Fofanov, Borys, Nykyforuk, Fofanov, and Krasivs'kij: Experience of Diagnosis and Treatment of Intussusception in Children



Problem statement and analysis of the recent research

Intestinal intussusception (II) is considered as one of the most common causes of acquired intestinal obstruction. Despite the fact that this pathology is well-known for pediatricians and pediatric surgeons, the incidence of diagnostic errors resulting in late hospitalization and complications of II, is very high reaching 50-80%, and the mortality rate in complicated intussusception reaches 18% [1, 3, 5]. Many issues regarding treatment strategy of II, primarily, indications and contraindications for conservative treatment remain controversial. The questions of the possibility of conservative disinvagination in the duration of the disease more than a day, in recurrent intussusception and in II in children older than 1 year remain controversial as well [4, 6, 8].

Therefore, the question of diagnosis and treatment of II in children is important and requires further study.

The objective of the research was to establish the causes of complications of intestinal intussusception in children as well as to determine the optimal diagnostic and treatment strategy.

Materials and methods

The analysis of medical records and examinations of 100 children with intestinal intussusception at the age of 1 month to 17 years who were treated at the clinic of pediatric surgery of the Ivano-Frankivsk National Medical University was made. There were 60 boys and 40 girls (1.5:1). II was most often observed at the age of 4-12 months (50% patients); at the age of 1-4 months it was observed in 12% of patients; at the age of 1-3 years II was diagnosed in 18% of patients; at the age of 3-17 years II was detected in 20% of children. All children were admitted to the hospital urgently; 24 patients were admitted within the first 6 hours after the disease onset, 51 children were hospitalized within 6-24 hours, 25 patients were admitted 24 hours after the disease onset.

In past medical history, only in 5 children changes in their nutrition were found, 3 patients developed II on the background of enterocolitis. 10 children were admitted to the clinic with suspected acute appendicitis. The most common clinical symptoms were expulsion of gastric contents which later was mixed with bile (70 patients); anxiety was observed in 62 patients; cramping abdominal pain was diagnosed in 45 children; delayed defecation was observed in 15 children; bloating was noted in 10 children. An objective examination often showed the following clinical symptoms: intussusception palpation (68 children), abdominal tenderness (53 patients), rectal bleeding (54 children). In 8 patients positive symptoms of peritoneal irritation were found; in 16 patients there were observed abnormal peristaltic sounds (reduced bowel sounds - 11 children, increased bowel sounds – 2 children, pathologicalbowel sounds - 3 children). Digital rectal examination was informative in 42 patients; decreased anal sphincter tone, intussusceptum in bimanual palpation and rectal bloody mucus discharge were detected.

Ultrasonography which was informative in 33 children was a screening method of diagnosis; doubtful results were obtained in 12 patients. In all cases Doppler sonography was performed which helped us assess the changes in blood circulation in the invaginated intestine. To diagnose II an X-ray study was used in 72 patients, in 48 cases plain abdominal X-ray was used (33 patients were diagnosed with the signs of intestinal obstruction). In the remaining 24 patients pneumocolonography was performed, that allowed diagnosing II in 62.5% of cases. In 20 children II was diagnosed when palpating the abdomen under general anesthesia. In 8 children II was diagnosed in diagnostic laparoscopy.

Ileocecal intussusception was diagnosed in 77 children; 13 patients had small bowel intussusception; there were no patients with colonic intussusception; in 10 patients the localization of intussusception was not established. During surgery, in 4 children severe II was observed; in one child multiple small intestinal intussusceptions was found.

Treatment of II was performed urgently immediately after the diagnosis; only 10 patients required the preoperative preparation. High priority was given to conservative treatment used in 74 patients, who had no absolute contraindications to it. In our clinic we use the method of retrograde pneumoinsuflation under general anesthesia with endotracheal intubation and administration of muscle relaxants (MI Gritsenko, 1989). Conservative disinvagination was effective in 64 (86.5%) patients. In one child conservative disinvagination was performed repeatedly after an initial unsuccessful attempt.

