Lead Point Research Articles

Conducting two evidence syntheses in six weeks – experiences with and evaluation of a pilot project

BackgroundEvidence synthesis organisations are trying to meet commissioners’ needs for rapid responses to their evidence synthesis commissions. In this project we piloted an intensive process, working to complete evidence syntheses within six-weeks, rather than the standard lead time of 4–6 months. Our objective was to explore how researchers experience working intensively, identify barriers and facilitators, and determine how a more intensive approach to evidence synthesis could be more systematically introduced in the future.MethodsIn a pre-planning phase, an intensive work group was established, and two commissions were selected for this pilot project. The evidence synthesis process was divided into two phases: planning and intensive. The planning phase, involved scheduling the intensive phase, exploring new digital tools, and identifying peer reviewers. The intensive phase encompassed the entire evidence synthesis process. Two review teams were formed, each with a team lead supported by a process lead and leadership contact point. Throughout the project, teams engaged in reflective meetings to evaluate and adjust processes as needed.ResultsDuring the planning phase, teams identified significant uncertainties regarding scopes, research questions, and inclusion criteria. To address this, they engaged with commissioners earlier than originally planned, clarified these aspects, and prepared protocols. Despite some minor deviations from the original plan, both reviews were completed on schedule, with one team expanding their scope due to the absence of eligible studies. Teams operated flexibly, held regular meetings, and found the process seamless due to fewer interruptions. Machine learning tools facilitated rapid study selection. The process lead role, created to guide and evaluate the project, proved beneficial, providing structure and support, although clearer role delineation with the leadership contact point could have improved efficiency.ConclusionsOverall, the intensive process fostered focus and productivity, allowing teams to manage short-term deliverables effectively. The researchers preferred working intensively with one evidence synthesis over being involved with many projects at the same time. They felt that time use was more effective, and they were able to complete the tasks in a focused way. However, there are several implications that should be considered before implementing an intensive approach in future evidence syntheses.

Mantle Cell Lymphoma of Gastrointestinal Tract as a Lead Point for Intussusception: A Case Report

Mantle Cell Lymphoma of Gastrointestinal Tract as a Lead Point for Intussusception: A Case Report

Burkitt's Lymphoma-induced Intussusception in a five-year-old Girl: A Case Report and Literature Review

Intussusception in children over the age of two frequently has an identifiable pathologic lead point linked to underlying causes, such as intestinal hematomas, lymphomas, polyps, duplications, and Meckel's diverticulum. These cases, which frequently present with severe abdominal pain paroxysms, warrant further investigation. A 5-year-old girl with abdominal pain was diagnosed with Burkitt's lymphoma, which caused her intussusception.

Cancer masquerading as an intussusception: Experience at tertiary care rural hospital

One segment of the intestine telescopes into another, resulting in obstruction or intestinal ischemia. A pathological lead point, such as a tumor, causes the disease. A pathologic lead point in the lumen, wall, or outside the wall can cause adult intussusception (AI). Retrospective case series of eight patients diagnosed with AI over 18 years in a tertiary rural tertiary a decade (2010-2020). Out of 8 AI cases6 were women, and 2 were men. The median age at diagnosis was 44 years. AI was verified by USG (25%), with CT scan being (100%) sensitivity preoperatively. AI distribution (2 in the small bowel, four at the ileocecal region, and 2 in the colon). The most commonly reported presenting symptom was abdominal pain. (8/8,100%). 75% (6/8) of patients underwent urgent surgery after presenting with acute intestinal obstruction. At the same time, two cases underwent elective surgery. Out of them, five cases were malignant (adenocarcinoma) (62.5%), and three cases were benign tumors (37.5%). (Inflammatory myofibroblastic tumor, a Meckel’s diverticulum, and appendicitis). Due to the lack of specific symptoms, the diagnosis of AI by clinicians and surgeons is frequently missed out. When dealing with acute abdominal pain and signs of bowel obstruction, it's important to consider this less common diagnostic possibility because intussusception is a surgical emergency with high mortality rates in the case of delayed treatment. A surgical approach must be practiced to avoid missing underlying causes like neoplasm.

