|Year : 2019 | Volume
| Issue : 3 | Page : 167-170
Pediatric ileocolic intussusception
Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala, India
|Date of Submission||19-Jul-2019|
|Date of Acceptance||27-Aug-2019|
|Date of Web Publication||11-Sep-2019|
Department of Radiology, Holy Family Hospital, Thodupuzha - 685 605, Kerala
Source of Support: None, Conflict of Interest: None
Intussusception occurs when a more proximal portion of the bowel invaginates into more distal bowel. These patients often present with a wide range of nonspecific symptoms, with <1 quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. Thus, the diagnosis continues to rely on clinical suspicion. Intussusception is the most common cause of small bowel obstruction in young infants. Therefore, a high index of suspicion and thorough knowledge of this condition is of major importance to be able to diagnose and treat this potentially life-threatening condition. Surgical intervention in intussusception can be prevented by nonoperative reduction, especially if presented early with no signs of peritonitis. Timely nonoperative reduction can prevent surgical intervention and complications. Here, we present a case of an 18-month-old infant who presented with ileocolic intussusception.
Keywords: Barium enema, bowel obstruction, intussusception, intussusceptum, intussuscipiens
|How to cite this article:|
Ravikanth R. Pediatric ileocolic intussusception. Apollo Med 2019;16:167-70
| Introduction|| |
Intussusception, which is defined as the telescoping or invagination of a proximal portion of the intestine (intussusceptum) into a more distal portion (intussuscipiens), is one of the most common causes of bowel obstruction in infants and toddlers. Intussusception was first described by Barbette in 1674, and it was first successfully treated surgically by Wilson in 1831. In 1876, Hirschsprung first reported the technique of hydrostatic reduction, and in 1905, after monitoring a series of 107 cases, he reported a 35% mortality attributable to intussusception. Intussusception occurs in approximately 17.7 children/100,000/year in India. Population-based incidence of intussusception shows highest incidence between 5 and 9 months of age, being uncommon in neonates. There is a male predominance of 3:2. The majority of pediatric cases involve the ileocolic (or ileocecal) portion of the intestine. The most common location of idiopathic intussusception is at the hepatic flexure.
Bouts of abdominal pain may be evidenced by pulling of knees against the abdomen with an interim asymptomatic healthy child. In ileocolic intussusception, palpation of the abdomen may reveal a sausage-shaped mass which is located in the right upper quadrant. A wide spectrum of symptoms may range from painless intussusception to constipation, dehydration, diarrhea, intestinal prolapse, rectal bleeding, sepsis, shock, syncope, vomiting, and altered mental status (lethargy and irritability). Lethargy is seen most frequent in infants and young children with or without history of gastrointestinal symptoms. Altered mental status has been hypothesized to be secondary to a combination of factors such as dehydration, electrolyte imbalance, and endorphins or toxic metabolic products released from the ischemic bowel which can affect the brain. Here, we present a case of 18-month-old infant who presented with ileocolic intussusception.
| Case Report|| |
An 18-month-old infant presented with a 6-h history of lethargy, vomiting, and refusal to feed. He became very sleepy and had a high-pitched cry. He had three vomits before presentation which was nonbilious. There was no history of fever, constipation, or diarrhea. He had no history of significance. He was born by normal vaginal delivery at term and did not require any resuscitation. He was bottle-fed. On examination, he was lethargic, pale, and quiet. Body temperature was 36.4°C, and capillary refill time was <2 s, heart rate was 134/min, and blood pressure was 85/42 mmHg. His abdomen was scaphoid and soft with normal bowel sounds. There were no masses palpable. Nine hours after admission, he passed a small amount of blood per rectum. On reexamination of the abdomen, he had a palpable mass in the epigastrium. Random blood glucose was mildly raised at 7.6 mmol/l. Blood gases and urea and electrolytes were unremarkable. Full blood count was unremarkable apart from neutrophilia of 10.9 × 109/l (normal ranges: 1.2–7.5). C-reactive protein was <0.5 mg/l. Ultrasonography performed demonstrated target/doughnut sign of ileocolic intussusception and a pseudokidney appearance [Figure 1]a and [Figure 1]b. A short history of lethargy, vomiting, refusal to feed, and irritability in 18-month-old infant would suggest sepsis. Intussusception and malrotation with volvulus were considered as differentials when he passed small amount of blood per rectum with palpable mass in the epigastrium and the history of bilious vomit. Successful pneumatic reduction of intussusception was performed, and the child was relieved of symptoms.
