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Recurrent Intussusception in Infants

Ali Ghribi, Sondes Sahli, Nada Sghairoun, Fatma Fitouri, Manef Gasmi, Mourad Hamzaoui

Department of Pediatric Surgery, Children’s Hospital of Tunis Tunis El Manar University, Tunisia

 

Correspondence:

Ali Ghribi

Department of Pediatric Surgery

Children’s Hospital of Tunis

Tunis El Manar University Bab Saadoun 1007 Tunis, Tunisia

Tel: 002167156810

Fax: 0021671562810

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


Abstract

Background

The majority of intussusceptions, between 2 months and 2 years, are idiopathic. Indication of surgery in infants with recurrences is still matter for debate. The aim of our study was to review our experience to better define the management of recurrent intussusceptions.

Material and methods

A retrospective study was conducted involving all patients treated for intussusception at the department of pediatric surgery of Tunis Children’s Hospital, over a 5-year period, going from 2008 through 2012. Patients admitted for more than one episode of intussusception were further investigated.

Results

During 5-year period, 170 infants and children younger than 2 years were diagnosed as having ileocolic intussusception. There were 10 patients with 12 recurrences. Overall recurrence rate was 6 %. Recurrent intussusception occurred in all cases following successful hydrostatic reduction. Nine infants underwent a second hydrostatic reduction of intussusception. The reduction was successful in all cases. The other infant was taken directly to the operating room because it was too sick to undergo enema. No lead point was found at surgery. The two patients who presented a second recurrence had a successful nonoperative reduction. Subsequent laparoscopic exploration was normal in both cases.

Conclusion

Based on our experience and on reviewing the literature, we recommend radiological reduction for more than the third episode of intussusceptions but we must take into consideration the socio-economic level of the parents. Surgery should be reserved for irreducible recurrences and in patients with a suspected pathologic lead point.

Keywords: recurrent, intussusception, infant, reduction

 

Introduction

Intussusception is a common life-threatening acute abdominal emergency that typically occurs in children between 2 months and 2 years. At this age, the majority of intussusceptions are idiopathic. The recurrence rate following nonoperative reduction ranges from 10% to 15%. Patients with recurrent intussusception (RI) may be subject to repeated enema reductions or surgical intervention. Indication of surgery in infants with recurrences is still matter for debate. We reviewed our experience to better define the management of RI.

Material and methods

A retrospective study was conducted involving all patients treated for intussusception at the department of pediatric surgery of Tunis Children’s Hospital, over a 5-year period, going from 2008 through 2012. Information considered included clinical presentation, radiological findings and results of treatment. Reduction of intussusception by contrast enema was considered successful when there was free and massive reflux of contrast into the small bowel. Patients admitted for more than one episode of intussusception were further investigated. The amount of time between the first episode of intussusception and the recurrent episode was noted.

Results

During the study period, 170 infants and children younger than 2 years were diagnosed as having ileocolic intussusception. Of this group, 10 patients with 12 recurrences were collected. All these ten infants had a successful reduction by contrast enema at the first episode of intussusception. Eight children had one recurrence each and two had two recurrent intussusceptions. Overall recurrence rate was 6 %. There were 4 boys and 6 girls (sex ratio = 0.66). Age of the 10 infants at the first episode of intussusception ranged from 6 months to 2 years (average, 17.6 months). Seven patients were younger than 1 year. Time to each recurrence ranged from 1 day to 8 months (average, 2.9 months). Table I shows the time to RI episodes. Seven patients had a RI within 7 days. The earliest recurrence occurred within 24 hours in which the likelihood of incomplete reduction was removed (Fig. 1)

Table I: Time to each recurrence  

Timeinterval

Recurrentepisodes (n)

<24 hours

1

1-7 days

8

>1 month

3

Figure 1: Successful reduction of the initial episode of intussusception by contrast enema for the patient who had presented RI within 24 hours 

8.4.1

Comparison of symptoms occurring at the initial attack and those occurring at recurrent attacks revealed no significant difference (Table II). Pain and vomiting were the two predominant clinical features. A viral illness was not more prevalent prior to the recurrent intussusception. Average time lag from onset of symptoms until initiation of treatment for the recurrent cases was 20 hours, compared with 38 hours for patients with an initial episode. Nine infants underwent a second hydrostatic reduction of intussusception. The reduction was successful in all cases. The other infant was taken directly to the operating room because it was too sick to undergo enema. No lead point was found at surgery. The two patients who presented a second recurrence had a successful nonoperative reduction. Subsequent laparoscopic exploration was normal in both cases. No complication related to enema reduction was observed in any RI patient.

