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Long B, Easter J, Koyfman A. High risk and low incidence diseases: Pediatric intussusception. Am J Emerg Med 2025; 91:37-45. [PMID: 39987626 DOI: 10.1016/j.ajem.2025.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2024] [Revised: 02/02/2025] [Accepted: 02/15/2025] [Indexed: 02/25/2025] Open
Abstract
INTRODUCTION Pediatric intussusception is a serious condition that carries with it a high risk of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of pediatric intussusception, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Intussusception is one of the most common pediatric abdominal emergencies. This is associated with one part of the intestine telescoping into another, resulting in bowel edema. If the intussusception remains untreated, obstruction, ischemia, necrosis, and perforation may result. Most cases are idiopathic, with 10-25 % associated with a pathologic mass or lead point. The most common age group affected includes those between 3 months to 5 years. The triad of intermittent abdominal pain, currant jelly stool, and sausage-shaped mass is uncommon, though most patients will present with intermittent abdominal pain. Nonbilious emesis and bloody stools (gross blood or guaiac positive) are also common. Younger patients can present atypically, including altered mental status or lethargy. Thus, intussusception should be considered in pediatric patients with abdominal pain, emesis, and a sausage-shaped mass, as well as those with atypical presentations such as altered mental status or lethargy if there is no other etiology found on testing. The diagnostic modality of choice is ultrasound. Plain radiography may assist in evaluating for obstruction and perforation. Treatment includes prompt reduction of the intussusception. In patients who are stable and have no evidence of perforation, non-operative reduction with hydrostatic or pneumatic reduction should be attempted. Operative intervention is necessary in those who are unstable, peritonitic, or have a focal lead point. Discharge may be appropriate for patients following successful non-operative reduction if the patient is able to tolerate clear fluids, is asymptomatic, and can return for any recurrence of symptoms. CONCLUSION An understanding of pediatric intussusception and its many potential mimics can assist emergency clinicians in diagnosing and managing this high risk disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Joshua Easter
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
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Wang S, Wang Y, Jia L, Wang X. Transient and persistent small-bowel intussusception in children: a decision tree analysis model based on ultrasound and clinical findings. BMC Gastroenterol 2025; 25:294. [PMID: 40275162 PMCID: PMC12023406 DOI: 10.1186/s12876-025-03839-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2024] [Accepted: 04/02/2025] [Indexed: 04/26/2025] Open
Abstract
PURPOSE To develop a systematic and efficient decision tree analysis (DTA) model to improve the diagnostic accuracy of transient small-bowel intussusception (TSBI) and persistent small-bowel intussusception (PSBI) in children. METHODS From February 2019 to June 2022, ultrasound (US) features and clinical findings of pediatric patients with small-bowel intussusception (SBI)-including SBI diameter, outer bowel wall thickness, thickness of the head and body of the intussusceptum, length of the intussusceptum, and presence of pathological lead points (PLPs)-were recorded and analyzed. A classification and regression tree algorithm was then used to develop a DTA model, which was trained and validated by randomly categorizing the patients into training (60%, 200/331) and validation (40%, 131/331) datasets to assess diagnostic performance. RESULTS A total of 331 patients with SBI (270 with TSBI and 61 with PSBI) were included; the maximum age was 9 years. The initial diagnostic predictor in the DTA model was the detection of a PLP via US, followed by intussusceptum length (P < 0.001). The sensitivity, specificity, and accuracy of the DTA model were 98.2%, 100%, and 98.6%, respectively. CONCLUSION The DTA model developed in this study facilitated the differential diagnosis of TSBI and PSBI in pediatric patients with SBI, with a clinical concordance rate of 98.6%.
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Affiliation(s)
- Shao Wang
- Department of Ultrasound, NationalCenterforChildren'sHealth, Beijing Children's Hospital, Capital Medical University, No.56 Nanlishi Road, Xicheng District, Beijing, China
| | - Yu Wang
- Department of Ultrasound, NationalCenterforChildren'sHealth, Beijing Children's Hospital, Capital Medical University, No.56 Nanlishi Road, Xicheng District, Beijing, China
| | - Liqun Jia
- Department of Ultrasound, NationalCenterforChildren'sHealth, Beijing Children's Hospital, Capital Medical University, No.56 Nanlishi Road, Xicheng District, Beijing, China
| | - Xiaoman Wang
- Department of Ultrasound, NationalCenterforChildren'sHealth, Beijing Children's Hospital, Capital Medical University, No.56 Nanlishi Road, Xicheng District, Beijing, China.
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ZEYTUN H, BASUGUY E, ARSLAN S, AYDOĞDU B, OKUR MH. Surgically proven small bowel intussusception in children: Analysis of 36 cases. DICLE MEDICAL JOURNAL 2022. [DOI: 10.5798/dicletip.1197193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background: Intussusception is one of the most common abdominal emergencies in children. While the majority of childhood intussusceptions are ilecolic and idiopathic, small bowel intussusceptions are rare and a pathological trigger is often blamed for the etiology. Ultrasonography is the most commonly used diagnostic tool in the diagnosis of intussusception.
Objectives: To determine auxiliary diagnostic criteria for ultrasonography in the differentiation of small bowel intussusceptions based on ultrasonography, reduction and surgical findings of surgically confirmed small bowel intussusceptions and to contribute to the diagnosis and treatment algorithm of small bowel intussusceptions based on our clinical experience.
Methods: The records of patients who underwent surgery for small bowel intussusception at the Faculty of Medicine, Department of Pediatric Surgery between January 2008 and December 2020 were retrospectively reviewed. Demographic characteristics, ultrasonographic findings, onset and duration of symptoms, treatment method, intraoperative findings and histopathological results of the patients were recorded.
Results: Thirty-six pediatric patients with small bowel intussusception were operated. The average age of these patients was 59 ± 49.7 months and %78 was male. The location of the small bowel intussusception detected by ultrasound scan was the paraumbilical area and left quadrant in 19 (53%) patients and the right quadrant in 15 (42%) patients. In ultrasonography, the mean diameter of the invaginated segment was 3 (1.2-6.5) cm and the mean length was 6.7 (3-15) cm. Pathological lead points were detected in the etiology of nineteen (53%) patients. Thirteen (36%) patients underwent segmental resection and anastomosis due to necrosis.
Conclusions: Small bowel intussusceptions are often localized in the paraumbilical and left upper quadrant. However, it should be kept in mind that it may be localized in the right lower quadrant like ileocolic invaginations. Enema reduction can be used as an adjunctive diagnostic method to exclude ileocolic invaginations rather than treatment in these patients. The diameter and length of the invaginated segment may be decisive in the surgical decision of the small bowel intussusception.
