Clinical Manifestations and Management of Intussusception in Children

Introduction

Intussusception means “Invagination of one segment of the bowel into an immediately adjacent segment of the bowel or a segment of proximal intestine (intussusceptum). It telescopes or invaginates into the lumen of the more distal bowel (intussuscipien)¹”.It is  being one of the commonest causes of intestinal obstruction in infants and  children between the ages of 3 months to 3 years, and the peak age of presentation is 4 to 8 months¹.

The incidence varies from 1 to 4 per 1000 live births². The Male: Female ratio is 3:1 respectively2 with male preponderance. Vomiting, abdominal pain, and passage of red currant jelly stool are the Classical Triad of symptoms, noted in only one third of patients. Sausage shaped mass is palpable in 60% of the cases in the Right hypochondrium³.

In the pediatric population, Ileocolic intussusception is the most common type. The etiology of intussusception in children is typically idiopathic, often influenced by anatomic mostly lymphoid hyperplasia or infectious factors (viral and parasite)⁴. Plain abdominal films are mostly not sensitive for the diagnosis of intussusception and may be completely normal⁵. The first-line investigation for the diagnosis of intussusception in children is abdominal ultrasound, that has higher sensitivity (98%-100%) and specificity (88%100%)⁶.

The most constant finding is a scanty amount of gas in the right iliac fossa⁷. If the presentation is late in the course of the disease, the patient may exhibit signs of peritonitis or bowel ischemia with pain out of proportion to physical exam f indings⁸, it is demonstrated in only 25-50% of cases.  Thus Plain radiography is presently used only to rule out other complications such as intestinal perforation and pneumoperitoneum9. Previously, contrast enema x-ray exposure had been the gold standard for the diagnosis of intussusception¹⁰.

In this study, we are reviewing various methods in the management of pediatric Intussusception over the last 3 years that includes assessment of the efficacy of non-operative(hydroreduction) and operative management and analysis of the risk factors affecting the success rate.

Materials and Methods

This study was conducted in our institute for 3years, February 2016 to January 2019 to find out the pattern of clinical presentation in children with intussusception, utilization of various methods of management and their outcome.

Children presented with symptoms of intussusception less than 48 hours without any features of peritonitis or evidence of intraperitoneal free gas were considered for hydroreduction.

Children with symptoms of intussusception more than 48 hours, recurrent intussusception, failed hydroreduction or patients with peritonitis or intraperitoneal free gas and hemodynamically unstable were managed surgically.

Method of hydroreduction

Informed written consent was taken from the patient’s guardian for hydrostatic reduction. AnIntravenous line was set up and blood samples were taken for estimation of electrolytes and cross matching of blood.

Patient was resuscitated and nasogastric tube was inserted. Blood pressure and pulse rate were monitored during the procedure. Intravenous antibiotics (Ceftriaxone(50mg/kg BD)          & Metronidazole (15mg/kg thrice a day)) were administered and all the preparations needed for the surgery were made as a safety  in the case of emergency or when the procedure failed.

Vital were recorded. The children were sedated using Midazolam and Ketamine. A Foley’s catheters of size 14 Fr to 18 Fr were used according to the age of the children. Catheter was lubricated with 2% Lignocaine gel and introduced into the rectum (5 cms from the anal verge). The balloon of Foley’s catheter was inflated with 10- 15 ml distilled water, Catheter was connected with warm normal saline bag and flow of saline was allowed into the rectum. The saline bag was suspended on a drip stand at approximately 100 cm from the patient’s bed level.

The ultrasound was then used to guide the reduction (Fig 1) till the intussusception passedbeyond the Ileocecal valve. Complete reduction was considered once intussusceptum wasdisappeared and passage of saline through the Ileocecal valve into the ileum seen.

Evaluation of Successful reduction was inferred as the saline administrated through Foley’s catheter was visualised under USG passing into the proximal of the invaginated segment. In unsuccessful cases, if some movement of the mass was present and child had no abdominalsigns second attempt was made after a lapse of 30 minutes interval. Then Foley’s catheter wasremoved and saline was allowed to drain through the anus.

