Articles

Idiopathic intussusception in infancy and childhood

Stanley J. Crankson, FRCS, Abdullah A. Al-Rabeeah, FRCS(C), James D. Fischer, FRCS(C), Saud A. Al-Jadaan, FRCS(C), Mohammed A. Namshan (MBChB).

ABSTRACT
Objective: Idiopathic intussusception is an important cause of abdominal pain, bleeding per rectum and intestinal obstruction in infancy and childhood. This aim of this study was to undertake a retrospective review of all children who presented with idiopathic intussusception over a 17-year period. Methods: The medical records of children who presented with idiopathic intussusception from January 1984 through December 2000 at King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia were reviewed. The data obtained included age, sex, clinical presentation, diagnostic investigations, mode of treatment, length of hospital stay and results. Results: Thirty-three children (21 male, 12 female) presented with 37 episodes of intussusception. Their mean age was 8.4 months (range 5 hours to 36 months). The clinical features included rectal bleeding (81%), vomiting (78%), abdominal colic/pain (65%) and abdominal mass (62%). All cases were ileocolic intussusception with no leading point. Barium enema was attempted in 36 cases with success in 20 (56%). Laparotomy was required in 16 cases, manual reduction being successful in 11 (30%) and 6 (16%) had bowel resection. At surgery, after attempted barium reduction, 9 (56%) cases had the intussusception already reduced to the cecum. Seventy percent of the cases presented within 24 hours of onset of symptoms. The 4 recurrences in 3 children had successful enema reduction. There was no mortality but 3 operative cases required late surgery for adhesive intestinal obstruction including one requiring bowel resection. Conclusion: Idiopathic intussusception commonly presents as an ileo-colic type but is uncommon in our institution. The clinical features are classical, rectal bleeding being the most common. The majority presented within 24 hours of onset of symptoms and barium enema reduction was successful in 20 out of 36 cases in which it was attempted. Since most intussusceptions were already in the cecum at surgery after failed enema reduction, a repeat or delayed enema reduction could be considered in stable cases. Recurrent intussusception occurred in 3 non-operated cases and adhesive intestinal obstruction in 3 laparotomy cases. Saudi Med J 2003; Vol. 24 Supplement 1: S18-S20

ntussusception is an important cause of intestinal obstruction, bleeding per rectum and abdominal pain in childhood. Although it occurs infrequently, it is one of the most common abdominal emergencies in the pediatric age group. It may be ileo-colic (80%), ileoileal, cecocolic, colocolic or jejunojejunal in type. Intussusception may also be classified as primary idiopathic, secondary where there is a definite pathological lead point but may also occur as

postoperative complication.1,2 Primary idiopathic intussusception is not associated with an obvious cause in 90% of cases except lymphoid tissue hyperplasia. The accepted management of idiopathic intussusception consists of adequate resuscitation, radiological confirmation of diagnosis, and radiological reduction (unless contraindicated) with surgical intervention as a last resort except in special cases.3 The classical cases of idiopathic intussusception are readily diagnosed

From the Department of Surgery, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. Received 12th November 2002. Accepted for publication in final form 21st December 2002. Address correspondence and reprint request to: Dr. S. J. Crankson, Consultant Pediatric Surgeon, King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia. Tel. +966 (1) 2520088. Fax. +966 (1) 2520140. E-mail: cranksons@yahoo.com