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Bergmann KR, Arroyo AC, Tessaro MO, Nielson J, Whitcomb V, Madhok M, Yock-Corrales A, Guerrero-Quesada G, Chaudoin L, Berant R, Shahar-Nissan K, Deanehan JK, Lam SHF, Snelling PJ, Avendano P, Cohen SG, Friedman N, Ekpenyong A, Pade KH, Park DB, Lin-Martore M, Kornblith AE, Montes-Amaya G, Thomas-Mohtat R, Jin J, Watson D, Sivitz A. Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests. Ann Emerg Med 2021; 78:606-615. [PMID: 34226072 DOI: 10.1016/j.annemergmed.2021.04.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/13/2021] [Accepted: 04/27/2021] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.
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Affiliation(s)
- Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN.
| | - Alexander C Arroyo
- Department of Pediatric Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Mark O Tessaro
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan Nielson
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Valerie Whitcomb
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Manu Madhok
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Adriana Yock-Corrales
- Department of Emergency Medicine, Hospital Nacional de Niños: "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - German Guerrero-Quesada
- Department of Surgery, Hospital Nacional de Niños: "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - Lindsey Chaudoin
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - Ron Berant
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Keren Shahar-Nissan
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - J Kate Deanehan
- Department of Pediatric Emergency Medicine, Johns Hopkins Children's Center, Baltimore, MD
| | - Samuel H F Lam
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, CA
| | - Peter J Snelling
- Department of Pediatric Emergency Medicine, Gold Coast University Hospital and Griffith University, Southport, Queensland, Australia
| | - Pablo Avendano
- Division of Pediatric Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Stephanie G Cohen
- Department of Pediatrics and Emergency Medicine, Children's Healthcare Atlanta and Emory University, Atlanta, GA
| | - Nir Friedman
- Department of Pediatric Emergency Medicine, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Atim Ekpenyong
- Department of Pediatrics, University of California, San Diego, CA
| | - Kathryn H Pade
- Department of Pediatrics, University of California, San Diego, CA
| | - Daniel B Park
- Department of Pediatrics and Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Margaret Lin-Martore
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Aaron E Kornblith
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Gerardo Montes-Amaya
- Department of Pediatric Emergency Medicine, Hospital Infantil Ciudad Juárez, Chihuahua, Mexico
| | - Rosemary Thomas-Mohtat
- Department of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC
| | - Jing Jin
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Dave Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ
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Melvin JE, Zuckerbraun NS, Nworgu CR, Mollen KP, Furtado AD, Manole MD. Management and Outcome of Pediatric Patients With Transient Small Bowel-Small Bowel Intussusception. Pediatr Emerg Care 2021; 37:e110-e115. [PMID: 29746364 DOI: 10.1097/pec.0000000000001503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the management and outcomes of healthy pediatric patients diagnosed radiologically with transient and benign small bowel-small bowel intussusception (SB-SBI). METHODS Retrospective cohort study of healthy patients 0 to 18 years of age who presented to a children's hospital emergency department from January 1, 2005, to June 30, 2015, and had transient and benign SB-SBI characterized by spontaneous resolution (ie, transient), diameter of less than 2.5 cm, no lead point, normal bowel wall thickness, nondilated proximal small bowel, and no colonic involvement (ie, benign radiographic features). Charts were reviewed for demographics, clinical presentation, radiologic studies obtained, outcomes, and further management. Medical and radiologic records were also reviewed for 1 year after presentation for any subsequent pathologic diagnoses. RESULTS Sixty-eight patients were included in our study, with a total of 87 episodes of transient and benign SB-SBI on initial or follow-up examination. Overall, 39 patients (57%) were admitted to the hospital, and 38 patients (56%) had a surgical consultation. Twenty-four patients (35%) had further radiologic studies obtained, including computed tomography scans, esophagogastroduodenoscopy, Meckel's scan, barium swallow studies, and magnetic resonance imaging. All studies were negative for concerning pathology including apparent lead points. None of the patients required surgical intervention or had any complications. CONCLUSIONS Transient and benign SB-SBIs with reassuring radiologic and clinical features diagnosed in healthy pediatric patients are likely incidentally found and are unlikely to be associated with a pathologic lead point.
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Affiliation(s)
| | | | | | | | | | - Mioara D Manole
- Division of Pediatric Emergency Medicine, Department of Pediatrics
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Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians. J Emerg Med 2021; 60:626-632. [PMID: 33483198 DOI: 10.1016/j.jemermed.2020.11.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/05/2020] [Accepted: 11/22/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists. OBJECTIVE Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT. METHODS We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P-and radiology-performed US (RPUS) results was assessed. RESULTS One hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51-99%; specificity 98%; 95% CI 92-100%; positive predictive value 80%; 95% CI 44-96%; negative predictive value 99%; 95% CI 93-100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07-162.36) and with a negative POCUS was 0.11 (95% CI 0.02-0.72). CONCLUSIONS POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department-performed POCUS is a rapid and accurate method for diagnosing INT.
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Goel I, Anand R, Choudhury SR, Agarwal S. Evolving Concepts in Ultrasonography of Pediatric Intussusceptions: Unequivocal Differentiation of Ileocolic, Obstructive and Transient Small-Bowel Intussusceptions. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:589-597. [PMID: 31924421 DOI: 10.1016/j.ultrasmedbio.2019.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 06/10/2023]
Abstract
The main aim of the study was to elaborate on the various ultrasonographic parameters that can be used for definite differentiation of ileocolic, obstructive small-bowel and transient small-bowel intussusceptions (SBI). In this study, 90 children (63 boys and 27 girls) with suspected intussusception were evaluated. Of these, 54 cases were diagnosed as obstructive intussusceptions (33 ileocolic and 21 ileoileal), 15 cases were classified as transient SBIs and 21 cases were negative for intussusception. The mean fat core diameter was 1.45 ± 0.32 cm for ileocolic versus 0.37 ± 0.06 cm for obstructive SBI versus 0.29 ± 0.08 cm for transient SBI (p < 0.001). The mean lesion diameter was 3.23 ± 0.08 cm for ileocolic intussusceptions and 2.12 ± 0.038 cm for SBI (p < 0.001), and the ratio of inner fat core to outer wall thickness was greater than 1 for ileocolic intussusceptions and less than 1 for SBI. A statistically significant difference was found between segmental invagination of transient versus obstructive SBIs with mean values of 1.93 ± 0.39 cm and 3.17 ± 0.25 cm, respectively, and an "optimal" threshold at 2.5 cm.