Table II: Clinical presentations of the initial and recurrent episodes of intussusception

Clinicapresentation

Initial  episodes (n=10)

Recurrent episodes (n=12)

Vomiting

8

10

Abdominal pain

9

11

Bloody stools

5

4

Abdominal mass

3

4

History of virainfection

7

6

Discussion

Recurrent intussusception is a common sequel after the first intussusception. The reported recurrence rates range from 8% to 15%. Incidence of RI ranged from 10% to 15% after barium or air reduction and from 1% to 3% after surgery [1, 2]. The adhesions resulting from surgery and appendectomy may explain the reduced recurrence rate. In our series of 170 infants, the incidence of RI after nonoperative reduction represented 6%. It was lower than the incidence reported in the literature. Many authors have suggested that the use of pneumatic reduction allows a lower incidence of recurrence in comparison with hydrostatic enema [1]. In our study, seven of ten patients with RI were younger than 1 year at the first episode and 90% of the recurrences developed within 6 months of the initial episode. The same findings were found in other series [1, 2], which is probably related to the fact that the incidence of intussusception decreases significantly after the toddler period. In our series, like in the series of Niramis et al. [1], the comparison of symptoms between initial and recurrent attacks revealed no significant difference. Facteau et al. [2] found that fewer RI patients presented with signs of advanced intussusception (such as vomiting and blood per rectum). It took much less time on average to make the diagnosis of RI, perhaps because the onset of symptoms alerted the parents to the diagnosis much sooner (Table III).

Table III: Average time to onset of treatment 

Series

Initial episode

Recurrent episodes

Niramis et al.

36

17.5

Fecteaetal.

36.5

22

Our series

38

20

The typical symptoms raised the index of suspicion of the parents about a possible recurrence of intussusception. A pathologic lead point (PLP) for the intussusception was identified in 2–12% of children. A PLP is rarely identified in patients aged less than 2 years. It was found in 3 infants of 75 RI patients (4%) in the series of Niramis et al. and in 9 patients among 114 (7,9%) in the series of Hsu et al. [3]. The success rate of enema reduction for RI was close to that for the first episode [4]. Niramis et al. [1] found that the success rates after BE and AE reduction in recurrent cases were as high as 96% and 92%, respectively. Reducibility was 95 % for recurrent episodes in the series of Daneman et al. [5]. In our study hydrostatic enema was effective in 100% of cases. The lowest success rate of enema reduction was associated with previous surgery [2]. The number of recurrences that occur before the patient is subject to operative intervention is still open to debate. Hsu et al. found, for all ages, that the possibility of RI increased with each recurrence and 100% of patients with a fourth episode experienced recurrence so they recommended surgical intervention at the third episode of intussusception [3].

In our department, nonoperative reduction was always considered the initial treatment of choice of RI in infants even at the third attack. We often adopted a delayed laparoscopic exploration after reduction of the third episode of intussusception. As for the two patients who underwent surgery, we didn’t find any lead point. Because of the high reduction rate of recurrences, of the rarity of lead points and of the lack of perforation, we recommend radiological reduction for more than the second RI. But successful reduction does not completely exclude a lead point, for this reason a careful search for PLP is mandatory in RI [5]. Surgery should be reserved for irreducible recurrences, for demonstrated PLP. We think that multiple recurrences do not a contra-indicate radiological reduction in infants and young children aged (<) younger than 2 years but we must also take into consideration the risk of irradiation, the cost of enemas and the socio-economic level of the parents.

Conclusion

The majority of cases of recurrent intussusception in infants and in children younger than 2 years are idiopathic. We recommend radiological reduction for more than the third episode of intussusception. Surgery should be reserved for irreducible recurrences, in patients with a suspected pathologic lead point. We think that several episodes of recurrence at this age do not contra-indicate non operative reduction but we must take into consideration mainly the socioeconomic level of the parents.

 

 

 

References

1. Niramis R, Watanatittan S, Kruatrachue A, Anuntkosol M, Buranakitjaroen V, Rattanasuwan T et al. Management of recurrent intussusception: nonoperative or operative reduction? J Pediatr Surg 2010; 45:2175–80

2. Fecteau A, Flageole H, Nguyen LT, Laberge JM, Shaw KS, Guttman FM. Recurrent Intussusception: Safe Use of Hydrostatic Enema. J Pediatr Surg 1996; 31:859-61

3. Hsu WL, Lee HC, Yeung CY, Chan WT, Jiang CB, Sheu JC et al. Recurrent Intussusception: When Should Surgical Intervention be Performed? Pediatr Neonatol 2012; 53:300-3

4. Ein SH. Recurrent Intussusception in Children. J Pediatr Surg 1975; 10:751-55

5. Daneman A, Alton DJ, Lobo E, Gravett J, Kim P, Ein SH. Patterns of recurrence of intussusception in children: a 17-year review. Pediatr Radiol. 1998; 28:913-9