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Original Articles

INTUSSUSCEPTION IN INFANTS AND CHILDREN: A REVIEW OF 60 CASES

Abdulrahman A. Al-Bassam, FRCS(Ed); Nouri Orfale, MD

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Sixty pediatric patients with intussusception seen at Maternity and Children's Hospital over 2.5 years were retrospectively reviewed. There were 33 males and 27 females ranging in age from 1.5 months to 108 months with a mean of 11.5 months. Seventeen patients (28.3%) presented more than 48 hours after their symptoms started. Vomiting was the most common symptom (93.3%) followed by rectal bleeding (71.6%) and abdominal pain (48.3%). The clinical signs included the presence of blood per rectal examination in 58.3% of patients and palpable mass in 46.6% of patients. Most intussusceptions were of ileocolic type (88%). Hydrostatic barium enema reduction was tried in 50 patients (83.3%) with an overall success rate of 56%. Fify-three percent of patients had surgical treatment for their intussusception. Ten patients (16.6%) required bowel resection. The leading point was identified in 10% of patients. Meckel's diverticulum was the most common finding. The average hospital stay was two to five days after barium reduction and seven days after surgical treatment. There were no deaths. One patient had perforation of the bowel during hydrostatic reduction and another had chest infection postoperatively. There were no recurrences in our series. In conclusion, it appears that failure to diagnose intussusception in the first 24 hours will decrease the successful rate of hydrostatic reduction and increase the need for surgical intervention and the period of hospitalization. Barium enema reduction is the
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treatment of choice in all cases unless contraindicated. The clinical pattern of intussusception in this part of the world is more or less the same as in other countries. Ann Saudi Med 1995;15(3):205-208.

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Intussusception is one of the most common causes of intestinal obstruction in the first two years of life. In the majority of cases there is no underlying cause. The classical presentation of abdominal colic, abdominal mass, and passage of red currant 25 jelly stool occur in only one-third of cases.1 Although barium enema is the standard method for the diagnosis and treatment, a new method of using air enema and ultrasound-guided hydrostatic 30 reduction have been introduced with successful 2-4 results. This paper studies the clinical presentation and management of intussusception as seen at Maternity and Childrens Hospital in 35 Riyadh over a period of 2.5 years in infants and children.

Maternity and Childrens Hospital, Riyadh, over 2.5 years were studied. The diagnosis was confirmed radiologically and/or at surgery. The records of these patients were reviewed with respect to age, sex, nationality, hospital stay, month of

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Material and Methods

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The medical records of 60 consecutive infants 45 and children treated for intussusception at

From the Division of Pediatric Surgery (Dr. AlBassam), King Khalid University Hospital, Riyadh and Department of Surgery (Dr. Orfale), Maternity and Childrens Hospital, Riyadh. Address reprint requests and correspondence to Dr. Al-Bassam: P.O. Box 86572, Riyadh 11632, Saudi Arabia. Accepted for publication 22 August 1994. admission, clinical presentation, investigation, mode of treatment, morbidity and mortality, underlying cause and incidence of recurrence. Barium enema for diagnostic and therapeutic purposes was performed in most of the patients. In our hospital, barium enema reduction was performed by introducing barium contrast through a
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Foley catheter placed into the rectum and secured by inflation of the catheter balloon and strapping of the buttocks. A column of barium was delivered from the reservoir holder at a height of 1 meter 25 above the x-ray table. The barium distribution within the colon was fluoroscopically visualized. Successful reduction was considered achieved when barium refluxed to the distal ileum. Patients who had successful reduction were discharged 30 home when tolerating a normal diet. All unsuccessful trials at reduction and contraindication for hydrostatic reduction in our service were taken to surgery.

(91.6%) were below one year of age. The majority of patients were between four and six months (Figure 1). Thirty-five patients were Saudis. The average hospital stay was 2.5 days after barium enema reduction and seven days after surgical exploration.

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Results

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Sixty infants and children were evaluated and treated for intussusception over two-and-one-half years. There were 33 males and 27 females. The mean age of the patients was 11.5 months (range 45 1.5 month to 108 months). Fifty-five patients
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INTUSSUSCEPTION FIGURE 1. Age incidence in 60 cases of intussusception at Maternity and Childrens Hospital, Riyadh, over 2.5 years.

