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Article history:
Received 22 July 2014
Received in revised form 2 September 2014
Accepted 24 September 2014
Key words:
Ileocolic intussusception
Intussusception
Pediatric
Hydrostatic
a b s t r a c t
Background: The likelihood of a lead point as the cause of ileocolic intussusception increases as children get older.
This study looks at whether a different management strategy should be employed in older patients.
Methods: 7 year multi-institutional retrospective study of intussusception in patients aged b 12 years.
Results: Ileocolic intussusception with complete data was found in 153 patients: 109 02 years, 34 35 years, and
10 612 years, respectively. Bloody stools occurred in 42/143 of 05 years and 0/10 of 612 years, p b 0.001. Combined hydrostatic and/or surgical reduction was successful in 113/143 05 year olds vs 5/10 612 year olds,
p b 0.001. Enemas were safe but reduced only 1 patient over age 5. Resections were required in 29 patients
(15 idiopathic, 14 lead points). Lead points were found in 4/109 children under 3 years, in 5/34 aged 35 years
and 5/10 aged 612 years (p = 0.04 vs 35 years and p b 0.001 vs 05 years). Lead points consisted of 7 Meckels
diverticula and 7 others.
Conclusion: Children older than 5 years are much more likely to have a pathologic lead point and early surgical
intervention should be considered. In this study, enema reduction was safe but minimally benecial in this
age group.
2015 Elsevier Inc. All rights reserved.
in all patients regardless of age [4]. It was standard training in the senior
authors institution to perform surgery on all pediatric patients with intussusception older than 2 years of age. Similarly, Van der Laan et al.
found that all patients older than 2 years of age with intussusception required laparotomy with the majority requiring a bowel resection [5].
This study was performed to determine the characteristics of older
children (312 years old) with ileocolic intussusception, to determine
the incidence of pathological lead points and most importantly, to determine how to best manage these patients.
1. Materials and methods
Hospital records from six regional hospitals within a single
healthcare system were searched using the diagnosis code intussusception. Electronic medical records of all patients with this diagnosis from
January 2007 to December 2013 were reviewed. Patients aged greater
than 12 years were excluded, because it was felt that they would
share the same characteristics as adult patients with respect to this diagnosis. Hospital charts were reviewed by three individuals. Only cases
with a diagnosis of ileocolic intussusception were included in the
study. The following data were extracted from electronic medical records: demographics, date of birth, age at diagnosis of intussusception,
symptoms at presentation (emesis, grossly bloody stool, fever), length
of symptoms, and date of last follow up. Fever was dened as oral or rectal temperature greater than 100.6 F. Radiology reports were reviewed
for the following information: date of contrast enema, number of contrast enema studies, presence of radiologic lead point, level of
648
Table 1
Patient characteristics.
Emesis
Bloody stools
Fever
Age (years)
Number
Percent
Number
Percent
Number
Percent
0
1
2
35
Total 05
612
Total
55
37
17
34
143
10
153
1.9
2.1
2.4
2.2
2.1
3.3
2.1
45
24
11
20
80
4
180
82
65
65
59
56
40
29
12
1
6
42
0
90
53
32
6
18
29
0
6
6
1
7
13
3
33
11
16
6
21
9
30
1.1
1.5
1.5
1.5
0.2
2.2
1.2
649
Table 2
Therapeutic intervention.
Hydrostatic Enema
Operations
Age (years)
Resected (%)
Lead Point (% of N)
0
1
2
35
Total 05
612
Total
55
37
17
34
143
10
153
45 (82)
34 (92)
15 (88)
32 (94)
126 (88)
4 (40)
130 (85)
17 (38)
20 (59)
10 (67)
19 (59)
66 (52)
1 (25)
67 (52)
39 (71)
13 (35)
8 (47)
11 (32)
71 (50)
9 (90)
80 (52)
25 (64)
11 (85)
5 (63)
6 (55)
47 (69)
4 (44)
51 (51)
14 (36)
2 (15)
3 (38)
5 (45)
24 (34)
5 (56)
29 (36)
1 (1.8)
2 (5.4)
1 (5.9)
5 (14.7)
9 (6.3)
5 (50)
14 (18)
ischemia and necrosis while the remaining 5 intussusceptions were reduced intraoperatively. There were 2 lead points seen in the 14 patients
aged 1 year who were taken to the operating room and 12 patients who
had their intussusception reduced intraoperatively. Although there
were a total of 39 patients aged 012 months who were taken to the operating room, only 1 patient had a pathologic lead point (Meckels diverticulum). In total the pathologist identied 4 patients with follicular
hyperplasia or lymphoid hyperplasia large enough to serve as the lead
point for the intussusception. There may not be substantial differences
between this diagnosis and an enlarged Peyers patch, which is felt to
represent a potential lead point in younger children with intussusception. However, the focus population in this study is the 612 year old
age group, and lymphoid hyperplasia was only diagnosed in one of
these patients.