Adult Ileal Duplication Cyst Acting as Lead Point of Ileo-Caecal Intussusception: A Rare case of Complete Bowel obstruction in Adults

Adult Ileal Duplication Cyst Acting as Lead Point of Ileo-Caecal Intussusception: A Rare case of Complete Bowel obstruction in Adults

Adult intussusception: a systematic review of current literature.

Intussusception in adults is a rare condition characterized by a low incidence, which complicates the establishment of standardized management protocols unlike those readily available for pediatric cases. This study presents a case series from our institution alongside a systematic review of existing literature. The objective is to delineate effective management strategies for adult intussusception. A systematic search of databases was conducted covering the period from January 2000 to May 2024. The study focused on adult patients diagnosed with intussusception either pre-operatively or intraoperatively and managed with either surgical intervention or conservative methods. The analysis also included retrospective review of patient records from our institution, specifically targeting individuals over 18years of age, to determine the predominant types of intussusception and identify any pathological lead points associated with these cases. In our study, a total of 1,902 patients were included from 59 selected articles, with a mean age of 52.13 ± 14.95years. Among them, 1,920 intussusceptions were diagnosed, with 98.3% of cases identified preoperatively. Computed tomography (CT) scan was the primary diagnostic modality used in 88.5% of cases. Abdominal pain was the predominant presenting symptom, observed in 86.23% of cases. Only 29 out of 1,920 cases underwent attempted reduction, while the majority required surgical resection due to the high incidence of malignancy in adult cases. The most common type of intussusception identified was colocolic (16.82%), followed by enteric (13.28%), ileocolic (4.89%), and ileocaecal (0.78%) types. A pathological lead point was observed in 302 out of 673 patients (44.84%), with a notably higher frequency of malignancy associated with colocolic intussusception. Surgical management remains the cornerstone in treating adult intussusception, particularly in cases involving the colocolic type, where there is a significant risk of underlying malignancy. Attempts at reduction are generally avoided due to the potential risk of tumor dissemination, which could adversely impact patient outcomes. Contrast-enhanced computed tomography (CECT) of the abdomen is pivotal for accurately diagnosing intussusceptions and guiding appropriate management strategies. It is imperative to adhere strictly to oncological principles during surgical interventions to ensure optimal patient care and outcomes.

Non-Hodgkin’s lymphoma as a cause of intussusception: a case report

Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment. This condition is frequent in children and presents with the classic triad of cramping abdominal pain, bloody diarrhea and a palpable tender mass. Secondary intussusception is caused by organic lesions, such as Meckel’s diverticulum, benign and malignant lesions, metastatic neoplasms or sometimes iatrogenically. Surgery is the definitive treatment of secondary intussusception. Formal bowel resection with oncological principles is followed for every case where a malignancy is suspected. A ten-year-old female presented to the casualty with severe pain in abdomen associated with 1 episode of blood in stools diagnosed with intussusception. She was taken for emergency laparotomy, and no lead point was identified. She presented with recurrent intussusception and was taken for re-exploration, when a definitive approach was opted for, and she underwent a resection of the obstructed bowel at the ileo-caecal junction and an ileo-ascending anastomosis. On histopathology, the ileo-caecal junction showed a proliferative, circumferential mass which was confirmed to be a diffuse large B cell lymphoma. It is uncommon for pediatric intussusception to result from a neoplasm. It takes imaging modalities to make the diagnosis. Surgical intervention is required as soon as a suspicion is raised in order to avoid consequences such gut necrosis and ischemia.