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clinically but intussusception may mimic other conditions. Radiological investigations should therefore be undertaken promptly in suspected cases. Barium enema has been the imaging study of choice for the diagnosis and treatment in the absence of any contraindications such as peritonitis, septicemia or advanced intestinal obstruction. Pneumoperitoneum on abdominal radiograph would indicate a perforation an absolute contraindication.4 The alternative of gas (air/oxygen) enema is reported to be quicker, less messy, delivers less radiation to patients and has increased reduction rate.4,5 Ultrasonography (US) is a helpful diagnostic tool for those children whose clinical presentation or plain abdominal film is suspicious but not diagnostic for intussusception. Ultrasonography has characteristic findings of doughnut or target sign on transverse section and pseudo-kidney or sandwich on longitudinal section.1,2 Therapeutic saline enema under US guidance has been reported with a success rate of 83-95.5% but the procedure takes a long time for the inexperienced and is more operator dependent.5,6 The advantages of this procedure are the avoidance of radiation and detailed evaluation of intussusception. The incidence of pediatric intussusception in the Kingdom of Saudi Arabia (KSA) is unknown. A retrospective review of idiopathic intussusception over a 17-year period at King Fahad National Guard Hospital, Riyadh, KSA is herein presented. Methods. Thirty-one children with idiopathic intussusception were managed at King Fahad National Guard Hospital, Riyadh, KSA from January 1984 through December 2000. The medical records of these children were reviewed with regards to age, sex, clinical presentation, investigations, mode of treatment, length of hospital stay, and results. Barium enema was used for diagnosis and reduction of intussusception. Successful reduction was proven by adequate reflux of contrast into the distal ileum: If unsuccessful, laparotomy was performed. Results. Thirty-three children, 21 males and 12 females were treated for ileocolic intussusception. There were 4 recurrences in 3 children. The mean age was 8.4 months (range 5 hours to 36 months). Thirty-one (94%) children were under 12 months of age and 23 (70%) were between 5-9 months old. The clinical features included rectal bleeding (81%), vomiting (78%), abdominal pain/colic (65%) and abdominal mass (62%) (Table 1). The classic clinical triad of abdominal pain, abdominal mass and rectal bleeding occurred in 16 (43%) children. After initial resuscitation, the child had a plain abdominal radiograph and the findings are as per Table 2. Barium enema and recently water-soluble contrast enema was used in all cases except one of peritonitis to confirm the diagnosis and for enema reduction. Successful reduction was possible in 20 (56%) cases, the apex of intussusception was in the transverse colon in 23 (70%) cases, descending

Table 1 - Clinical features (N=37).

Features Rectal bleeding Vomiting Abdominal pain/colic Abdominal mass Diarrhea Triad (abdominal pain, abdominal mass, rectal bleeding)

(%)

30 (81) 39 (78) 24 (65) 23 (62) 13 (35) 16 (43)

Table 2 - Plain abdominal radiograph findings (n=37).

Findings Normal Abdominal mass Meniscus sign Absence of cecal gas and stool in RIF Small bowel obstruction RIF - right iliac fossa

(%)

11 (29.7) 8 (21.6) 2 (5.4) 2 (5.4) 14 (37.9)

colon/sigmoid in 12 (37%) and ascending colon in one (3%). Laparotomy was performed in 17 cases, operative reduction in 6, operative reduction and appendicectomy in 5 and bowel resection in 6. At surgery, 9 (56%) children had the intussusception already reduced to the cecum after prior enema. Bowel resection was required for gangrenous ileum and cecum in 3 cases, perforated cecum during reduction at operation in one, and gangrenous ileum in 2 cases. The mean duration of symptoms of all children was 33 hours (range 5-96 hours). Twenty-six (70%) cases presented within 24 hours of onset of symptoms and for the series for successful enema cases, the mean duration was 30 hours (range 5-72 hours) and 41 hours (range 8-46 hours) for laparotomy cases (P value = 0.0048). The mean length of stay was 2.4 days (range 1-5 days) and 6 days (range 1-23 days) for successful enema reduction and laparotomy cases respectively (P value = 0.00023). These P values are statistically significant. All 4 cases of recurrent intussusception were from the enema reduction group and were successfully reduced by repeat enema. Adhesive small bowel obstruction occurred in 3 children who had previous laparotomies. One child required laparotomy and release of adhesions and another required bowel resection and the third responded to non-operative management.
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Discussion. The peak incidence of intussusception is between the 5th and 9th month of life and in this review 70% of the children were within this age group. Ninety-four percent of our patients were within the first year of life, the youngest being only 5 hours old. Intussusception in the prenatal and neonatal period is however, considered extremely uncommon. The incidence of intussusception in KSA is unknown with 60 cases reported over 2.5 years in one institution.7 This report however, included secondary intussusception. In our review of idiopathic intussusception over 17 years, we encountered an average of only 2 cases per year, therefore making it a very uncommon condition at our institution. Male preponderance has been our experience and of others, although not validated by Al-Bassam and Orfale.1,7 The classic triad of abdominal pain, abdominal mass, and red currant jelly stool which was encountered in 43% of our cases is also the experience of others.5 The most common features are vomiting in infants and colicky abdominal pain in older children.1 Rectal bleeding which is considered to be a sign of mucosal sloughing or intestinal ischemia was found in 81% which was surprising considering that 70% of children presented early in the first 24 hours. The role of the abdominal radiograph in children with suspected intussusception is uncertain. In our study, the abdominal radiograph was not suggestive of intussusception in 29.7% of patients. However, signs suggestive of intussusception included meniscus sign (5.4%), absence of cecal gas (5.4%), abdominal mass (21.6%) and small bowel obstruction (39.7%). In a retrospective review of abdominal radiographs in children with suspected intussusception by Sargent et al,6 intussusception was identified in only 27 of 60 (45%) children. We think that the abdominal radiograph may be omitted in most children in whom there is a high clinical index of suspicion for intussusception, particularly if barium enema is used diagnostically. The current reduction techniques, the spontaneous reduction of intussusception at surgery, and easy operative reduction have led to the adoption of repeat enemas in stable patients. In 9 patients in our study, intussusception had been reduced to the cecum and probably a repeat enema would have achieved successful reduction. Saxton et al,8 reported over 50% success rate in 22 patients who had delayed enema following an unsuccessful first attempt and confirmed by others.1,9 We believe that this should be considered in all stable patients before surgery. Operative reduction has been necessary in cases in whom radiological techniques are contraindicated or have failed; when a pathological lead point is suspected; or in the case of multiple recurrences.1 Laparotomy is associated with an invasiveness, morbidity and increased length of stay as apparent in our review. Laparoscopy has been used for diagnosis of failed reduction, for laparoscopic-assisted pneumatic reduction and hydrostatic saline enema during the procedure.10,11 Poddoubnyi et al,10 reported a success of 65.3% in the