The control of disinvagination efficiency was carried out according to clinical data (palpation of the abdomen), data of control abdominal ultrasound (22 patients), contrast X-ray examination of the digestive tract (25 patients); in 25 patients normal passage of contrast was observed without performing an X-ray.

The remaining 36 patients underwent surgery, 9 (25%) of them underwent a laparoscopic disinvagination. In 27 cases open surgery – disinvagination – was used. In 7 patients in addition to disinvagination bowel resection was performed; in 7 children it was appendectomy; in 2 children disinvagination was followed by Meckel diverticulum resection; in 2 cases mesenteric lymph node biopsy was performed; in one patient with malrotation syndrome in addition to disinvagination detorsion of the intestine was performed. The indications for bowel resection included bowel necrosis in 6 patients and intestinal polyposis in 1 patient. In 3 children during laparoscopic disinvagination simultaneous interventions (hernia repair using the PIRS method in two children and appendectomy in one child) were carried out. During surgery, in 11 (30.6%) patients there were found pathomorphological causes of II: 5 children had Meckel diverticulum; in 5 children mesenteric lymphadenitis (in one case – of Yersinia pseudotuberculosis etiology) was observed; 1 child was diagnosed with Peutz-Jeghers syndrome. They were removed during surgery.

Results and Discussion

In studied children, age range of the incidence of II changed significantly compared to children treated within the last decade. The typical age (4-12 months) was observed in 50% of patients only, however, 38% of patients were over 1 year of age, and 20% of children were older than 3 years. In the majority of older patients clinical picture was not typical, which created some difficulties in diagnosis.

All children with intestinal intussusception recovered. The complications of intestinal intussusception were observed in 7 patients, most of them were admitted to the clinic 24 hours after the onset of illness. 5 of them developed intestinal necrosis that required resection of the bowel. 2 children developed intestinal perforation and peritonitis. In one case perforation occurred after an attempt of performing conservative disinvagination (intracolonic pressure less than 120 mm Hg), the child underwent laparotomy, bowel resection and anastomosis were performed. In other child operative disinvagination was performed; programmable re-laparotomy was performed one day after operative disinvagination due to the ischemic changes in the intestine; bowel resection was not performed. One day after this procedure the signs of intestinal perforation appeared; the child was re-operated on; bowel resection and anastomosis were performed. In one child the postoperative complication, namely, intestinal obstruction due to anastomositis was found; it was cured conservatively. Another child developed aspiration pneumonia caused by late admission to the hospital and prolonged vomiting.

Re-laparotomy was used in three cases; two patients underwent elective (programmed re-laparotomy) and one patient underwent urgent re-laparotomy due to the presence of signs of peritonitis.

Recurrent intussusception was observed in 5 patients; 4 patients developed this condition after conservative disinvagination, one child - after surgery.

The timelessness of making the diagnosis of II has improved over the last period, however, late hospitalization of children remains at the level of 25%. Namely in this group of patients 90% of complications are observed; in such cases we used mainly surgery. To make the diagnosis of II is more difficult in children of older age group, in which typical clinical signs of the disease are rarely seen. In the majority of them II is caused by intestinal pathology (polyps, tumors, Meckel diverticulum, etc.). We present our observation of the case of multiple II due to Peutz-Jeghers syndrome in a 17-year-old child.

Сase report

A 17-year-old patient G. (medical record No 11990/2009) was admitted to the surgical department of the Ivano-Frankivsk Regional Pediatric Hospital on September 23, 2009 with complaints of cramping abdominal pain, repeated vomiting 4 hours after the disease onset. As indicated in the medical history, the patient’s mother was operated on for intussusception caused by polyps in the surgical department of Regional Pediatric Hospital in 1967.At the age of 46 years she died from malignant tumors of the small intestine. In the patient’s grandfather intestinal polyposis was diagnosed as well.