Epidemiology, clinical features, and outcomes of intussusception in young children: A tertiary center experience

Background: Intussusception in young and old children is different. A study of clinical features, associations, and outcomes of these cases would enhance understanding to guide proper management. Objectives: Analysis of the epidemiology, associations, clinical features, and management outcomes of intussusception in children younger than 2 years. Patients and Methods: A retrospective descriptive study on intussusception patients younger than 2 years was conducted from January 2018 to December 2022 in the department of pediatric surgery at a tertiary center. Demographic details, clinical features, and management outcomes data were collected and analyzed. Results: A total of patients were 133 with mean, median, and modal age of 9.5, 7, and 6 months, respectively; the maximum incidence was in March. 81.95% of cases were idiopathic; important lead points were Meckel diverticulum, inflamed appendix, roundworm, cecal duplication, and intraluminal polyps. Two postoperative cases occurred in Wilms’ tumor and congenital diaphragmatic hernia patients, whereas two postrotavirus vaccination cases were seen. Ten (7.5%) had associated malrotation which necessitated Ladd’s procedure. Only 15 cases presenting early responded to nonoperative treatment (9/15 hydrostatic reduction and 6/15 conservative management); among late presenters, 12.71% had manual reduction, 68.64% had resection and anastomosis while in 16.95%, temporary stoma was needed. Wound infection, burst abdomen, subacute intestinal obstruction, recurrent intussusception, peristomal excoriation, and stomal prolapse were a few complications along with one death. Conclusion: Intussusception in children younger than 2 years is a heterogeneous group. Although mostly idiopathic, several associations and well-defined lead points require additional intervention. Early diagnosis and prompt intervention ensure a favorable outcome with fewer complications.

An unusual case of longest intussusceptum without any pathological lead point in an adult: A rare case report from a peripheral tertiary care institute of Eastern India

Bowel obstruction is known to be caused by intussusception, which is far more common in pediatric patients. The majority of people with adult intussusception require a predisposing cause, which might be a benign lesion, a malignant lesion, or an irregularity of the intestinal wall such as inflammatory bowel disease. Adult intussusception is a very rare condition. We present the case of a patient presenting with upper abdominal pain, nausea, vomiting, and weakness. The patient had ongoing mild intermittent abdominal pain for months which was investigated with an upper gastrointestinal endoscopy that showed gastritis. There were features of peritonism on clinical examination and this was associated with raised inflammatory markers. A contrast-enhanced multidetector computed tomography (MDCT) scan showed a long-segment telescoping of the ileum into the cecum with ascending colon with proximal bowel distension suggesting bowel obstruction: Ileocolic intussusception. The patient underwent emergency surgical resection with a double-barrel stoma. Histopathology assessment did not identify a causative factor for the intussusception. An uncommon instance of adult idiopathic enteroenteric intussusception is presented here. The diagnosis can be established with the use of the clinical history of chronic intermittent abdominal pain, entire abdomen ultrasonography, and abdomen MDCT. In patients who are unstable and exhibit indications of peritonitis, surgery remains the only choice, even though a more cautious strategy is outlined in the literature. Adult intussusception is a rare and challenging diagnosis to make. Individuals suffering from intussusception may experience prolonged bouts of sporadic abdominal pain that intensify suddenly as a result of acute obstruction. The most helpful investigative technique for confirming the intussusception diagnosis is CT.

Antegrade long giant ileocolic intussusception via colon–cecum cancer lead points: case report with focus on the sign of the python colon

BackgroundIleocolic intussusception is a rare condition that is difficult to diagnose. A pathological lead point, usually malignant, is often the cause of adult intussusception. In emergency scenarios, radiologists must be able to identify this entity and its causes and express their opinions on associated complications.Case presentationThe hospital's emergency room admitted a 75-year-old woman who was suffering from intermittent abdominal pain and constipation. An abdominal contrast-enhanced computed tomography revealed a long giant ileocolic intussusception. Considering the clinical stability and the absence of signs of complications on CT, the patient did not undergo an urgent surgical procedure but underwent a colonoscopy the following day. Surprisingly, the colonoscopy highlighted the spontaneous resolution and revealed the presence of the three tumour lead points in the cecum and ascending colon. A CT was performed after the colonoscopy, confirming the intussusception's resolution. The surgeon performed a right oncological hemicolectomy. The malignant lead points on histological examination were moderate to poorly differentiated adenocarcinomas.ConclusionsA giant and long ileocolic intussusception with a long embedded visceral segment (the python colon sign) could suggest pathological lead points in the cecum and ascending colon. Despite the large size, a spontaneous resolution of the python colon is possible. In this scenario, even if, on imaging, it is impossible to macroscopically identify a lead point, in cases of giant and long ileocolic intussusceptions, every effort must be undertaken to search for the cause of the intussusception.