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Affiliation(s)
- Ishan Goel
- Department of Radiodiagnosis, Lady Hardinge Medical College and associated hospitals, Delhi, India.
| | - Rama Anand
- Department of Radiodiagnosis, Lady Hardinge Medical College and associated hospitals, Delhi, India
| | - Subhasis Roy Choudhury
- Department of Pediatric Surgery, Lady Hardinge Medical College and associated hospitals, Delhi, India
| | - Shilpi Agarwal
- Department of Pathology, Lady Hardinge Medical College and associated hospitals, Delhi, India
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Patsikas MN, Papazoglou LG, Paraskevas GK. Current Views in the Diagnosis and Treatment of Intestinal Intussusception. Top Companion Anim Med 2019; 37:100360. [PMID: 31837757 DOI: 10.1016/j.tcam.2019.100360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/01/2022]
Abstract
Intestinal intussusceptions most often occur in young dogs and cats. Common locations for intestinal intussusceptions include enterocolic, eneteroenteric or colocolic. Ultrasonography is highly reliable for diagnosing of intussusception and for prediction of its reducibility. Abdominal structures that may mimic intussuception can be seen ultrasonographically. Intussusceptions is a surgical emergency. Immediate stabilization of the animal followed by manual reduction or intestinal excision of the affected intestine through midline celiotomy are required. Recurrence is a common postsurgical complication. Enteroplication may be considered for recurrence prevention but is not without complications. Prognosis is good in uncomplicated cases.
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Affiliation(s)
- Michail N Patsikas
- Companion Animal Clinic, School of Veterinary Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Lysimachos G Papazoglou
- Companion Animal Clinic, School of Veterinary Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George K Paraskevas
- Department of Anatomy and Surgical Anatomy, School of Medicine, Aristotle University of Thessaloniki, Greece
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Park BL, Rabiner JE, Tsung JW. Point-of-care ultrasound diagnosis of small bowel-small bowel vs ileocolic intussusception. Am J Emerg Med 2019; 37:1746-1750. [PMID: 31257125 DOI: 10.1016/j.ajem.2019.06.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Identification of intussusception is feasible with emergency department (ED) point-of-care ultrasound (PoCUS) due to its ease-of-use and high accuracy. Little is known about the clinical characteristics and outcomes of small bowel-small bowel intussusception (SB-SBI) relative to ileocolic intussusception (ICI) identified by PoCUS. METHODS We conducted a retrospective cohort study at a single, tertiary care, urban pediatric ED of intussusception identified by PoCUS. Demographic information, clinical data, and outcomes, including clinical course, intussusception characteristics, recurrence rates, and interobserver agreement (Cohen's kappa), were evaluated. RESULTS ED PoCUS identified thirty-seven patients with intussusception over a 4-year period. Twenty-one patients (57%) identified were SB-SBI. The median age was 54 months (IQR 35-76 months) for SB-SBI and 8 months (IQR 5.8-13.5 months) for ICI. The mean diameter was 1.68 cm (SD 0.52 cm) for SB-SBI and 2.74 cm (SD 0.43 cm) for ICI (p < 0.05). Two of 21 (9.5%) SB-SBI subjects required surgical intervention, while the rest spontaneously reduced. Fourteen of 16 (88%) ICI subjects required intervention. There were two (9.5%) recurrences of SB-SBI and 1 (6.3%) recurrence of ICI confirmed on PoCUS. Cohen's kappa was 0.85 (95% CI 0.68-1.0). CONCLUSIONS SB-SBI may be identified more frequently than previously thought when screened with ED PoCUS. Older children with SB-SBI may have underlying lead-points and may require surgical intervention. PoCUS can help differentiate between variants of intussusception that range from a surgical emergency to a transient source of abdominal pain that may be recurrent and otherwise unexplained, allowing clinicians to better manage these patients accordingly.
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Affiliation(s)
- Brian L Park
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, United States of America.
| | - Joni E Rabiner
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Medical Center, 3959 Broadway, New York, NY 10032, United States of America
| | - James W Tsung
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, United States of America; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, United States of America
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Radiographic and Clinical Factors in Pediatric Patients With Surgical Small-bowel Intussusception. J Surg Res 2019; 233:167-172. [DOI: 10.1016/j.jss.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/03/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023]
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Unusual ultrasound appearance of small bowel intussusception and secondary bowel obstruction in a child with Peutz-Jeghers syndrome. Clin Imaging 2017; 43:136-139. [PMID: 28314199 DOI: 10.1016/j.clinimag.2017.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/15/2017] [Accepted: 03/07/2017] [Indexed: 11/22/2022]
Abstract
Small bowel intussusception (SBI) in pediatric patients resolves spontaneously in the majority of cases. Pathologic small bowel intussusception with a lead point is rare in children. Ultrasound (US) is the preferred initial imaging study for the diagnosis of intussusception. We report a case of long-segment SBI and secondary bowel obstruction caused by a large hamartomatous polyp. This case emphasizes unique, atypical ultrasound findings that may be encountered in small bowel intussusception, with correlative radiographic, CT (computed tomography) and intra-operative findings. Increased awareness of these atypical imaging features can lead to early diagnosis and decrease the risk of potential complications including mesenteric venous thrombosis, bowel ischemia and necrosis.
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Abstract
We present a case series describing an infant and a child who presented with abdominal discomfort and their conditions were diagnosed with intussusception by point-of-care ultrasound. These cases illustrate how point-of-care ultrasound led to the expeditious diagnosis of intussusception.
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13
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Chowa EP, Frasure SE. Adult Female With Abdominal Pain. Ann Emerg Med 2016; 67:e11-2. [PMID: 27015929 DOI: 10.1016/j.annemergmed.2015.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Indexed: 12/01/2022]
Affiliation(s)
| | - Sarah E Frasure
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
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14
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Circular right upper quadrant mass, not intussusception. Pediatr Emerg Care 2015; 31:384-7. [PMID: 25931346 DOI: 10.1097/pec.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Point-of-care ultrasound is fast becoming a routine diagnostic tool in the pediatric emergency department, including in resource-limited settings. We describe a case where a patient was initially diagnosed with intussusception and admitted to a hospital. While serving as a patient model for a point-of-care ultrasound course, he was found to have a liver abscess. We discuss the manner in which the ultrasound study for ileocolic intussusception is performed and potential mimickers of ileocolic intussusception.
