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Prolapsed intussusception in children: clinical study and therapeutic aspects

Ngom G, Kane A, Ndour O, Fall M, Cissokho Acn, Ndoye M

Department of Pediatric Surgery, « Aristide Le Dantec» Hospital, Dakar, Senegal


Correspondence

Ngom Gabriel

Department of Pediatric Surgery
«Aristide Le Dantec» Hospital
BP: 6863 Dakar – Etoile, Senegal
Phone numbers: 00221 77 552 00 80
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


Abstract

Aim: To analyze clinical and therapeutic aspects of prolapsed intussusceptions in Dakar.

Patients and methods: A retrospective study was conducted from June 1998 to November 2009 in the Pediatric Surgery Department. Nine children including 7 boys and 2 girls with an average age of 7.6 months presented prolapsed intussusception. Clinical aspects taken into consideration were the consultation period, complains and general and physical signs. Therapeutic aspects studied were the intervention period, operative findings, therapeutic methods and post-operative recovery. The mean follow-up period was 30 months.

Results: All children were referred for rectal prolapse. History taken from parents revealed: vomiting (8/9), excessive crying (7/9) and rectal bleeding (4/9). Five children presented malnutrition and dehydration. Physical examination revealed abdominal distension in all cases. Characteristics of the prolapsed mass and the presence of a sulcus between it and the rectal wall allow the diagnosis of prolapsed intussusception. Surgery discovered a long mesentery (8/9) and lack of colic apposition (7/9). In 5 children, a disinvagination by manual expression was successful. Bowel resection was performed in 4 children who presented intestinal necrosis. The post-operative course was uneventful in 4 cases; evisceration was noted in one case and one child presented wound suppuration. Three children died within 48 hours post-operatively.

Conclusion: Clinical aspects allow differentiating rectal prolapse from prolapsed intussusception. Surgical treatment is safer because of the delayed presentation.

Key words: prolapsed intussusceptions, children, sulcus, surgical treatment

 

 

Introduction

Intussusception is the common cause of intestinal obstruction in children. In developed countries diagnosis is made early whereas in developing countries, children are received late at the referral centre [1, 2]. Moreover, it is not unusual to find prolapsed intussusception through the anus [3]. In Africa, isolated observations of prolapsed intussusception have been reported but no original study has been published. To fill the gap, this work was undertaken with the aim of reporting on the clinical and therapeutic aspects of prolapsed intussusception in children.

Patients and methods

This was a retrospective study conducted between June 1998 and May 2009 in the only Paediatric Surgery Department in Dakar. All children under 16 years of age presenting prolapsed intussusception were included in the study. Prolapsed intussusception in children: clinical stud y and therapeutic aspects

Thus, nine observations of prolapsed intussusceptions were listed out of a total of seventy two intussusceptions. The average age of the children was 7.6 months ranging from 2 months to 9 months. The series comprised seven male children and two female children.

Clinical aspects that were studied were the consultation period, complains and general and physical signs. Therapeutic aspects taken into consideration were the intervention period, operative findings, therapeutic methods and post-operative recovery. The mean follow-up period was 30 months.

Results

Clinical findings

The average consultation period was 29 days ranging from 6 days to 95 days. All children were referred for rectal prolapse. History revealed abdominal pain interspersed with remission in 7 children. Eight children presented vomiting which was food in 7 cases and bilious in one case. Four children had rectal bleeding A dysenteric syndrome was the reason for consultation in 4 children who had bloodymucoid stools. Five children presented with malnutrition and dehydration.

A constant sign was found in the physical examination: a red-colour with irregular surface and firm consistency mass prolapsed in anus. This mass was necrotic in 4 cases. Digital rectal examination revealed sulcus between the prolapsed mass and the rectal wall (fig. 1) which allowed the diagnosis of prolapsed intussusception. All children had abdominal distension.