|Figure 1: Longitudinal ultrasound image (a) demonstrating ileocolic intussusception in an 18-month-old male child. Transverse ultrasound image (b) more proximally demonstrating target/doughnut sign of ileocolic intussusception and pseudokidney appearance|
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| Discussion|| |
A recent and extensive review by the World Health Organization on intussusception concluded that, in developed countries, the baseline incidence of intussusception is between 0.5 and 4.3 cases/1000 live births or 0.7–1.2 cases/1000 children aged <1 year. Accurate estimates of the incidence of intussusception are not available for most developing countries. Standard diagnostic modalities include ultrasonography which is a fast, noninvasive, and simple reproducible test. The sensitivity (98%–100%) and specificity (88%–100%) are high but are clearly operator dependent. At some centers, it has displaced radiographs as the initial imaging test of choice. Other indications for its use are suspected cases of intussusception where abdominal X-rays are nonconclusive, evaluation for reducibility, presence of a lead point mass, potential incomplete reduction after enema, and intussusception limited to small bowel. Classic findings include the target lesion or doughnut sign on transverse imaging and the pseudokidney sign on longitudinal imaging.
When the intussusceptum invaginates and pulls along the mesentery, there is compromise of venous return. This is followed by engorgement of the intussusceptum, edema, and bleeding from the mucosa, which leads to currant jelly stools. Finally, the arterial blood supply of the intestine gets compromised leading to necrosis, perforation, and/or shock. Children <3 months and >2 years are most likely to have a “lead point” or specific identified cause, such as (in decreasing order of incidence) Meckel diverticulum, duplications, polyposis, and lymphomas. Hyperplasia of the intestinal Peyer's patches has been identified as the leading point in infant cases. Most cases are reported during summer and spring which favor a not fully understood infectious mechanism. Hyperplasia of Peyer's patches can occur secondary to viruses such as adenovirus, enterovirus, echovirus, and human herpesvirus. The most common surgical complication of patients with Henoch–Schönlein Purpura is intussusception.
Its incidence is also increased in the postoperative period probably due to edema or adhesions. In 1999, the Rotashield rotavirus vaccine was removed from the US market due to its increased association with intussusception, especially between 3 and 14 days postplacement of the vaccine. Subsequently, vaccines such as Rotateq and Rotarix have been developed. The clinical presentation having typical triad of severe intermittent abdominal pain, currant jelly stools, and vomiting is seen in <20% of cases. Recurrent intussusception is present in only 5%–8% of children and is most common after hydrostatic versus surgical reduction. Fifty percent of recurrent intussusception cases occur within 48 h of a prior episode. Most postoperative intussusception cases are located in the small bowel.
Computed tomography (CT) scan is usually not indicated in children since the diagnosis is generally confirmed by the ultrasound or enema. The CT scan involves high costs, radiation exposure, and sedation risk which are overall less convenient for this population group. Medical therapy includes expeditious diagnosis, and management is essential to successful outcomes in infants with intussusception. Once the diagnosis of intussusception is entertained, surgical personnel should be notified, an intravenous (IV) line was inserted, and IV hydration was started. A nasogastric tube should be inserted and placed to suction. If the patient is markedly distended or has a dilated loop of bowel, an abdominal radiograph should be obtained. Antibiotics should be administered based on the clinical suspicion of peritonitis or infection (sepsis) or in patients with a markedly elevated white blood cell count. Preoperatively, IV crystalloid resuscitation is started (10 mL/kg × 2 plus 1.5 × maintenance fluid). A Foley catheter is placed to guide fluid resuscitation. A nasogastric tube is placed. Broad-spectrum IV antibiotics are administered. Body temperature must be preserved in the operating room. A type and screen of the patient's blood should be obtained. As with any patient with a bowel obstruction, careful induction (i.e., rapid sequence) of anesthesia should take place because of the risk of regurgitation and aspiration.