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Rajagopal R, Mishra N, Yadav N, Jhanwar V, Thakur A, Mannan N. Transient versus surgically managed small bowel intussusception in children: Role of ultrasound. Afr J Paediatr Surg 2015; 12:140-2. [PMID: 26168754 PMCID: PMC4955411 DOI: 10.4103/0189-6725.160368] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND To evaluate and compare the ultrasound (US) features of transient small bowel intussusception (SBI) with those which required surgical management. MATERIALS AND METHODS US features of 26 children with 32 intussusceptions from January 2014 to August 2014 were recorded and compared with follow-up imaging or surgical findings. RESULTS Transient SBI when compared to surgically managed intussusception has shorter length of intussusception (mean 2.25 cm, range 1.8-4.5 cm vs. mean 5.6 cm, range, 2.3-7.8 cm), smaller transverse diameter (mean, 1.2 cm, range 0.8-2.3 cm vs. mean, 3.3 cm, range 2.9-5.4 cm) and thin wall (mean, 3.3 mm, 2.3-4.9 mm vs. mean, 6.8 mm, range, 4.3-11.2 mm). Four out of five surgically managed intussusceptions were associated with the lead point while none of the transient SBI had any lead point. Peristalsis was absent in all surgically managed intussusceptions. CONCLUSION Transient SBI is associated with a shorter length of intussusception, smaller transverse diameter, thin walls, absence of the lead point and visible peristalsis. All these findings may help in distinguishing it from those requiring surgical management.
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Affiliation(s)
| | - Nitin Mishra
- Department of Radiodiagnosis and Modern Imaging, SMS Medical College, Jaipur, Rajasthan, India
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Nelson MJ, Paterson T, Raio C. Case report: transient small bowel intussusception presenting as right lower quadrant pain in a 6-year-old male. Crit Ultrasound J 2014; 6:7. [PMID: 24982750 PMCID: PMC4064808 DOI: 10.1186/2036-7902-6-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 05/13/2014] [Indexed: 12/19/2022] Open
Abstract
In children presenting to the emergency room with right lower quadrant pain, ultrasound is the preferred initial modality. In our patient, a 6-year-old male with a sudden onset of severe right lower quadrant pain, the differential is broad, including appendicitis and intussusception. In order to narrow our differential and secure the diagnosis, our first modality was ultrasonography. With the increased use of point-of-care ultrasound in the emergency department, the diagnosis of appendicitis and ileo-colic intussusception has been made more frequently. In addition, other entities such as transient small bowel intussusception may be identified. As in our case, obstruction secondary to intussusception must be ruled out with observation, serial abdominal exams, clinical improvement, or further imaging.
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Affiliation(s)
- Mathew J Nelson
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
| | - Tara Paterson
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
| | - Christopher Raio
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
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Gelabert C, Torradas J, Nelson M. Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old. Am J Emerg Med 2014; 32:1301.e1-2. [PMID: 24792936 DOI: 10.1016/j.ajem.2014.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 03/22/2014] [Indexed: 11/19/2022] Open
Abstract
Intussusception is a common emergency in patients age of 3 months to 5 years. In adults, the diagnosis is infrequent but must be considered in the clinical setting of abdominal pain and vomiting. We present a case of a 61-year-old woman presenting with epigastric abdominal pain and vomiting, diagnosed with intussusception secondary to gastrointestinal stromal tumor. Serial bedside ultrasound examinations uncovered the diagnosis of intussusception, confirmed by computed tomographic scan during a paroxysm of pain. Intussusception has a much higher predilection for neoplasms in adults, with a high morbidity and mortality, so early recognition is critical in improving patient outcomes.
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Affiliation(s)
- Christopher Gelabert
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030.
| | - Jose Torradas
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030
| | - Mathew Nelson
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030
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Lioubashevsky N, Hiller N, Rozovsky K, Segev L, Simanovsky N. Ileocolic versus small-bowel intussusception in children: can US enable reliable differentiation? Radiology 2013; 269:266-71. [PMID: 23801771 DOI: 10.1148/radiol.13122639] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To assess clinical and ultrasonographic (US) criteria that can be used to confidently differentiate ileocolic from small-bowel intussusception. MATERIALS AND METHODS Institutional review board approval was obtained for this retrospective study, and the need to obtain informed consent was waived. US and clinical data for children given a diagnosis of intussusception in the years 2007 through 2011 were evaluated. The diameters of the intussusception and the inner fat core, the outer bowel wall thickness, and the presence or absence of lymph nodes inside the intussusception and mesentery were noted. The Student t test, the Mann-Whitney test, and the Levene test were used for comparison of parametric variables, while the χ(2) and Fisher exact tests were used for comparison of categoric data. RESULTS There were 200 cases of intussusception in 174 patients (126 boys, 48 girls; mean age, 17.2 months (range, 0 years to 7 years 1 month); 57 (28.5%) were small-bowel and 143 (71.5%) were ileocolic intussusceptions. Mean lesion diameter was 2.63 cm (range, 1.3-4.0 cm) for ileocolic versus 1.42 cm (range, 0.8-3.0 cm) for small-bowel intussusception (P < .0001). Mean fat core diameter was 1.32 cm (range, 0.6-2.2 cm) for ileocolic versus 0.1 cm (range, 0-0.75 cm) for small-bowel intussusception (P < .0001). The ratio of inner fat core diameter to outer wall thickness was greater than 1.0 in all ileocolic intussusceptions and was less than 1.0 in all small-bowel intussusceptions (P < .0001). Lymph nodes inside the lesion were seen in 128 (89.5%) of the 143 ileocolic intussusceptions versus in eight (14.0%) of the 57 small-bowel intussusceptions (P < .0001). Children with ileocolic intussusception had more severe clinical symptoms and signs, with more vomiting (P = .003), leukocytosis (P = .003), and blood in the stool (P = .00005). CONCLUSION The presence of an inner fatty core in the intussusception, lesion diameter, wall thickness, the ratio of fatty core thickness to outer wall thickness, and the presence of lymph nodes in the lesion may enable reliable differentiation between ileocolic and small-bowel intussusceptions.
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Affiliation(s)
- Natali Lioubashevsky
- Department of Medical Imaging, Hadassah-Hebrew University Medical Center, POB 24035, Jerusalem, Israel 91120
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Abstract
BACKGROUND During the past decade, point-of-care ultrasound (POC US) has been increasingly performed in emergency medicine for a variety of indications. However, pediatric emergency physicians have been slower to understand the importance of POC US in the diagnosis of critical care cases. OBJECTIVE This study aimed to illustrate the usefulness of POC US in improving workflow in the emergency department (ED) with an early diagnosis in a critically ill child by a pediatric emergency attending physician. CASE On arrival to the ED, an early diagnosis of intussusception was made using real-time POC US by a pediatric emergency medicine attending physician well trained in pediatric US. CONCLUSIONS This report illustrates the impact that POC US can make during an early diagnosis of intussusception. With thorough knowledge of the US features characteristic of intussusception, its accurate diagnosis using POC US has the potential to reduce morbidity and mortality as well as improve patient flow and throughput time in the ED.