7.1.1

Figure 1: Sulcus between the prolapsed mass and the rectal wall

7.1.2 7.1.3

Figure 2: Comparison between rectal prolapse and prolapsed intussusception

Therapeutic aspects

The children received ressuscitation before surgery. They were operated on average 2.5 hours after diagnosis confirmation. Surgical exploration found eight cases of ileo-colic intussusception and 1 case of sigmoido-rectal intussusception. Eight children had a long mesentery and 7 had a lack of colic apposition. Four children had intestinal necrosis. Surgery was performed under general anesthesia with oro-tracheal intubation. A transverse laparotomy has always been done. A surgeon positioned at the perineum realized a soft expression of the prolapsed mass. The abdominal team completed the disinvagination. This maneuver was successful in five children and was complemented by an appendectomy. In 4 children bowel resection was necessary because of the existence of an intestinal necrosis. The resection was followed by an end-to-end anastomosis in two cases and a stoma in two other cases. The average hospitalization period was 19 days and ranged from 9 days to 30 days. The postoperative course was uneventful in 4 cases. Two children presented respectively an evisceration and wound infection that evolved satisfactorily with treatment. Three children died. The fatalities involved two children who had extensive bowel resection and a child who presented hemodynamic instability.

Discussion

The long consultation period in our context can be explained by a misdiagnosis in health facilities that received the children at the very beginning of symptoms. This period is long compared to Western series, but is closer to that of some series in developing countries where the disease is most often seen as a rectal prolapse [3, 4]. This diagnostic confusion is found in some series of literature. This confusion further delays the diagnosis as was the case in Gnassingbé’s study in Togo [3]. The poor condition of most children is explained by the long consultation period. The physical sign common to all children was an exteriorized mass in the anus. Its characters allowed differentiating it from rectal prolapse (table I, fig 2). But the essential element is the presence of a sulcus between the rectal mass and the rectal wall which allowed us to diagnose invagination. The prevalence of ileo-colic forms is consistent with results of most authors. Anatomical abnormalities are described as favouring the occurrence of prolapsed intussusception. In ileo-colic forms, a long mesentery and a lack of colic apposition can allow an intussuscepted mass to migrate up to the anus. These abnormalities were found in most of our children who presented ileo-colic forms. For sigmoido-rectal intussusception, the sigmoid goes through the rectum and reaches the anus rapidly [7].

Table I: Differences between prolapsed intussusception and rectal prolapse

Characteristics

Intussusception

Rectal prolapse

Consistency

Firm

Soft

Surface

Irregular

Regular

Sulcus

Present

Absent

 

Table II: comparison of necrosis percentages on the basis of diagnosis periods

Series

Total number

Diagnostic period

Necrosis percentage

Davies [7]

8

12 days

12%

Nouri [4]

4

15 days

25%

Our study

9

30 days

44.4%

 

Despite the long intussusception evolution time, only 4 children presented intestinal necrosis. This could be explained by the anatomical nature of intussusception. Indeed, it is established that in ileo-colic forms, the progression is maximal and ischemia is minimal. Table II allows a comparison of the percentage of intestinal necrosis found by various authors. Thus, it can be observed that the longer the diagnostic period, the higher the necrosis percentage. The choice of a therapeutic method in prolapsed intussusception depends on several factors: the consultation period, the patient’s general condition, the aetiology of intussusceptions and the presence of intestinal necrosis. The authors are unanimous in their indication of the reduction by enema as a first-line treatment of intussusception, as surgery is used only in the event of failures and contraindications of enema or in suspected cases of a secondary intussusception [8,9,10].

In our context, surgery was performed in all cases. Because of the unusually long consultation period, trying a disinvagination with enema would be very risky. Intestinal necrosis led to bowel resection in 4 children. This resection was followed by an immediate anastomosis or stoma, as the choice was guided by the general condition of the child. In literature, most authors advocate a termino-terminal anastomosis [3, 11]. In 2 children whose status was altered we preferred to perform a stoma.

The average hospitalization period in our context is longer than that of Maazouna and Rakotoarisoa’s series which was 6 days and 5.6 days respectively [11,12]. This could be explained by post-operative complications and prolonged hospital stays for children with intestinal stoma. As for mortality, it is high compared to most series [13, 14]. Two children who had extensive bowel resection died of short bowel syndrome. One child died of hemodynamic instability. The quality of resuscitation could be called into question in this case because it is a child who was received in a poor general condition. Thus, rigorous resuscitation is essential before surgery to improve the results.

Conclusion

There are some similarities between our results and most comparative studies on the clinical and therapeutic aspects. However, differences were noted relating to the consultation period which is long, the systematic practice of surgery, the long hospitalization period and the high rates of morbidity and mortality.

 

 

 

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