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There was no significant seasonal variation in incidence of intussusception in our patients. On review of the clinical presentation of these patients, 32 (53.3%) presented within 24 hours of the onset 30 of symptoms. Seventeen patients (28.3) presented at 48 hours and 11 patients (18.3) presented at 72 hours or more. Vomiting was the most common symptom (93.3%) followed by abdominal pain and bleeding per rectum (Table I). Four patients (6.6%) had upper respiratory tract infection at the time 35 of admission. One patient presented with convulsions due to electrolyte disturbance and that was the cause of his admission. Another patient was referred for rectal prolapse and actually had 40 prolapse of the intussusception through the anus. Review of the clinical signs of these patients (Table 2) revealed the presence of fever in seven patients (11.6%) and abdominal mass in 28 patients (46.6%). Most of these masses were felt in the 45 right upper quadrant.

Abdominal distention was reported in 16 patients (26.6). Rectal examination revealed red currant jelly stool in 35 patients (58.3%) and palpable intussusception in 12 patients (20%). Five patients (8.3%) presented in shock and three patients (5%) presented with generalized peritonitis due to gangrenous bowel; all of them were seen 48 hours or more after the onset of their symptoms. Ultrasound of the abdomen was done in seven patients to rule out other surgical conditions and was diagnostic in three (24.8%). Barium enema was requested in 50 patients (83.3%). In 10 patients, barium enema was not done because the general condition did not permit or the patient had long-standing bowel obstruction with peritonitis. Barium enema was diagnostic in all cases. In one patient, barium enema was complicated by perforation of the colon; that study was done outside our hospital. Twenty-eight patients (56%) experienced complete hydrostatic reduction of intussusception with barium enema and 22 patients (44%) required surgical treatment of
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intussusception. Surgical treatment was simple reduction in 22 patients and resection and anastomosis in 10 patients. All patients who had resection presented late (three to seven days) after their symptoms started. 25 Fifty-three patients (88%) had ileocolic intussusception and seven patients had ileoileocolic. A lead point was identified in six patients (10%). Meckel's diverticulum occurred in four cases and enlarged mesenteric lymph nodes in two 30 cases. There were no recurrences and there were no deaths in this series. One patient had chest infection postoperatively.

We saw nearly 25 cases per year which represent 0.18% of the total annual admission to Childrens Hospital. The condition has been known to have a male preponderance6-8 but in our study that was not clearly demonstrated (33 male, 27 female); in most cases (60% to 94%) intussusception occurs in the first year of life.8-10 Fifty-five of our patients (91.6%) were below the age of one year. The commonly affected infants were between the ages of four to six months, which was more or
TABLE 1. Symptoms Vomiting Bleeding per rectum Symptoms in order of frequency. No. of patient 56 (93.3%) 43 (71.6%)

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Discussion

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Intussusception is a common pediatric disease. The incidence of this condition has striking variation from one country to another. The hospital incidence varies from five to 63 cases per year. 5
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INTUSSUSCEPTION 1 (1.6%)

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Fleshy mass protruding from anus

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TABLE 2. Sign Currant jelly stool per rectal examination Abdominal mass Signs in order of frequency. No. of patient 35 (58.3%)

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3 (5%)

less similar to other studies.8,10,11 The other age groups were not immune to this condition. We have seen one patient at the age of 45 days and three patients above the age of six years. We did not see any significant seasonal variation in the incidence of intussusception in our patients although this observation is controversial in the literature.5,6 Around half of the patients (53.3%) presented within 24 hours of the onset of symptoms. In the remaining half, 17 patients (28.3%) presented at 48 hours and 11 patients (18.3%) presented at 72 hours or more; this indicates a late presentation of our patients which may be due in part to the delay in seeking medical advice or missing the diagnosis by attending physicians. The classic triad of abdominal colic, palpable abdominal mass and rectal bleeding which makes the diagnosis easy was seen in 25% of our patients. This combination was reported to range from 12% to 40% of cases.1,12