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20
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Abstract
The use of bedside emergency ultrasound in pediatric abdominal emergencies is becoming more widespread and can be a useful adjunct in the assessment of children who present with abdominal pain. Our case describes an infant who presented to the emergency department with vomiting, in whom an emergency ultrasound evaluation led to timely diagnosis and intervention of an unanticipated condition.
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Sonographic findings predictive of the need for surgical management in pediatric patients with small bowel intussusceptions. Langenbecks Arch Surg 2011; 396:1035-40. [PMID: 21274558 DOI: 10.1007/s00423-011-0742-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE This study aims to evaluate ultrasound findings that are predictive of the need for surgical management in pediatric patients with small bowel intussusceptions (SBIs). METHODS A retrospective review of pediatric patients with SBIs treated from 2004 to 2009 was conducted. Patients were divided into surgical and non-surgical groups. Demographic data, ultrasound findings, treatments, and outcomes were collected and analyzed. RESULTS There were 56 cases of SBIs in 31 males and 25 females ranging in age from 4 months to 9 years; 39 patients were managed conservatively and 17 patients underwent surgery. The mean length and diameter of the intussusception in the surgical group were 6.53 and 2.78 cm, respectively, and 3.21 and 1.81 cm, respectively in the non-surgical group (both, P < 0.001). Multivariate logistic regression analysis indicated that diameter, length, and thickness of the outer rim were independent predictors of surgery. Receiver operating characteristic curve analysis indicated an intussusception diameter ≥2.1 cm, length ≥4.2 cm, and thickness of the outer rim ≥0.40 cm were optimal cutoff values for predicting the need for surgery. CONCLUSIONS A diameter ≥2.1 cm, length ≥4.2 cm, and thickness of the outer rim ≥0.40 cm predict the need for surgical management in pediatric patients with SBIs.
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22
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Shiu JR, Chao HC, Chen CC, Chi CY. Rare concurrent ileoileal and ileocolic intussusceptions in a child presenting with painless hematochezia. Pediatr Neonatol 2010; 51:359-62. [PMID: 21146803 DOI: 10.1016/s1875-9572(10)60070-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 12/30/2009] [Accepted: 01/22/2010] [Indexed: 11/24/2022] Open
Abstract
Double-site intussusceptions are very rare in children, and only a few have been reported. Here, we report a 17-month-old boy with double intussusceptions, whose clinical manifestations were painless hematochezia and anemia. Ultrasonography demonstrated an edematous, dilated bowel and two target lesions, suggesting multiple sites of intussusception. At surgery, intussusceptions were found in the ileoileal and ileocolic segments of the intestine. The cecum and proximal ascending colon were resected because of a gangrenous ileocolic intussusception. The ileoileal intussusception was reduced manually. Postoperatively, the patient was stable with no subsequent intestinal obstruction or hemorrhage.
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Affiliation(s)
- Jr-Rung Shiu
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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23
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Ko SF, Tiao MM, Hsieh CS, Huang FC, Huang CC, Ng SH, Lee SY, Chen MC. Pediatric small bowel intussusception disease: feasibility of screening for surgery with early computed tomographic evaluation. Surgery 2010; 147:521-528. [PMID: 20004447 DOI: 10.1016/j.surg.2009.10.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 10/06/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study investigated the feasibility of early computed tomographic (CT) evaluation and the operative results of pediatric small bowel intussusception with deteriorating ischemic or obstructive symptoms, so-called small bowel intussusception disease (SBID). METHODS Between 1988 and 1999, among 18 patients surgically proven SBID (conventional group), 12 mimicked ileocolic intussusception and were conventionally managed with abdominal radiography, ultrasonography, reduction enema, and eventually operation. Between 2000 and 2008, we applied a modified approach with inclusion of early CT evaluation if ultrasonography showed a target lesion suspicious for SBID (diameter RESULTS There were no significant differences between the 2 groups in age, gender, clinical presentations, leukocyte count, ultrasonographic features, locations of SBID, or the presence of lead points. Most patients presented with vomiting, abdominal pain, or irritable crying. In comparison with the conventional group, early CT group patients had a significantly shorter duration between admission and surgery (31.44 +/- 30.39 vs 7.47 +/- 5.95 hours; P < .01) and a lower rate of bowel complications (44.4% vs 6.7%; P = .02). CONCLUSION Pediatric SBID may present with nonspecific symptoms and may mimic ileocolic intussusception leading to delayed operative intervention. Early CT evaluation of patients with suspicious SBID ultrasonographic features is effective in avoiding futile reduction enema and significantly reducing the waiting time for operative management and the resultant incidence of bowel complications.
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Affiliation(s)
- Sheung-Fat Ko
- Department of Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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25
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Diagnosis of pediatric intussusception by an emergency physician-performed bedside ultrasound: a case report. Pediatr Emerg Care 2009; 25:177-80. [PMID: 19287275 DOI: 10.1097/pec.0b013e31819a8a46] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The past decade has seen a rapid evolution in the use of bedside ultrasound (BUS) in the emergency department (ED). In addition, it has been increasingly used in the pediatric population for a variety of indications. As ED BUS is a relatively new modality in pediatric emergency medicine, novel indications are increasingly being recognized. We report a case of a 9-month-old infant who presented with signs and symptoms suggestive of intussusception, whose diagnosis was made using ED BUS in the pediatric ED. Knowledge of the sonographic appearance of intussusception can aid the emergency physician in the prompt diagnosis of this condition while potentially minimizing complications that may result from a delay in diagnosis.
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26
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Abstract
Intussusception is the most common cause of intestinal obstruction in children between 3 months and 6 years. Intussusception occurs when a more proximal portion of bowel invaginates into more distal bowel. These patients often present with a wide range of non-specific symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. Thus, the diagnosis continues to rely on clinical suspicion. This review article discusses the clinical presentation of intussusception and the state-of-the art diagnostic and treatment options, as well as a review of the pertinent literature.