use of laparoscopic-assisted treatment with a conversion to open procedure of 34.7%. In a report by Hay et al,11 14 (70%) of 20 patients were saved from unnecessary laparotomy using laparoscopy for diagnosis of failure and for hydrostatic saline enema. Operative reduction was required in 11 (65%) of 17 patients, resection being necessary in 6 (35%) in our study. Resection usually reflects either delay in presentation or diagnosis and the experience of the surgeon. Perhaps in our study this reflects delay in presentation since only one patient required resection as a result of perforation during the manual reduction. In conclusion, idiopathic intussusception is an uncommon condition in our institution. Although most children present within 24 hours of onset of symptoms rectal bleeding is the most common clinical feature. After resuscitation, abdominal radiograph is necessary to exclude perforation and other intraabdominal causes. Contrast enema is still used at our institution for both diagnosis and enema reduction, despite the recent use of gas pneumatic reduction, US with hydrostatic saline enema and laparoscopic-assisted pneumatic or saline enema reduction. Repeat enema or laparoscopy should be considered for failed reduction before laparotomy. Of course, for patients with peritonitis or when a pathological lead point is suspected, laparotomy is indicated.
Acknowledgment. We wish to express our sincere gratitude to Ms. Mel Rabago for her secretarial help and Dr. Saeed Ahmed for his review of the manuscript.

References
1. Stringer MD, Pablot SM, Brereton RJ. Paediatric intussusception. Br J Surg 1992; 79: 867-876. 2. Crankson SJ, Al Mane KA. Intussusception. A cause of postoperative intestinal obstruction. Saudi Med J 2000; 21: 683-685. 3. Di Fiore JW. Intussusception. Semin Pediatr Surg 1999; 8: 214-220. 4. Teele RL, Vogel SA. Intussusception: the paediatric radiologists perspective. Pediatr Surg Int 1998; 14: 158-162. 5. Daneman A, Alton DJ. Intussusception. Issues and controversies related to diagnosis and reduction. Radiol North Am 1996; 34: 743-746. 6. Sargent MA, Babyn P, Alton DJ. Plain abdominal radiography in suspected intussusception: a reassessment. Pediatr Radiol 1994; 24: 17-20. 7. Al-Bassam AA, Orfale N. Intussusception in infants and children: a review of 60 cases. Annals of Saudi Medicine 1995; 15: 205-208. 8. Saxton V, Katz M, Phelan E, Beasley SW. Intussusception: a repeat delayed gas enema increases the non-operative reduction rate. J Pediatr Surg 1994: 29: 588-589. 9. Gorenstein A, Raucher A, Serour F, Witzling M, Katz R. Intussusception in children: reduction with repeated, delayed air enema. Radiology 1998; 206: 721-724. 10. Poddoubnyi IV, Dronov AF, Blinnikov OI, Smirnov AN, Darenkov IA, Dedov KA. Laparoscopy in the treatment of intussusception in children. J Pediatr Surg 1998; 33: 1194-1197. 11. Hay SA, Kabesh AA, Soliman HA, Abdelrahman AH. Idiopathic intussusception: the role of laparoscopy. J Pediatr Surg 1999; 34: 577-578.

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