The prevalence of pathological lead points in various age groups is
shown in Fig. 1. The overall prevalence of lead points in the different
age groups 0, 1, 2, 35 and 612 was 1.8%, 5.4%, 5.9%, 14.7% and 50%, respectively. To determine if any clinical parameters (other than age)
could predict the presence of a pathological lead point, additional analyses were performed. For example, emesis was present in 50% of patients with a pathological lead point and in 70% of patients without a
pathological lead point. Similarly, bloody stools were present in only
21% of patients with a pathological lead point and in 33% of patients
without a pathological lead point, all non-signicant. Total follow-up
for this study ranged from 1 to 199 months with a mean of 78 months.
months. Patient charts were reviewed to determine the length of follow
up while looking for recurrent intussusception. If present, this would
have suggested that intussusception caused by a pathological lead
point may have been reduced. In this specic patient population
(reduced intussusception), follow-up ranged from 1 to 130 months,
mean 74 months. Within this time frame, 9 patients were encountered
who came back with a recurrent intussusception, however, none were
found to have a surgically proven pathological lead point.
was not helpful, or even harmful. This question has not been specically
addressed in other reports in the literature. This is a hard question to answer given the relatively low prevalence of intussusception within this
older age group. This study utilizes a patient database with access to
over 4 million patients within a single healthcare system spread out
over a seven year interval. Some of the providers were adult radiologists
and adult general surgeons, especially for the older patients. Other providers were pediatric radiologists and pediatric surgeons. As such, the
success rate for hydrostatic reduction was lower than is generally quoted in the pediatric radiology literature. This fact no doubt inuenced a
surgeons decision to either attempt a hydrostatic reduction or proceed
directly to surgery. It is retrospective and there was no specic protocol
utilized by the various facilities. In view of these important limitations,
no rm conclusions can be reached about whether contrast enemas
should be obtained in older patients. Hydrostatic reduction was only
attempted in four patients aged 612 years. One of these was successfully reduced. Five of the ten patients in this age group were unable to
have their intussusceptions surgically reduced and underwent surgical
resection of a pathological lead point. If hydrostatic reduction had
been attempted in all 10 patients, it is unlikely that these 5 patients
would have been reduced, giving at most a 50% success rate. Therefore,
only a 50% success rate should be expected, due to the higher incidence
of pathological lead points in this age group. This study does suggest
that attempted hydrostatic reduction appears safe in older patients, as
no perforations were observed. It also showed that a pathological lead
point is unlikely to be reduced using standard surgical or radiological
techniques. Based upon these data it is recommended that a therapeutic
enema reduction be attempted in all patients with suspected or proven
intussusception aged 5 years and below, who do not have a contraindication to the enema. This study can not say that hydrostatic reduction
should not be performed in older patients, only that it is less likely to
be successful in this older age group. The decision to attempt a contrast
enema must be made by the surgeon based upon the patients presentation and the skill level of their radiology department.
3. Discussion
The objective of this study was to determine if there is an age at
which attempted hydrostatic reduction of an ileocolic intussusception
50
Table 3
Pathologic ndings in patients with lead points.
Age (years)
0
1
2
35
612
Total
+
60
40
Patients w/lead
points
Meckels
diverticulum
Lymphoid
Hyperplasia+
Other
1
2
1
5
5
14
1
1
0
3
2
7
0
1
1
1
1
4
0
0
0
1
2
3
30
number of patients
without lead point
20
10
0
0 yr
1 yr
650
What this study does clearly show is that pathological lead points are
more likely at increasing ages, with a cutoff noted at age 6 years and
above. It was also unable to identify any clinical parameters (other
than age) that indicated the high likelihood that a pathologic lead
point is present. The exact reason why older patients (612 years) had
less emesis and bloody stools than their younger counterparts is not
clear. They did tend to present later than the younger patients. Perhaps
this is because many parents are more anxious about younger children
and infants who are not able to talk and bring them to the doctor sooner.
The higher incidence of fever in the older children may be due to the
higher likelihood of compromised intestine and/or a later presentation.
The overall incidence of pathological lead points in children with intussusception has been reported to be 1.5%12% [6]. In this study, pathological lead points were found to be more prevalent in older patients.
Pathological lead points occurred in 50% of patients aged 612 years,
but in only 4% of 02 year olds and in 15% of 35 year olds. Other studies
of intussusception had similar results. In a study of 1340 children aged
3 months to 12 years with recurrent intussusceptions, 3 of 7 patients
with pathological lead points were aged greater than 6 years and 1 patient was 4 years old [7]. Saxena and colleagues found 2 pathological
lead points in a study of over 100 children with intussusception aged
up to 16 years; both lead points were in children greater than 6 years
old [8]. Many other studies have shown an increased frequency of pathological lead points in children greater than 6 years old [911]. A radiologic study of patients aged 014 years with intussusception found an
equal distribution of radiological lead points among age groups [12].
However, these were lead points seen on imaging, not proven at surgery. In this study, every child with a pathological lead point eventually
underwent resection of the pathological lead point due to failed reduction. It is possible for a patient with a minor pathological lead point to
have their intussusception reduced. However, in this study, no patient
whose intussusception was initially reduced was subsequently found
to have a pathological lead point. One of the strengths of this study is
the long-term follow-up of patients who remain within our system. It
is unlikely that a lead point was missed given this length of follow up.
Early in the study period, patients with a possible diagnosis of intussusception were evaluated in a variety of ways, and sometimes without
the involvement of a pediatric surgeon until after the diagnosis was made.
In many cases, CT scans were done, in spite of the potential radiation exposure. Beginning in 2012 a regional protocol was established to expedite
the evaluation and treatment of children with suspected intussusception.
It begins with a plain abdominal X-ray and an abdominal ultrasound, as
this has been shown to be highly sensitive in diagnosing intussusception
[12]. It discourages the use of CT scans. Once imaging suggesting that an
intussusception is found the patients are transferred to facilities with
on-site pediatric surgeons and radiologists for denitive management.
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