Contrast enemas (barium, water soluble, and air) are diagnostic and therapeutic techniques, with reduction rates of 70%–90%. Barium enema is considered as the gold standard for nonsurgical treatment; this should be considered only after stabilizing the child, adequate hydration, and consultation with a pediatric surgeon. The only current absolute contraindication for barium enema is full bowel necrosis. Air enema's use has increased due to its lower perforation risk, less radiation exposure, faster, and better reduction rate. Intussusception recurrence rates for air versus liquid enema are reported to be similar, approximately 10%. Surgical intervention is needed only in unstable patients with nonoperative reduction contraindications or in prior unsuccessful reduction attempts. Barium enemas should be avoided in children with evidence of peritonitis, severe shock, sepsis, perforation, or extreme ages. Enema reduction should be attempted three times at the most before considering it unsuccessful and submitting the patient to surgery. Poor enema reduction rate is determined by (in descending order) symptoms longer than 24 h, age <3 months, dehydration, and intussusception of the rectum. Repeat enema is both safe and effective in recurrent intussusception. Spontaneous reduction occurs in approximately 10%–17% of patients, being most common in the small bowel. Finally, barium enema has been the gold standard in confirming the diagnosis and nonsurgical reduction of an intussusception. Water-soluble contrast has been used, and more recently, air enema reduction has been introduced. There are several reasons why radiologists have different preferences for which type of contrast they choose to use for the procedure. After the radiologist reduces the intussusception, they look for the contrast to reflux into the ileum. This is necessary to eliminate the possibility of an ileoileal intussusception. This is more difficult to see with an air-contrast enema compared to a barium or water-soluble contrast enema. Air leaking into the peritoneal cavity because of intestinal perforation may also be difficult to visualize. Those in favor of using the air-contrast enema technique argue that with perforation, the sudden loss of pressure would signal to the radiologist to stop the procedure.
If tension pneumoperitoneum results, this should be decompressed immediately with an 18G needle. Barium leaking into the peritoneal cavity may cause a chemical peritonitis. Using a water-soluble contrast may decrease this complication. An air-contrast enema is advocated as the preferred method by many pediatric surgeons, but since there is no clear consensus among radiologists of the best contrast enema option, this decision is best left to the pediatric surgeons performing the contrast enema procedure. Laparoscopy in the management of intussusception was initially limited to a diagnostic role. It was used to confirm unreduced bowel following an enema with prompt conversion to an open procedure. The laparoscope allowed the surgeons to avoid unnecessary open procedures in cases of spontaneous reduction following enema and enhanced the efficacy of hydrostatic or pneumatic reductions, reducing the need for an open procedure in approximately 30% of cases. Continued experience with laparoscopy and improved technology has led some centers to successfully utilize the technique for therapeutic reduction in confirmed cases of pediatric intussusception. The role of laparoscopy in intussusception is evolving and will be better defined as technology progresses and experience with the minimally invasive approach to this disease grows. IV fluid resuscitation is continued and calculated, taking into consideration maintenance requirements and third-space losses. On resolution of the ileus, diet is advanced at the discretion of the surgeon.
Intussusception results in bowel obstruction; thus, complications such as dehydration and aspiration from emesis can occur. Ischemia and bowel necrosis can cause bowel perforation and sepsis. Necrosis of a significant length of the intestine can lead to complications associated with short bowel syndrome. Whether treated by operative or radiographic reduction, late stricture (4–8 weeks) may occur within the length of the intestine involved. The overall mortality rate of intussusception is <1%. Recurrence rates following nonoperative reduction and surgical reduction are approximately 5% and 1%–4%, respectively. Criteria associated with a higher failure rate of nonoperative reduction include ileocolic intussusception, long duration of symptoms, raised neutrophil percentage, rectal bleeding, failed reduction with barium at another institution, age older than 2 years or younger than 3 months, duration of symptoms longer than 24 h, small-bowel obstruction on radiograph, dehydration of >5%, and inexperienced radiologist. Factors significantly predictive of bowel perforation are younger age and a longer duration of symptoms.
| Conclusion|| |
Surgical intervention in intussusception can be prevented by nonoperative reduction, especially if presented early with no signs of peritonitis. Timely nonoperative reduction can prevent surgical intervention and complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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