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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 691-695

Intussusception in children: effect of symptom duration on the outcome of hydrostatic reduction


Pediatric Surgery Unit, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria

Date of Submission06-Oct-2020
Date of Decision01-Feb-2021
Date of Acceptance20-Feb-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Chukwubuike K Emeka
MBBS, FMCS, FWACS, Department of Surgery, Enugu State University Teaching Hospital, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_367_20

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  Abstract 


Background
Intussusception is a common cause of intestinal obstruction in children, especially in infants. Intussusception is a pediatric abdominal surgical emergency, and hydrostatic reduction is an effective modality of treatment in selected group of patients. There are lack of data in Nigeria on the effect of symptom duration on hydrostatic reduction.
Aim
To evaluate the effect of duration of symptoms on the outcome of hydrostatic reduction of intussusception.
Patients and methods
This was a prospective study on the effect of symptom duration on the success of hydrostatic reduction of intussusception in children. This study was carried out at the pediatric surgery unit of a teaching hospital over a 3-year period. The patients were categorized into two groups: group A included patients who had successful reduction, and group B included patients who had unsuccessful (failed) reduction.
Results
A total of 96 cases of intussusception were managed during the study period, of which 32 (33.3%) patients underwent hydrostatic reduction. Mean age of the patients was 7 months, with a range of 4–12 months. Male to female ratio was 1.9: 1. All the patients had abdominal pain. There was more successful hydrostatic reduction in patients who presented within 48 h of onset of symptoms (group A), and this was statistically significant (P = 0.04).
Conclusion
Children with intussusception who present early (within 48 h of onset of symptoms) had more successful hydrostatic reduction when compared with patients who present after 48 h.

Keywords: children, duration, hydrostatic reduction, intussusception, outcome


How to cite this article:
Emeka CK. Intussusception in children: effect of symptom duration on the outcome of hydrostatic reduction. Menoufia Med J 2021;34:691-5

How to cite this URL:
Emeka CK. Intussusception in children: effect of symptom duration on the outcome of hydrostatic reduction. Menoufia Med J [serial online] 2021 [cited 2024 Mar 29];34:691-5. Available from: http://www.mmj.eg.net/text.asp?2021/34/2/691/319726




  Introduction Top


Intussusception could be defined as invagination of one segment of the intestine into another segment and is a common cause of intestinal obstruction in children. It is an abdominal surgical emergency [1],[2]. The symptom duration of intussusception refers to the interval between time of onset of symptoms of intussusception and time of presentation to the hospital. Outcome of treatment of intussusception is described as successful when the invaginating segment of bowel is pushed back to its original position and there is reflux of fluid into the terminal ileum during hydrostatic reduction. A meta-analysis on childhood intussusception showed an incidence of 74 per 100 000 children and a peak incidence of 5–7 months of age [3]. Etiologically, there are two main types of intussusception: (a) idiopathic intussusception and (b) intussusception resulting from pathologic lead point. Most of the cases of intussusception in children are idiopathic, where no obvious cause is found [4]. There are no pathognomonic symptoms and signs of intussusception. The triad of abdominal pain, vomiting, and passage of red currant jelly stool occurs in only one-third of the patients [5]. Other abdominal conditions such as gastroenteritis and malaria may have similar symptoms to intussusception, hence the delays in making a clinical diagnosis. An abdominal ultrasound has high sensitivity for the diagnosis of intussusception and for real-time monitoring of success during hydrostatic reduction of intussusception [6]. The options of treatment of intussusception could be nonoperative or operative. Nonoperative treatment entails the use of air (pneumatic), normal saline, barium, or other solutions (hydrostatic) as an enema for the reduction of the intussusception. Operative treatment involves laparotomy or laparoscopy. There is paucity of data on the relationship between the duration of symptoms of intussusception and successful hydrostatic reduction. Some practitioners perform hydrostatic reduction in children without regarding the length of time the intussusception has lasted. This study is necessary because it will provide information on when to perform hydrostatic reduction and when to go for operative treatment of intussusception.

Some previous studies have suggested that the duration of symptoms of intussusception has an effect on successful hydrostatic reduction, whereas some of the studies have not reported any difference in this outcome measure. The research question to be answered in this study is the relationship between successful hydrostatic reduction and the length of time the symptoms have lasted. The aim of this research was to evaluate the effect of duration of symptoms on the outcome of hydrostatic reduction of intussusception. This research will provide data on when to perform hydrostatic reduction in relation to the time of patient presentation. Time spent on hydrostatic reduction in late presenters will be used in operative treatment of intussusception. The outcome of this research helped the pediatric surgery unit establish a protocol/policy for managing children who presented with intussusception.