A Study of Predictors of Failure of Nonoperative Management of Ileocolic Intussusception in Children.

Surgery remains the mainstay in treating intussusception in developing nations. A correspondingly high bowel resection rate exists despite a shift to nonoperative reduction in high-income countries. We aimed to study the clinical profile of the patients with intussusception presenting to our hospital and to assess the clinical and radiological predictors of success or failure of nonoperative management of intussusception. This prospective study was conducted in the Department of Pediatric Surgery over a period of 3 years and included a total of 118 patients who presenting to our emergency division with features suggestive of intussusception and were managed accordingly either with hydrostatic reduction or by surgical intervention. We observed that the majority of the patients were males (65.5%). The mean age was 13.54 months. Intermittent pain was the most common symptom. Both pain and vomiting did not affect the outcome. Lab parameters like raised total leukocyte counts (TLC), C-reactive protein (CRP) and lactate levels were significantly associated with failure of hydrostatic reduction. Patients with air fluid levels on X-ray were more likely to end up in surgery. Ultrasound findings of bowel wall edema, aperistaltic gut loops and a pathological lead point was associated with failure of hydrostatic reduction as well. The overall success rate of hydrostatic reduction was 85.5%. Hydrostatic reduction of intussusception is a safe and effective method of management of intussusception whenever indicated. Factors that might reduce the chance of its success include continuous pain, irritability, tenderness, deranged lab parameters like TLC, CRP and lactate levels, air fluid levels on X-ray, bowel wall edema, aperistalsis and the presence of a lead point. Shah JY, Banday I, Hamdani HZ, et al. A Study of Predictors of Failure of Nonoperative Management of Ileocolic Intussusception in Children. Euroasian J Hepato-Gastroenterol 2024;14(1):81-85.

Polyp Endotherapy for Multiple Jejunal Lipomas Presenting as Small Bowel Intussusception: “Loop and Let Go Technique”

AbstractA 46-year-old woman presented with abdominal pain, vomiting, and intermittent constipation for the last 2 days. She had similar history of recurrent symptoms for the last 6 months. Abdominal examination showed mild central abdominal tenderness and generalized abdominal fullness and no palpable mass. A diagnosis of intestinal obstruction was considered. Nasogastric aspiration was performed with intravenous (IV) antibiotics and IV fluids. Computed tomography (CT) scan of the abdomen showed “bowel in bowel” or “target” sign appearance of jejunum with a submucosal hypodense lesion (suggestive of lipoma) acting as the lead point. There were two more submucosal lipomas of sizes approximately 3 cm each in the distal jejunal loops. A diagnosis of jejunal lipomas causing small bowel intussusception was made. The patient improved with conservative management. Exploratory laparotomy was planned with an intent to resect the small bowel. The patient did not provide consent for the same and so the option of enteroscopy-guided polyp endotherapy was offered to the patient. An antegrade single balloon enteroscopy was done (SIF-Q180, Olympus Medical Systems, United States). Three submucosal lesions with smooth overlying mucosa were noted in the mid and distal jejunum consistent with lipomas. The base of the lesions was ligated tightly using endoloop to make them ischemic and detach. Notable changes in color and mucosal appearance were noted after the application of endoloop. Since all the lipomas detected on cross-sectional radiologic imaging have been tackled via antegrade route, a retrograde enteroscopy was not attempted further. After 2 days, the patient was discharged in stable condition. Follow-up cross-sectional imaging at 3 months showed no residual lipomas, and she remained symptom-free at the end of 6 months.