The patient’s condition at admission was severe. Child was floppy, somnolescent. Hyperpigmentation in the form of dark brown spots on her face, fingers of both hands and multiple dark cyanotic spots on her lips were noted (Fig. 1). The body temperature was 36.8º C; heart rate - 80 beats per 1 minute; BP - 110/65 mm Hg. The abdomen was swollen, slightly asymmetrical, and soft when palpated; in the right iliac region a long spindle-shaped painful formation was palpated, similar formation was palpable in the left mesogastric area. Plain abdominal X-ray was performed – there was found no pathology. During abdominal ultrasound 2 intussusceptums of the small intestine (target symptoms) were found. Complete blood count: hemoglobin 99 g/L; erythrocytes - 3.3x1012/l; CP - 0.9; leukocytes – 15.7x109/l; eosinophils - 0%; band neutrophils - 13%; segmented neutrophils - 68%; lymphocytes - 16%; monocytes - 3%. Coagulogram: prothrombin index - 88%; total fibrinogen – 3,552; trombotest - norm. The diagnosis: Peutz-Jeghers syndrome, segmental polyposis of the jejunum and ileum, multiple intestinal intussusceptions.

Fig. 1.

Child with Peutz-Jeghers syndrome

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On October 24, 2009, under general anesthesia using mechanical ventilation and muscle relaxants laparotomy was performed. In surgical revisions multiple intestinal intussusceptions (2 intussusceptums) were detected. Disinvagination of two intussusceptums was performed, the intestines were viable; however, in their lumen during palpation multiple polyps of different sizes were detected. Jejunum-ileum resection was carried out, in their lumen multiple polyps were found, end-to-end anastomoses were used. Transanal intubation of the small intestine was performed. After surgery, infusion and antibiotic therapy were applied.

The description of macropreparation: two segments of the small intestine up to 10 cm in length, in their lumen there are two polyps on wide legs having a diameter of 5x5 and 5x6 cm which completely cover the intestinal lumen. There were no complications and the postoperative period was uneventful. On the 8th day after surgery the patient underwent fibroesophagogastroscopy, during which 3 broad-based stomach polyps 0.5-0.7 cm in diameter were found. On the 17th day the child was discharged from the hospital in a satisfactory condition. Clinical supervision and the removal of gastric polyps by endoscopy were recommended.

The conducted analysis showed that tactics of treating II in our clinic has changed over the last decade. In the previous decade the leading method of treatment was open surgery, which was used in 84% of cases, while in the last decade priority was given to conservative disinvagination, which was used in 74% of cases being effective in 86.5% of patients. We consider diagnostic laparoscopy being also an effective minimally invasive method of treatment to be a highly informative method of II diagnosis in the absence of typical clinical and paraclinical symptoms.

In the literature there are many discussions regarding the indications and contraindications for conservative treatment of II [2, 4, 7]. We have narrowed the contraindications for conservative treatment of II. We consider that the time of occurrence of rectal bleeding is more important indicator of the degree of ischemic changes in the invaginated intestine than the duration of the disease. The contraindications for conservative treatment of II, in our opinion, include the duration of rectal bleeding more than 12 hours, signs of peritonitis, recurrent intussusception. We consider the patient’s age of more than 3 years as a conditional contraindication for conservative treatment. This approach to the selection of II treatment allowed us to increase the proportion of conservative treatment as well as to reduce complications and prevent lethality in children with II.

Conclusions

  • The complications of intussusception in children are usually associated with untimely diagnosis and treatment.

  • Diagnostic laparoscopy is a highly informative method of diagnosis in the absence of typical symptoms of intussusception being also an effective minimally invasive treatment.

  • When selecting the method of intussusception treatment you should be guided by the duration of rectal bleeding and Doppler data being the most important criteria for determining the degree of the impairment of hemomicrocirculation in the invaginated intestine.

  • Conservative disinvagination is the priority method of treating intussusception.

References

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Copyright (c) 2017 O. Fofanov, O. Borys, R. Nykyforuk, V. Fofanov, I. Krasivs'kij

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