful underwent surgery. Five of these patients had ileoileocolic intussusceptions. On sonography, when surrounded by fluid, ileoileocolic intussusceptions had a typically complex, fronded appearance. The remaining patient in whom hydrostatic reduction was unsuccessful had ileocolic intussusception. Of six ileoileocolic intussusceptions, one was hydrostatically reduced and a second was converted into an ileoileal intussusception before requiring surgery. The other four intussusceptions were surgically treated. Our data suggest that sonographically guided hydrostatic reduction with Hartmann's solution can be used to treat ileocolic intussusception and to diagnose ileoileocolic intussusception.

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.

Pneumatic reduction of intussusception: 5-year experience.

Pneumatic reduction of 246 intussusceptions was attempted in 219 patients over a 5-year period. The mean age of the patients was 15.4 months. Successful reduction was achieved in 199 cases (80.9%). Bowel perforation occurred in seven cases (2.8%), requiring needle decompression of tension pneumoperitoneum in one case. Recurrence of intussusception occurred in 27 cases (11%). The mean fluoroscopy time was 3.5 minutes +/- 0.2 in successful reductions and 9.3 minutes +/- 0.9 in failed reductions (P less than .001). Logistic regression analysis helped identify four independent predictors of failure, as follows: (a) ileoileocolic intussusception (P less than .001), (b) long duration of symptoms (P less than .001), (c) rectal bleeding (P less than .01), and (d) failed reduction with barium at another institution (P less than .05). Predictors of bowel perforation were a younger age (P less than .05) and long duration of symptoms (P less than .05). Surgery was performed in 48 cases (19.5%), 16 of which required bowel resection. Transmural necrosis of bowel wall was found in nine specimens. The most important predictor of outcome in this series was a long duration of symptoms. Pneumatic reduction is a useful substitute for barium in the management of pediatric intussusception.

Intussusception: Barium or air?

At The Hospital For Sick Children, the use of air has recently replaced the use of barium in the reduction of intussusceptions. The purpose of this study was to review the results from 200 consecutive patients with intussusceptions, 100 patients treated with barium enema and 100 patients treated with air enema. The groups were similar with regard to sex, average and median ages, and presenting symptoms and signs. Successful reduction was achieved in 75% of episodes of intussusception treated with barium enema and 76% treated with air enema. Failure of either modality showed a high association with the presence of either a lead point or an ileoileal or ileoileocolic intussusception. Among those cases of unsuccessful reduction, operation was performed in all 59 cases; resection in 30 cases, manual reduction in 19, and spontaneous reduction was found in 10. There were three perforations during attempted reduction with barium and two with air. All perforations were treated by resection and primary anastomosis. There were 18 recurrent intussusceptions following barium enema reduction and nine following air enema reduction. Therefore, with the lower absorption of x-rays by air and the relatively inert nature of air (compared with barium in the event of a perforation), we feel that air enema is the treatment of choice in the initial management of intussusception.

Intussusception: factors related to treatment.

To provide guidelines for the choice of treatment of intussusception, 10 factors that are known to be related to the outcome of treatment were studied in a series of 146 children with intussusception. The length of history, vomiting, rectal bleeding, small bowel obstruction, ileoileocolic intussusception, and the presence of a leading point were all significantly related to failure of hydrostatic reduction. Only 'rectal bleeding' and 'duration of symptoms of more than 48 hours' contributed significantly to the prediction of failure of hydrostatic reduction by logistic regression analysis. We believe that as well as the generally accepted contraindications--signs of peritonitis or bowel perforation--the presence of rectal bleeding when symptoms have lasted more than 48 hours is a contraindication to hydrostatic reduction.

Ileo-ileocolic intussusception: radiological features and reducibility.

This paper concerns ileo-ileocolic intussusception rather than the commoner ileocolic intussusception. diagnostic criteria for ileo-ileocolic intussusceptions are established by retrospective study of radiological findings in 28 surgically proven cases. Using these criteria, 11 successfully reduced cases were found in the corresponding period (28.2%). All were apparently cured after one reduction: the evidence suggests that a small but significant number of ileoileocolic intussusceptions may be safely reduced by normal methods during barium enema.

Clinical aspects of intussusception

1. 1. The clinical aspects of intussusception in our series of 111 patients with respect to incidence by sex, age, and month of the year, are essentially no different from those previously reported in the literature. 2. 2. The incidence of temperature elevation over 38 °C was considerably lower than that cited in the literature. 3. 3. Successful reduction by barium enema was possible in 41 per cent of the patients. 4. 4. Small bowel and ileoileocolic intussusception was encountered in 38 per cent of our patients, and 22 per cent of these patients required resection. 5. 5. With an increased duration of symptoms there was an increased incidence of temperature elevation over 38 °C and abdominal distention. There was no increased incidence of blood in the stool or a palpable abdominal mass.