Recalcitrant intussusception: exploring potential associations with Helicobacter pylori infection - a case report and literature review

BackgroundIntussusception, a common cause of abdominal pain in children, often lacks clear underlying causes and is mostly idiopathic. Recurrence, though rare, raises clinical concerns, with rates escalating after each episode. Factors like pathological lead points and Henoch-Schönlein purpura (HSP) are associated with recurrent cases. On the other hand, the prevalence of Helicobacter pylori (H. pylori), often asymptomatic, in children has been declining. Although its infection is reported to be linked with HSP, its role in recurrent intussusception remains unexplored. Further research is needed to understand the interplay among H. pylori (culprit pathogen), HSP (trigger), and intractable intussusception so as to develop effective management strategies.Case presentationA two-year-old girl experienced four atypical episodes of intussusception at distinct locations, which later coincided with HSP. Despite treatment with steroids, recurrent intussusception persisted, suggesting that HSP itself was not a major cause for intractable presentations. Subsequent identification of H. pylori infection and treatment with triple therapy resulted in complete resolution of her recalcitrant intussusception.ConclusionThis instructive case underscored a sequence wherein H. pylori infection triggered HSP, subsequently resulting in recurrent intussusception. While H. pylori infection is not common in young children, the coexistence of intractable intussusception and steroid-resistant recurrent HSP necessitates consideration of H. pylori infection as a potential underlying pathogen.

Inflammatory fibroid polyp– a rare aetiology for adult ileocolic intussusception

We report a case of an adult ileocolic intussusception secondary to an inflammatory fibroid polyp (IFP), a rare and unexpected association between a surgical condition, and an underlying histopathological process. Intussusception is an uncommon surgical diagnosis in adults, and an IFP is rare mesenchymal tumour. Surgical intervention of the intussusception in an adult patient, given the uncertain aetiology of the lead point, is recommended as gold standard.

Ileo-ileal intussusception secondary to malignant metastatic melanoma: a case report

Intestinal intussusception in adults is a rare manifestation and almost certainly represents a pathological lead point such as a neoplasm. We present such a case of ileo-ileal intussusception with an extraluminal deposit of metastatic melanoma (MM) acting as a lead point. A 48-year-old gentleman presented with small bowel obstruction secondary to ileo-ileal intussusception. His past medical history included an advanced cutaneous melanoma awaiting work-up. An emergency laparotomy with small-bowel resection and primary anastomosis was performed. Histopathological analysis confirmed metastatic melanoma and systemic therapy was commenced. Melanoma commonly metastases to the small intestine, they often present with intussusception and small bowel obstruction or bleeding. The risk factors for metastatic spread include superficial spreading melanoma, a Clark level of III or IV, Breslow thickness above 1mm, regression, ulceration, and high mitotic rate. Diagnosis is made radiologically with CT, endoscopy, contrast studies or nuclear medicine. Emergency operative management is indicated to relieve the obstruction and definitive therapy is indicated. Malignant melanoma with distal metastases is considered a stage IV disease and such patients are subject to systemic therapy including surgical resection, chemotherapy, immunotherapy, or a combination of all three. Ileo-ileal intussusception with MM as a lead point is a very rare presentation in antemortem patients. A CT scan is the investigatory modality of choice and emergency surgery is indicated to relieve obstruction and obtain histology. Prognosis is poor but novel immunotherapy agents herald opportunities even in palliative patients.

An unusual cause of adult transverse colonic intussusception with obstruction: Multiple large submucosal lipomas in a 50-year-old male

Intussusception is a gastrointestinal condition that predominantly affects the pediatric population. Although uncommon, it can occur in adults and is typically due to a pathological lead point that causes telescoping of the intestine during peristalsis. In this case, a 50-year-old male presents with abdominal pain, distension, diarrhea, and unintentional weight loss, which was revealed to be caused by intussusception that originated at a cluster of submucosal lipomas in the transverse colon. This patient had recently immigrated to the U.S. from Africa, and had missed his colorectal screening, which is recommended at age 45 for every person. It is crucial to accurately screen for, diagnose, and surgically treat this condition to prevent downstream complications such as bowel infarction or perforation.