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27
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Saxena AK, Seebacher U, Bernhardt C, Höllwarth ME. Small bowel intussusceptions: issues and controversies related to pneumatic reduction and surgical approach. Acta Paediatr 2007; 96:1651-4. [PMID: 17888055 DOI: 10.1111/j.1651-2227.2007.00497.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM This study aims to determine the incidence, clinical presentation, management and outcome of small bowel intussusceptions (SBI) in the paediatric population managed at our centre. METHODS Hospital charts of SBI patients from 1999 to 2006 were reviewed retrospectively. The data collected involved the clinical presentation, diagnostic examinations, management strategy as well as outcome. RESULTS Ileocecal intussusceptions were documented in 83 patients (74.8%) and SBI in 28 (25.2%). The median age of patients with SBI was 2.5 years (range 9 weeks to 16 years). In 18/28 patients SBI reduced spontaneously. Ileoileal SBI had an incidence of 80% in the 10/28 cases requiring intervention. In seven patients, pneumatic reductions were successful in 6/7 ileoileal intussusceptions, but unsuccessful in 1/7 where the level of intussusception (jejunojejunal intraoperative findings) could not be determined by ultrasound. Surgical intervention was required in four patients with bowel resection in three cases. CONCLUSION Pneumatic reduction is successful in ileoileal intussusceptions with signs of bowel viability. It should be attempted with caution in patients with jejunojejunal or ileoileal SBI with pathologic lead points or bowel ischaemia. Accurate interpretation of ultrasound along with judicious implementation of pneumatic reduction or surgical options can reduce morbidity. Early diagnosis is associated with better outcomes using non-surgical reduction techniques.
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Affiliation(s)
- A K Saxena
- Department of Pediatric Surgery, Medical University of Graz, Graz, Austria.
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Sahu S, John BM, Mishra KB, Dhavala SS. Intussusception : Pain Abdomen in Paediatrics Revisited. Med J Armed Forces India 2007; 63:380-1. [PMID: 27408057 PMCID: PMC4922071 DOI: 10.1016/s0377-1237(07)80028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2005] [Accepted: 12/21/2006] [Indexed: 10/18/2022] Open
Affiliation(s)
- S Sahu
- Graded Specialist (Radiology), No 7 Air Force Hospital, Nathu Singh Road, Kanpur Cantt
| | - B M John
- Graded Specialist (Paediatrics), Command Hospital, Air Force, Bangalore
| | - K B Mishra
- Classified Specialist (Surgery), No 7 Air Force Hospital, Nathu Singh Road, Kanpur Cantt
| | - S S Dhavala
- Classified Specialist (Radiology), No 7 Air Force Hospital, Nathu Singh Road, Kanpur Cantt
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29
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Park NH, Park SI, Park CS, Lee EJ, Kim MS, Ryu JA, Bae JM. Ultrasonographic findings of small bowel intussusception, focusing on differentiation from ileocolic intussusception. Br J Radiol 2007; 80:798-802. [PMID: 17875595 DOI: 10.1259/bjr/61246651] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The purpose of this study was to evaluate the typical ultrasonographic findings of transient small bowel intussusception (SBI) and to differentiate it from ileocolic intussusception (ICI) in paediatrics. 22 transient SBI (male:female = 13:9, age: 7-132 months (mean 38 months)) and 27 ICI (male:female = 19:8, age: 1-60 months (mean 13 months)) patients diagnosed on ultrasonography were retrospectively evaluated. The findings of location, diameter, thickness of outer rim, and inclusion of mesenteric lymph nodes within intussuscipiens were compared. In the transient SBI, the head of intussusception was located in the right lower quadrant (RLQ) in 11 (50%), the right upper quadrant (RUQ) in 2 (9.1%) and the periumbilical area in 9 (40.9%) cases. The anteroposterior (AP) diameter ranged from 0.84-2.4 cm (mean 1.38 cm), and thickness of outer rim ranged from 0.10-0.34 cm (mean 0.26 cm). No mesenteric lymph nodes were contained within the intussuscipiens. In the ICI, the head was located in the RUQ in 17 (63%), the epigastrium in 7 (25.9%) and the left upper quadrant in 3 (11.1%) cases. The AP diameter ranged from 1.89-3.32 cm (mean 2.53 cm), and the thickness of the outer rim ranged from 0.30-0.86 cm (mean 0.53 cm). Mesenteric lymph nodes were contained within the intussuscipiens in 26 (96.3%) cases. In conclusion, when compared with ICI, the transient SBI occurs predominantly in the RLQ or periumbilical region, has a smaller AP diameter, a thinner outer rim, and dose not contain mesenteric lymph nodes.
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Affiliation(s)
- N H Park
- Department of Diagnostic Radiology, Myongji Hospital, Kwandong University, College of Medicine, 697-24 Hwajung-dong, Dukyang-ku, Koyang, Kyunggi 412-270, Republic of Korea.
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Bailey KA, Wales PW, Gerstle JT. Laparoscopic versus open reduction of intussusception in children: a single-institution comparative experience. J Pediatr Surg 2007; 42:845-8. [PMID: 17502196 DOI: 10.1016/j.jpedsurg.2006.12.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The role of laparoscopic surgery in treating intussusception has been controversial. This study reviews our institution's experience with the laparoscopic approach (LAP) compared to the open surgical approach (OPEN). METHODS Retrospective analysis of all patients undergoing surgery for intussusception at our center from January 2002 to February 2006. Statistical assessment included Student's t test and chi2 analysis. RESULTS A total of 41 patients required operation for intussusception (18 LAP, 23 OPEN). Mean age was 22 months for LAP and 11 months for OPEN (P = .17). In the LAP group, 28% (5/18) were converted to an open procedure. Operative times and complications were not significantly different. Pathologic lead points were found in 33% (6/18) LAP and 35% (8/23) OPEN patients (P = 1.0). Time to full feeds was significantly shorter (LAP vs OPEN: 3.4 +/- 2.7 vs 5.6 +/- 3.4 days, P = .02). Length of stay was shorter (LAP vs OPEN: 4.8 +/- 3.5 vs 9.1 +/- 7.5 days, P = .03). CONCLUSIONS Intussusception can be treated safely and effectively using a LAP with a significant decrease in time to full feeds and length of stay. The LAP should be considered as the initial approach for stable patients with intussusception requiring operative intervention.