Generalized peritonitis Annals of Saudi Medicine, Vol 15, No 3, 1995

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The frequency of symptoms and signs in patients with intussusception varies widely from 25 one study to another. The most common symptoms in our patients were vomiting followed by rectal bleeding and abdominal pain, which was comparable with other studies.9,10 The presence of rectal blood and abdominal 30 mass were the most common signs on examination. Similar findings were revealed in other studies.8,10 Barium enema is the method of choice for the treatment of intussusception. We have it done in 35 83.3% of our patients with a success rate of 56%. This rate is probably lower than that reported by others.4,9 Hydrostatic reduction in 1317 barium enemas from 11 reviews showed a success rate ranging between 19% and 85%.10 The wide range 40 in the success rate can be explained by the difference in time of patient presentation to the hospital, experience of the attending radiologists and other factors. Air enema for diagnosis and reduction of intussusception has been reported to be 45 reliable, safe and effective.3,4 We have no experience with this new modality. Ultrasound was
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used in seven of our patients but unfortunately was of low diagnostic accuracy (25%). Ultrasound was found to be a reliable diagnostic screening modality in suspected cases of intussusception and ultrasound guidance is a promising technique for therapeutic reduction of intussusception.2,13. Thirty-two of our patients (53%) had a surgical intervention with simple reduction in 22 patients (68.8%) and resection and anastomosis in 10 patients (31.2%). Our resection rate is high compared to other series but can be explained by late presentation of those patients who had resection. In the majority of cases (88%) the intussusception was ileocolic, which was similar to the findings in many studies. Pathological lead points were seen in six patients (10%) and Meckel's diverticulum was the most common. This 5,10,11 observation was reported in other studies. Other lead points that can cause intussusception are lymphoma, polyps, a nodule of ectopic pancreas, enterogenous cyst and small bowel tumors.5,14,15 The reported mortality of 3079 patients with intussusception from 13 reviews ranged between

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0% and 3.4%.10 We had no deaths in this series. One patient had perforation of the colon attributed 20 to hydrostatic reduction and one patient developed chest infection postoperatively. None of our patients had recurrence. The overall recurrence rate was 4% to 14%.11

Other methods of using air enema ultrasoundguided reduction can be tried when an expert radiologist is available. The clinical pattern of this fairly common condition in this part of the world is more or less the same as in other countries.

Conclusion

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Acknowledgment

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Failure to diagnose the intussusception in the first 24 hours will decrease the rate of successful hydrostatic reduction and therefore will increase the need for surgical intervention and the period 30 of hospitalization. Barium enema reduction is the treatment of choice in all cases of intussusception unless contraindicated.

We would like to thank our surgical colleagues at Maternity and Childrens Hospital, Riyadh, for permission to review their patients.

References

1. Bruce J, Huh YS, Cooney DR, Karp MP, Allen JE, Jewett TC. Intussusception: evolution of current
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management. J Pediatr Gastroenterol Nutr, 25 9. 1987;6:663-74. Woo SK, Kim JS, Suh SJ, Paik TW, Choi SO. Childhood intussusception: US-guided hydrostatic reduction. Radiol 1992;182:77-80. Shiels WE, Maves CK, Hedlund GL, Kirks DR. 30 Air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates. Radiol 1991;181:169-72. Palder SB, Ein SH, Stringer DA, Alton D. Intussusception: barium or air. J Pediatr Surg 35 1991;26:271-5. Ravitch MM, Welch KJ, Benson CD, et al. Pediatric Surgery, Vol 2, 4th ed. Chicago, Year Book 1986;868-82. Ein SH, Stephens CA. Intussusception: 354 cases 40 in 10 years. J Pediatr Surg 1971;6:16-27. Gierap J, Jorulf H, Livaditis A. Management of intussusception in infants and children: a survey based on 288 consecutive cases. Pediatr 1972;50:535-46. 45 Hutchinson IF, Olayiwola B, Young DG. Intussusception in infancy and childhood. Br J Surg 1980;67:209-12.

Liu KW, MacCarthy J, Gurney EJ, Fitzgerald RJ. Intussusception - current trends in management. Arch Dis Child, 1986;61:75-7. 10. Rundkivi PJ, Smith HL. Intussusception analysis of 98 cases. Br J Surg 1981;68:645-8. 11. Dawod ST, Osundwa VM. Intussusception in children under two years of age in the State of Qatar: analysis of 76 cases. Ann Trop Pediatr 1992;12:121-6. 12. Refund H, Hurvits H, Schiller M. Etiology and therapeutic aspects of intussusception in childhood. Am J Surg 1977;134:272-4. 13. Bhistikul DM, Listernick R, Shkolnik A, et al. Clinical application of ultrasonography in the diagnosis of intussusception. J Pediatr 1992;121:182-6. 14. Ein SH, Shandling B, Reilley BJ, Stringer DA. Hydrostatic reduction of intussusception caused by lead points. J Pediatr Surg 1986;21:883-6. 15. Puri P, Guiney EJ. Small tumors causing intussusception in childhood. Br J Surg 1985;72:493-4.

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