  Patients and methods Top


This was a prospective study of children aged 12 months and younger who had hydrostatic reduction of intussusception between January 2017 and December 2019 at the pediatric surgery unit of a teaching hospital. The teaching hospital serves the whole of Enugu State, which according to the 2016 estimates of the National Population Commission and Nigerian National Bureau of Statistics has a population of approximately four million people and a population density of 616.0/km2. The hospital also receives referrals from its neighboring states. Selection and recruitment into the study were based on clinical features suggestive of intussusception and ultrasound confirmation of intussusception evidenced by target sign and pseudokidney signs on imaging. Selection of patients was performed by a consultant pediatric surgeon, and the ultrasound scan was performed by a consultant radiologist. Only children with ultrasound-confirmed diagnosis of ileocolic intussusception were enrolled into the study. Patients with marked abdominal distension, those with features of peritonitis, and those with other types of intussusception (such as ileoileal or colocolic) were excluded from the study. A total of 23 patients were excluded from this study. The patients were prospectively enrolled, but the outcome measures (successful/unsuccessful hydrostatic reduction) were retrospectively analyzed. The outcome measures were assessed during the same hospital admission, not exceeding 7 days.

Ethical approval was obtained from the ethics and research committee of the hospital, and patients' caregivers gave their consent for this study.

Preprocedure protocol

On presentation to the hospital, the patients were clinically evaluated and the patients' caregivers counseled. The treatment protocol was explained and informed consent obtained. Intravenous access was secured, intravenous fluid set up, and blood samples collected for full blood count and serum electrolytes. Nasogastric tube and urethral catheter were passed and monitored. The patient was taken to the ultrasound suite where an ultrasound scan was conducted by a radiologist. The diagnosis of intussusception was confirmed by the presence of target sign and pseudokidney sign on transverse and longitudinal sections, respectively.

Procedure proper

A size 24 Foley's catheter was inserted into the anus of the patient and the catheter balloon inflated using 30 mm of water. The patient's buttocks were taped to avoid fluid leakage. Normal saline was placed 100 centimeters above the level of the patient and allowed to run into the patient's colon under gravity until the pressure equilibrates. There were three attempts of hydrostatic reduction with each lasting for 3 min. This procedure was performed by a pediatric surgeon under ultrasound guidance using real-time scanner with 5-MHz linear transducer (TITAN; Sonosite Inc., Bothell, Washington, USA). Visualization of the normal saline in the ileum and disappearance of the intussusception mass are the evidence of successful hydrostatic reduction. Unsuccessful reduction is defined as failure of the normal saline to get into the ileum and persistence of the intussusception mass. Patients with successful reduction were categorized as group A, whereas patients with unsuccessful reduction were categorized as group B.

Postprocedure protocol

Patients who had successful hydrostatic reduction were taken to the ward and oral intake started when bowel function returned. Subsequently, the patients were discharged home. Patients who had unsuccessful reduction were taken to theater for operative treatment. The follow-up period was for 6 months.

Data collection and analysis

The following data were collected: age, sex, presenting symptoms, duration of symptoms before presentation (<48 h/≥48 h), outcome of treatment, and complications of hydrostatic reduction. Statistical Package for the Social Sciences (SPSS) for Windows, version 23 (IBM Corp., Armonk, New York, USA) was used for data entry and analysis. Data were expressed as percentages, mean, and range. χ2 or Student's t test was used to test for significance. P value less than 0.05 was considered statistically significant.


  Results Top


A total of 96 cases of intussusception were managed during the study period. Overall, 32 (33.3%) patients underwent hydrostatic reduction and formed the basis of this report. A total of 64 (67.7%) patients had marked abdominal distension with features of peritonitis and were treated operatively. All the patients had ileocolic intussusception. There were 21 (65.6%) and 11 (34.4%) females [Table 1].
Table 1: Demographic features of patients

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The patients presented with abdominal pain, bilious vomiting, abdominal mass, and passage of red currant jelly in various combinations [Table 2].
Table 2: Presenting symptoms of the patients

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Preceding the symptoms of intussusception, five (15.6%) patients had respiratory infections in the form of nasal discharge and cough: four (12.5%) patients had gastrointestinal infection that was characterized by diarrhea and vomiting, and one (3.1%) patient had evidence of both respiratory and intestinal infections.

There was more successful hydrostatic reduction in patients who presented within 48 h of onset of symptoms (group A) [Table 3].
Table 3: Mean duration of symptoms of the patients and outcome

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One (3.1%) patient had bowel perforation that happened during the procedure. This patient was taken to theater immediately for operative treatment. There was no recurrence of intussusception and no mortality in any of the patients.


  Discussion Top


The oldest nonoperative treatment method of intussusception was the use of barium enema under fluoroscopic monitoring. Following the works of Guo et al. [7] on pneumatic reduction in 1986 in the People's Republic of China, the use of pneumatic reduction of intussusception increased and barium was no longer recommended. However, pneumatic reduction involves the use of fluoroscopy which exposes the children with intussusception to radiation. Ultrasound-guided hydrostatic reduction of intussusception using normal saline, which do not make use of radiation, is widely and currently practiced, especially in low-income countries [2]. Delayed presentation of patients with intussusception may result in its transanal protrusion [8]. Hence, the interval between the onset of symptoms and hydrostatic reduction of intussusception could be an important factor in its success or otherwise.