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Affiliation(s)
- Karen A Bailey
- Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
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Munden MM, Bruzzi JF, Coley BD, Munden RF. Sonography of pediatric small-bowel intussusception: differentiating surgical from nonsurgical cases. AJR Am J Roentgenol 2007; 188:275-9. [PMID: 17179377 DOI: 10.2214/ajr.05.2049] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether there are clinical or sonographic findings that can be used to differentiate benign self-limited small-bowel intussusception from pathologic small-bowel intussusception that necessitates surgical intervention. MATERIALS AND METHODS A retrospective search was performed of abdominal sonograms obtained at two institutions between January 1996 and June 2005. Sonographic findings were correlated with medical and surgical records. RESULTS A total of 35 cases of isolated small-bowel intussusception were found. Thirteen (37%) of these cases necessitated surgical intervention, and 22 (63%) of the cases were benign and self-limiting. Patients with self-limiting intussusception were younger than patients with intussusception necessitating surgical intervention (mean, 4.2 vs 7.5 years; p = 0.0327). Abdominal sonograms depicted ascites and small-bowel obstruction significantly more frequently in patients with small-bowel intussusception necessitating surgery (n = 7 [54%] for each finding) than in patients with self-limiting intussusception (n = 2 [9%], n = 0) (p = 0.006 and p = 0.0003, respectively). At sonography, patients who later underwent surgical intervention had small-bowel intussusception of significantly greater length (mean, 7.3 cm) than those treated conservatively (mean length, 1.9 cm) (p < 0.0001). Intussusception length greater than 3.5 cm was considered a sensitive and specific independent predictor of the need for surgery (sensitivity, 93%; specificity, 100%). CONCLUSION When small-bowel intussusception is detected in infants and children undergoing abdominal sonography, intussusception length greater than 3.5 cm is a strong independent predictor of the need for surgical intervention.
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Affiliation(s)
- Martha M Munden
- Edward B. Singleton Diagnostic Imaging Services, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030-2399, USA
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Koh EPK, Chua JHY, Chui CH, Jacobsen AS. A report of 6 children with small bowel intussusception that required surgical intervention. J Pediatr Surg 2006; 41:817-20. [PMID: 16567200 DOI: 10.1016/j.jpedsurg.2005.12.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE We aim to justify the need for surgical intervention in our patients with childhood small bowel intussusceptions (SBIs) and review the current concepts in childhood SBI. MATERIALS AND METHODS We retrospectively reviewed the clinical charts of all patients with surgically confirmed SBI between July 1999 and October 2002. Demographic data, clinical presentation and investigations, operative and pathologic findings, and outcome were analyzed. RESULTS Of 173 patients with intussusception, 6 (3.5%) were diagnosed with SBI. Median age was 11 months. Ultrasonography revealed intussusceptions in all patients, but only 1 was diagnosed with SBI. Air enema reductions were attempted in 4 of 6 patients with all ending up in failure and surgery. Surgery revealed ileoileal intussusceptions in 4 patients and jejunojejunal intussusceptions in 2 patients. Two patients had long intussusceptions measuring between 30 and 50 cm in length. Five patients had pathologic lead points, and bowel complications occurred in 2 patients. All underwent bowel resection and primary anastomosis. CONCLUSION Despite reports on spontaneous reduction of SBI, surgery was unavoidable in all our patients with SBI because of the presence of pathologic lead points and/or bowel complications. Air enema reduction was ineffective in SBI. Due caution should be exercised when selecting patients for expectant management.
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Affiliation(s)
- Elisa Poh Kim Koh
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore 229 899, Singapore
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Cunha FMD, Figueirêdo SDS, Nóbrega BBD, Oliveira GL, Monteiro SS, Lederman HM. Intussuscepção em crianças: avaliação por métodos de imagem e abordagem terapêutica. Radiol Bras 2005. [DOI: 10.1590/s0100-39842005000300010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A intussuscepção, uma emergência médica, ocorre com maior freqüência em crianças com idade abaixo dos dois anos. A tríade clássica de dor abdominal, fezes avermelhadas "em geléia" e massa abdominal palpável é observada em menos de 50% dos casos, tornando difícil seu diagnóstico clínico. Todavia, o diagnóstico de intussuscepção pode ser efetuado com radiografia simples, ultra-sonografia, tomografia computadorizada e enema baritado ou com gás/solução salina, com variável acurácia. Alguns destes métodos de imagem também proporcionam valiosa utilidade à terapia desta condição. Os autores fazem uma revisão da literatura, com ensaio iconográfico dos achados em pacientes com intussuscepção, e discutem os conceitos atuais e tópicos controversos relacionados ao seu tratamento.
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Abstract
OBJECTIVE To describe the sonographic (US) and clinical features of spontaneously reduced small bowel intussusception, and to discuss the management options for small bowel intussusception based on US findings with clinical correlation. MATERIALS AND METHODS During a five years of period, 34 small bowel intussusceptions were diagnosed on US in 32 infants and children. The clinical presentations and imaging findings of the patients were reviewed. RESULTS The clinical presentations included abdominal pain or irritability (n = 25), vomiting (n = 5), diarrhea (n = 3), bloody stool (n = 1), and abdominal distension (n = 1), in combination or alone. US showed multi-layered round masses of small (mean, 1.5+/-0.3 cm) diameters and with thin (mean, 3.5+/-1 mm) outer rims along the course of the small bowel. The mean length was 1.8+/-0.5 cm and peristalsis was seen on the video records. There were no visible lead points. The vascular flow signal appeared on color Doppler images in all 21 patients examined. Spontaneous reduction was confirmed by combinations of US (n = 28), small bowel series (n = 6), CT scan (n = 3), and surgical exploration (n = 2). All patients discharged with improved condition. CONCLUSION Typical US findings of the transient small bowel intussusception included 1) small size without wall swelling, 2) short segment, 3) preserved wall motion, and 4) absence of the lead point. Conservative management with US monitoring rather than an immediate operation is recommended for those patient with typical transient small bowel intussusceptions. Atypical US findings or clinical deterioration of the patient with persistent intussusception warrant surgical exploration.
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Affiliation(s)
- Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam-gu, Seoul, Korea.
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35
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Hegenbarth MA. Bedside ultrasound in the pediatric emergency department: Basic skill or passing fancy? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2004. [DOI: 10.1016/j.cpem.2004.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Martínez Biarge M, García-Alix A, Luisa del Hoyo M, Alarcón A, Sáenz de Pipaón M, Hernández F, Pérez J, Quero J. Intussusception in a preterm neonate; a very rare, major intestinal problem--systematic review of cases. J Perinat Med 2004; 32:190-4. [PMID: 15085900 DOI: 10.1515/jpm.2004.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intussusception is an extremely rare disorder in preterm infants and it is often misdiagnosed as necrotizing enterocolitis. We report a case of intussusception in a 30-day-old preterm infant of 26 weeks of gestational age and a birthweight of 610 g who was diagnosed via abdominal ultra sonography. A systematic review of the literature was performed and reports on 23 previous cases were found. The presence of recognizable causes of intussusception in preterms, such as Meckel's diverticulum, bowel polypus, etc. was very infrequent. Comorbidity before and after intussusception is heterogeneous and related to prematurity. The intussusception is predominantly located in the small bowel (91.6%)--ileal or jejunal. The condition is misdiagnosed as NEC and managed conservatively until clinical deterioration occurs. A definitive diagnosis is thus established during abdominal surgery, which is usually delayed an average of 9.5 days from the onset of symptoms. Our case illustrates the capability of abdominal ultrasonography to establish early diagnosis of intussusception in the premature newborn.