Clinical condition of the patient was closely and carefully monitored throughout the procedure. After 48 hours review USG was done for followup and if there was no intussusception, oral feed started.IV administration was done before hydrostatic reduction and thenthey are continued on orally for 5 days.

Surgical Management: Surgical management was done by taking Right transverse Supraumbilical incision. Manual reduction of intussusceptum (Fig 2) was done  milking of the bowel (intussusceptum) from intussuscipient was tried if bowel healthy, Resection and anastomosis was done if bowel was nonviable or leading point like polyps or Meckel’s was part of intussuception segment. Patient was kept nil by mouth post operatively for 3 days, until there was passage of stools and intravenous antibiotics were given for 5days and discharged.

Results

65 children are included in the study (Table no: 1) of which 39 were male (60%) and 26 female (40%) . the study was carried for a period of  3years, from February 2016 to May 2019. Among the results youngest age was 5 months and oldest 5years.

Most of the children manifested with more than one clinical symptom (Table No: 2). Most commonly excessive cry (60%) and vomiting (53.3%) and less commonly they presented with abdominal distension and altered stools (26.6%).

On clinical examination palpable lump was felt in 26 (40%) patients, tenderness in 39(60%) patients and per rectal finding of Red currant jelly stool was encountered in 17(26.6%) (Table no 3). Ultrasound of abdomen was performed in all children to confirm the diagnosis (100% correlation) and to determine the level of obstruction (Table no:4) are analyzed.

The intussusception was seen up to the descending colon in 6(8.6%) patients. In 22(34.3%) of thepatients (34.3%) it was up to the transverse colon and in 26 patients (40%) up to the hepatic flexure. 11patients (17.1%) had the intussusception up to the ascending colon. After confirmation of the diagnosis and determining the location of the obstruction, routine blood investigations were done and modalities of treatment reviewed (Table no:5).

Out of 35 cases (54%) underwent hydroreduction, 3 cases (8.5%) failed to get reduced which were later planned for surgery, and 1 case (3%) had a recurrence within a month. The patients who were subjected to surgery includes 3(8.6%) where hydroreduction had failed, 2 with Meckel’s diverticulum as leading point with ischemic changes in bowel which was managed by bowel resection and anastomosis. One had inflamed Payer’s Patches as leading point which was reduced manually during surgery. In all these patients the intussusception was up to the transverse colon. 1 had recurrence after four months later which on surgical exploration showed presence of intraluminal polyp as leading point.

The duration of the procedure ranged from five minutes to twenty minutes. The volume of Normal saline required for reduction ranged from 300ml to 1300ml (Table 3). Thirty cases which were planned for open surgery, 20(66.6%) were reduced manually. In10(33.4%) children 3 (30%) turned out to be having Meckel’s diverticulum as a leading point and 7(70%) showed gangrene for which resection and anastomosis had to be done.

Discussion

Intussusception is a pediatric surgical emergency next to appendicitis as the most common cause of an acute abdominal emergency in children¹¹.

We evaluated 65 cases of intussusception which were diagnosed by ultrasound imaging. Most children developed intussusception in first 2 years of their life. There were 48 children (73.3%) between 6 months-2 years (Table no: 7). The age group is similar to the result of the study of stringer and colleagues who found 80% cases occurring before 2 years of age 12. 4 children (6.6%) belonged to less than 6 months. Waseem and colleagues have found recurrence of the disease is seen in second year of life in 50% or less12.Yalcin et al found 67% of his study population under 1 year. Intussusception is rare in neonates¹³.

Weihmiller et al found median age to be 21.1 months in their study. In the present study median age was 14 months^14. Out of 65 children 39 (60%) were males. Several investigators world over have found a Male predominance.

In our study, children most commonly presented with excessive cry (60%), vomiting (53.3%) and pain in abdomen (43.3%). This is comparable to the results of the study by Yalcin et al where vomiting was the commonest complaint¹³. Abdominal pain was felt in 78.08% of patients in the study by Khan J et al, 50- 85% patients in studies reported by Julie EB et al, Hutchinson et al and Ein SH et al^15-18. The study conducted by Kumar et al showed the commonest symptom to be colicky abdominal Pain. Mansur et al have reported vomiting, abdominal distension; blood in stool and a palpable abdominal mass as the commonest presenting features^15-18.