In the present study, only about one-third of our patients were found suitable for hydrostatic reduction. This finding is similar to the reports of a study conducted in South-West Nigeria [9]. In contrast, another study from Egypt reported that 80% of their patients had hydrostatic reduction [10]. The low number of patients suitable for hydrostatic reduction in low-resource countries could be owing to late presentation, which is associated with bowel gangrene, perforation, and peritonitis. Ileocolic intussusception is the most common type of intussusception in children. Overall, 100% of our patients had ileocolic intussusception. Other studies also reported ileocolic intussusception as most common [11],[12]. Lymphoid hyperplasia in the terminal ileum due to viral infection is theorized to be the etiology of ileocolic intussusception [13].

The male predominance recorded is consistent with the report of other studies [1],[14]. However, one study reported female predominance [8]. The reason for the sex difference is not known. The mean age of our patients is comparable to the report of other researchers [15],[16]. However, a mean age as high as 22 months has been reported [14]. The exact reason for the differences in the mean age of the patients is not clear but may be owing to differences in weaning pattern and geographical locations. The peak age of our patients is in line with the report of Talabi et al. [16]. Peak age of intussusception may vary depending on if the intussusception is idiopathic or has a pathological lead point. Late presentation of our patients is evidenced in the mean 3 days lag period before presentation to the hospital. Other authors from developing countries also alluded to this late presentation [9],[17]. Poverty and ignorance, which is common in developing countries, may explain this late presentation.

Duration of hospitalization of our patient is at variance to the report of Fahiem-Ul-Hassan et al. [18]. Mallicote et al. [19] reported that 4 h of observation following successful hydrostatic reduction is not associated with adverse outcomes. Postreduction ileus owing to electrolyte imbalance may have accounted for the long period of stay of our patients.

Abdominal pain was the most frequent symptom, and this finding is consistent with the report of another study [20]. Abdominal pain in intussusception is colicky and intermittent. However, in painless intussusception, vomiting may be the only presentation [21]. Abdominal distension could be the most common presentation in late presenters [22].

Viruses such as adenovirus and rotavirus have been postulated to be involved in idiopathic intussusception. This theory is supported by the seasonal nature of these viral infections, which corresponds to the seasonal peaks of intussusception [23]. Viral infections of the intestinal tract lead to edema and hyperplasia of the Peyer's patches, which may serve as a lead point for intussusception. Similar to our findings, other workers also reported the relationship between viral infections and the risk of intussusception [24],[25].

Controversy exists on the association between duration of symptoms and successful hydrostatic reduction of intussusception [14]. In the present study, comparing group A and group B patients showed statistically significant difference in the success of hydrostatic reduction. This stipulates that prolonged duration of symptoms (≥48 h) was associated with failed reduction. This finding agrees with the report of other published series on nonoperative treatment of intussusception [14],[26]. However, a study conducted in Hong Kong documented that a mean duration of symptoms of 2.3 days did not affect the success rate of the reduction [27]. One study from Ife, Nigeria, reported that duration of symptoms does not influence the success of hydrostatic reduction [16]. These differences in findings are difficult to explain. Long duration of symptoms may compromise the blood supply of the bowel, making it irreducible. Nonviable bowel will not be reduced by hydrostatic pressure in a properly performed hydrostatic reduction [28].

Bowel perforation may complicate hydrostatic reduction of intussusception. The rate of perforation recorded in the present study is similar to the report of Talabi et al. [16]. Eraki [29] did not record any bowel perforation in their series. The state of the bowel or the technique of hydrostatic reduction may be responsible for the rate of bowel perforation.

The difference in findings between the present study and other studies that find no difference in outcome may be owing to difference in technique of hydrostatic reduction and age groups of the patients enrolled.


  Conclusion Top


In conclusion, hydrostatic reduction of intussusception is an effective method for the treatment of intussusception. Children with intussusception who present early (within 48 h of onset of symptoms) had more successful hydrostatic reduction when compared with patients that present after 48 h.

Limitations of the study

This study has a small number of cases. A larger number of cases would have availed better analysis.

Other variables that may affect hydrostatic reduction such as weight of the patient and location of the intussusception mass were not evaluated in the present study.

Suggestions and recommendations

  1. Parental awareness and update courses for medical practitioners on the need for early referral of children with intussusception are required.
  2. The problem of bowel perforation during hydrostatic reduction was solved by following strict techniques of hydrostatic reduction.
  3. Following the outcome of research, the channels of communications between the pediatricians and pediatric surgeons have improved. This eliminates delays in patients' review and management.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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