Adult ileal duplication cyst acting as lead point of ileo-caecal intussusception a rare case of complete bowel obstruction in adults

Enteric duplication cyst presenting as intussusception in adult and causing complete small bowel obstruction is a rare phenomenon. A 19 year old female presented with complaints of abdominal pain, bilious vomiting, abdomen distension and constipation for 2 days. Patient had similar episodes in the past. Computed tomography of abdomen showed dilated small bowels with “Target Sign” suggestive of Ileo caecal intussusception. Patients was taken for surgery and intraoperatively it was noted to have thick walled cystic swelling in the terminall ileum. Segmental resection done along with cyst and primary anastamosis was done. Histopathological confirmation was done as Duplication cyst.

Predictive factors for failure of nonsurgical management of intussusception and its in-hospital recurrence in pediatric patients: a large retrospective single-center study

BackgroundThis study explores the effectiveness of ultrasonography (USG)-guided saline enema reduction for ileocecal intussusception. It investigates factors, ascertainable through physical examination, ultrasound, and medical history, that impact the success of the procedure and the likelihood of recurrence.ResultsConducted at a tertiary referral center, the study included 323 pediatric cases diagnosed with intussusception between 2017 and 2023. Patient data, symptoms, signs, and outcomes were collected. Hydrostatic saline enema, performed under USG guidance, served as the primary non-operative treatment. Logistic regression models assessed the impact of clinical factors on success and recurrence rates. Out of 323 patients examined for eligibility, 184 met inclusion criteria and were analyzed. Successful reduction with saline enema was achieved in 86.7%. In-hospital recurrence occurred in 17.1%, notably higher for intussusceptions extending into the rectum (p < 0.03). Pathologic lead point was identified in 33.3% of operated cases. The study revealed a correlation between the increasing number of symptoms (p < 0.001) and reduced success rates in enema reduction, with vomiting (p < 0.02), diarrhea (p < 0.05), and peritoneal fluid (p < 0.008) negatively affecting outcomes. Symptom duration of 1–9 h (p < 0.001) and 10–24 (p < 0.01) correlated with higher success rates, but prolonged symptom duration of > 24 (p = 0.4) and 48–72 (p = 0.2) hours did not decrease chances for successful reduction.ConclusionsProlonged symptom duration of over 24 and 48–72 h should not be a definitive contraindication for non-operative treatment. Cumulation of symptoms typical for intussusception might reduce the chances of success. These findings contribute valuable insights into optimizing non-operative strategies for managing pediatric intussusception.

Jejunojejunal intussusception induced by a gastrointestinal stromal tumor: a case report and literature review.

Intussusception is defined as the invagination of a proximal segment of the bowel into the adjoining or distal segment. In most adults with intussusception, there is a demonstrable lead point with a definite pathologic abnormality. The clinical features of intussusception include chronic intermittent abdominal pain, nausea and vomiting, constipation, and a palpable abdominal mass. The present case report describes a 62-year-old woman with a 2-week history of abdominal pain and 9-day history of vomiting. Clinical, imaging, and histologic evaluations revealed a jejunojejunal intussusception with a gastrointestinal stromal tumor as the lead point. A gastrointestinal stromal tumor should be considered as a possible lead point in adult patients with intussusception. The implication of reducing the intussusception prior to tumor resection requires further evaluation in view of the risk of venous embolism, including direct spread of malignant cells, in cases involving a large polypoid mass with a necrotic surface that extends to the serosa as shown by intraoperative examination. Accordingly, the rationale for adjuvant therapy with imatinib also requires further evaluation.

A Case Report of a Rare Aetiology of a Sigmoid Volvulus Involving a Congenital Omental Defect

Sigmoid volvulus is a rare form of large bowel obstruction and makes up &lt; 5% of all colonic obstruction. The commonest aetiologies include a lead point involving an intra or extra luminal mass such as a malignancy or a benign stricture or colonic dysmotility especially in the geriatric population. Rare aetiologies include a mesenteric defect, or as in this case report, a congenital omental defect acting as the lead point. This makes for an increasingly unusual case report, and we believe that this is the first such report in English language literature. The management remains the same, irrespective of the aetiology. Endoscopic bowel decompression in the acute phase is followed by definite surgical management with or without a primary surgical anastomosis.