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Patsikas MN, Papazoglou LG, Papaioannou NG, Dessiris AK. Normal and Abnormal Ultrasonographic Findings That Mimic Small Intestinal Intussusception in the Dog. J Am Anim Hosp Assoc 2004; 40:147-51. [PMID: 15007051 DOI: 10.5326/0400147] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
On ultrasonographic examination of the abdomen, the appearance of healthy intestine, enteritis secondary to an intestinal foreign body, and postpartum involution of the uterus may be visualized in some imaging planes as a target-like structure that is subsequently misinterpreted as intestinal intussusception. To avoid misdiagnosis, the ultrasonographer should ensure multi-plane scanning of the lesion, paying particular attention to the completeness of the lesion’s peripheral ring structure and the overall width of the concentric rings of the target-like lesion. The presence of a semilunar or G-shaped hyperechoic center and the visualization of the inner intussusceptum (extending into the intussusception lumen) can be useful ultrasonographic findings that distinguish an intussusception from other lesions or from healthy tissues. These principles are illustrated through the following case presentations.
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Affiliation(s)
- Michail N Patsikas
- Department of Clinical Sciences, School of Veterinary Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Patsikas MN, Papazoglou LG, Papaioannou NG, Savvas I, Kazakos GM, Dessiris AK. Ultrasonographic findings of intestinal intussusception in seven cats. J Feline Med Surg 2003; 5:335-43. [PMID: 14623203 PMCID: PMC10822547 DOI: 10.1016/s1098-612x(03)00066-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2003] [Indexed: 11/27/2022]
Abstract
The medical records of seven cats with intestinal intussusception that were diagnosed by abdominal ultrasonography and exploratory laparotomy were reviewed. In transverse ultrasonographic sections the intussusception appeared as a target-like mass consisting of one, two or more hyperechoic and hypoechoic concentric rings surrounding a C-shaped, circular or non-specific shaped hyperechoic centre. Part of the intestine representing the inner intussusceptum, located close to the hyperechoic centre and surrounded by concentric rings, was also detected. In longitudinal sections the intussusception appeared as multiple hyperechoic and hypoechoic parallel lines in four cases and as an ovoid mass in three cases. In one case the ovoid mass had a 'kidney' configuration. Additional ultrasonographic findings associated with intestinal intussusception included an intestinal neoplasm in one cat. The results of the present study demonstrate that the ultrasonographic findings of intestinal intussusception in cats bear some similarities to those described in dogs and humans, are relatively consistent, and facilitate a specific diagnosis.
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Affiliation(s)
- M N Patsikas
- Department of Clinical Sciences, School of Veterinary Medicine, Aristotle University of Thessaloniki, 11 Stavrou Voutyra Street, 546 27 Thessaloniki, Greece.
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Davis CF, McCabe AJ, Raine PAM. The ins and outs of intussusception: history and management over the past fifty years. J Pediatr Surg 2003; 38:60-4. [PMID: 12866017 DOI: 10.1016/s0022-3468(03)00080-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- C F Davis
- Royal Hospital for Sick Children, Glasgow, Scotland United Kingdom
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Abstract
AIM: To re-evaluate the algorithm that has been used for over 40 years for diagnosis of acute abdominal pain among children.
METHODS: Among the 937 cases admitted to the surgical emergency ward in 2000, 656 cases of acute appendicitis were studied to evaluate the usefulness of the present algorithm for its calculated accuracy, false positive and false negative rates, the sensitivity and specificity in the instant diagnosis of various types of acute appendicitis in different age groups. The algorithm used was established in 1958 and revised for this study in 1999. It includes a 3-step analysis of clinical presentations, i.e.: firstly, a diagnosis of surgical pain by definite organic abdominal signs; then a diagnosis of the subgroup of surgical condition by special signs; and finally the diagnosis of the present disease by specific signs. A footnote describes a "comparative technique" of abdominal examination in non-cooperative children.
RESULTS: The general accuracy of diagnosis was 92.8%, overall mortality 0.1% among 973 cases of abdominal pain in 2000.373 attending surgeons and 241 residents including trainees joined the diagnosis and treatment with no remarkable difference in the results. The incidence of acute appendicitis, 656 in 973 cases, was 67.4% representing the majority of abdominal pain. In the series of 656 cases, the accuracy of diagnosis of acute appendicitis was 93.6%, false positive 6.4%, false negative 0.9%, sensitivity at first visit 82.7%, specificity for appendicitis 98.0%, no death or documentary complication.
CONCLUSION: The present algorithm used for diagnosis of acute abdominal pain is effective and preferable in reducing misdiagnosis and maltreatment at emergency. The use of some modern technology should be further explored.
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Affiliation(s)
- Hong Zhou
- Department of Pediatric Surgery, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing 100045, China.
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Yu PC, Ko SF, Lee TY, Ng SH, Huang CC, Wan YL. Small bowel obstruction due to incarcerated sciatic hernia: ultrasound diagnosis. Br J Radiol 2002; 75:381-3. [PMID: 12000699 DOI: 10.1259/bjr.75.892.750381] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 71-year-old woman presented with vomiting, abdominal pain and vague right gluteal discomfort. Abdominal ultrasound showed ascites and dilated small bowel loops with peristaltic movement, while transgluteal ultrasound revealed entrapped ascites beneath gluteal muscles and an oedematous, immobile bowel loop trapped between the sacrum and iliac bone with barely visible colour Doppler flow suggestive of an incarcerated sciatic hernia. CT demonstrated similar findings and subsequent surgery confirmed the diagnosis. To our knowledge, this is the first report of a pre-operative diagnosis of incarcerated sciatic hernia on ultrasound.
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Affiliation(s)
- P-C Yu
- Department of Radiology, Chang Gung University, Chang Gung Memorial Hospital at Kaohsiung, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien 833, Taiwan
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