The most reliable abdominal sign if present, is a palpable mass in the right upper quadrant of the abdomen. It was present in 39.3% in study conducted by Wong et al19, and was a risk factor suggestingthe need of operative treatment. Presence of palpable mass mostly signifies, relatively longer duration of intussusception that causes complete intestinal obstruction. In our study palpable mass was seen in 44% of cases and all cases were surgically managed.

Many non-surgical techniques are in practice, ultrasound guided enema therapy is more beneficial as compared to fluoroscopy in view of radiation exposure. Higher success rate of Hydroreduction procedure had become an alternate to surgery²⁰.

Pneumatic reduction is performed in some centres with fluoroscopy guidance at 80 - 120 mmHg pressure. The major disadvantage of this approach is the risk of pneumoperitoneum in the cases of perforation. Since the whole procedure is performed under fluoroscopic guidance, there is a great risk of exposure to ionizing radiation. Kim et al²¹.

In our study hydrostatic reduction was done using warm saline container lift at an elevation to a height of 100cms.

For diagnosis and guidance for hydrostatic reduction of intussusceptions, most institutes utilise high resolution ultra- sound. It has sensitivity between 98–100% in various series²².

The success rate of hydroreduction in our study was 88%,which is significant and comparable with other studies. No perforation or mortality occurred in any of our patients. However the studies conducted by Sadigh et al, reported that the success rate of pneumatic enema was significantly higher than that of hydrostatic enema²³. On the other hand, Bai et al²⁴, reported a high success rate of 95.5% in their large-scale study with⁵, 218 patients and Krishnakumar et al²⁵, reported a success rate of 96% .

Khorana et al. also reported that the success of the procedure was higher within the first 48 h after the onset of symptoms but success rate decreases beginning from the third day after the onset of the symptoms²⁶. In our study only children presented within 48 hours after initiation of symptoms were taken for hydroreduction to avoid unnecessary complications.

The length of the invaginated segment measured on USG and the success of the procedure has been investigated by He et al27 and Ozcan et al²⁸. He et al. reported that the success rate was lower in the patients with a length of > 7 cm. In our study a length of 14 cms of invaginated segment (upto Transversecolon) for which hydroreduction done and no complications seen. 

Pazo et al. evaluated 21 patients with intussusception and reported that successful reduction was achieved in the 2nd attempt in 9 (43%) and in the 3rd attempt in 4 (19%) patients²⁹. Conversely, Naidch et al. reported that successful reduction was achieved in the second attempt in only 2 (13.6%) out of 17 patients³⁰. In our study, 48% had successful reduction in 1stattempt and 40% in 2nd attempt. 2nd attempt was taken after a minimum 30 min interval, If failed in 2nd attempt patient have been taken for surgery.

Study conducted by Van den Ende et al³¹, showed success rate of 79% on  hydroreduction. Previous studies³² have reported success rates of 80.39%, success rate in the current study was 88.5% which was comparatively higher than other studies. Complications in hydroreduction in our study was not significant and is compared with study conducted by Tander et al³².

Recurrence rate after non-operative reduction of intussusception had varied between 5 to 20% with a mean of 10%^33,34. Most of the recurrent intussusceptions occurred within 48 hours but recurrences up to 1.5 years had been documented^33,34 In our study also recurrence rate was 8.5%, similar with the other studies and recurrence^35-39.

Operative reduction is indicated, when nonoperative reduction is either contra-indicated (eg peritonitis, perforation, profound shock) or unsuccessful. Open surgery has been the straight approach although laparoscopic reduction is also practicable and successful in uncomplicated cases40,41.

Conclusion

Management of Intussusception by Hydroreduction is safe and effective method similar to surgical management with a high success rate, minimal morbidity and mortality and less duration of hospital stay.