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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 101-106

Clinical and radiological predictors of the outcome of hydrostatic reduction of primary intussusception in childhood


1 Department of Pediatric Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
2 Department of Radiodiagnosis, Faculty of Medicine, University of Alexandria, Alexandria, Egypt

Date of Submission10-Oct-2019
Date of Decision21-Oct-2019
Date of Acceptance21-Oct-2019
Date of Web Publication27-Apr-2020

Correspondence Address:
BSc, MSc, MD Ahmed Elrouby
Lecturer of Pediatric Surgery, Faculty of Medicine, Alexandria University, 2 Omar Zafan St. Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJOP.AJOP_3_20

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  Abstract 


Introduction Success of hydrostatic reduction of intussusception using saline enema could be affected by several factors.
Aim This study aimed to detect the clinical and radiological predictors of successful hydrostatic reduction of primary intussusception.
Patients and methods This retrospective cross-sectional study included all patients with primary intussusception from the age of 6 months to 3 years. Patients with signs of peritonitis or bowel perforation were excluded from the study. Patients’ age, sex, duration and type of symptoms, general, abdominal, and digital rectal examination findings as well as findings in ultrasound of the abdomen (the presence and the site of an abdominal mass) and plain radiograph (PXR) of the abdomen standing (air fluid levels) were recorded and analyzed by appropriate statistical tools with the software SPSS version 10.0.
Results Factors that affected the success of hydrostatic reduction significantly included age at presentation (Student’s t test: 3.46, P=0.001), BMI (Student’s t test: 2.383, P=0.019), long duration of symptoms (Student’s t test: 8.812, P=0.000), passage of red currant jelly stools (χ2-test: 91.777, P=0.000), presence of palpable abdominal mass (χ2-test: 55.813, P=0.000), on the left side of the abdomen (χ2-test: 52.439, P=0.000), and positive findings in PXR abdomen standing (χ2-test: 59.911, P=0.000).
Conclusion Primary intussusception in patients with younger age group, low BMI, long duration of symptoms, passage of red currant jelly stool, palpable abdominal mass on the left abdominal side being confirmed by ultrasound of the abdomen, and the presence of air fluid levels in PXR abdomen standing have a lower rate of successful hydrostatic reduction.

Keywords: Hydrostatic reduction, predictors, primary intussusception, success


How to cite this article:
Elrouby A, Waheeb S, Ettaby A, Elabany A. Clinical and radiological predictors of the outcome of hydrostatic reduction of primary intussusception in childhood. Alex J Pediatr 2019;32:101-6

How to cite this URL:
Elrouby A, Waheeb S, Ettaby A, Elabany A. Clinical and radiological predictors of the outcome of hydrostatic reduction of primary intussusception in childhood. Alex J Pediatr [serial online] 2019 [cited 2020 Jun 2];32:101-6. Available from: http://www.ajp.eg.net/text.asp?2019/32/3/101/283322




  Introduction Top


Intussusception is the most common cause of small intestinal obstruction in childhood, which is the most common pediatric surgical emergency. Primary intussusception develops usually between 4 and 10 months of age at the ileocecal region in about 90% of cases [1].

Ultrasound (US)-guided hydrostatic reduction of intussusception has been described for the first time by Kim and colleagues in 1982 and since this date it was widely used in the treatment of suitable cases of intussusception with acceptable results saving the patients from the morbidities which may accompany surgical exploration [2].


  Aim Top


The aim of the present work was to study the clinical and radiological predictors of successful hydrostatic reduction of primary intussusception in childhood.


  Patients and methods Top


This retrospective, cross-sectional study included all the patients who had primary intussusception from the age of 6 months to 3 years as proved by US of the abdomen and who were indicated for hydrostatic reduction by saline enema between January 2017 and December 2018 at El Chatby University Children Hospital, Alexandria, Egypt.

Patients who presented symptoms of peritonitis and/or perforated bowel on plain-radiograph (PXR) abdomen standing were excluded from the study.

All the patient records were reviewed and gender, sex, and BMI were recorded. Body temperature, level of consciousness, and the presence of dehydration on admission were reviewed. Nature and duration of symptoms (red currant jelly stool, vomiting, abdominal pain) as well as the presence of abdominal distension, rigidity, tenderness, palpable abdominal mass, and/or the presence of a prolapsing mass on digital rectal examination were reviewed and recorded. Finally, the presence of air fluid levels in PXR abdomen standing and the location of the mass in US abdomen were reported.

Signing of informed consent by the parents was followed by resuscitation and initiation of hydrostatic reduction using saline enema. Under sonographic guidance of high-resolution ultrasound Just Vision400 (Toshiba Corporation, Tokyo, Japan) apparatus and with the patient lying in the left lateral position, a Foley’s catheter 16–18 Fr was inserted rectally until the Y-piece is reached. Then the balloon was inflated by 20–30 ml of saline and the catheter pulled out until the balloon hitched snugly in the rectum and the buttocks were tapped together for anal seal. The enema was then started by elevation of the container with about 1 l of warm saline for 100–150 cm above the level of the patient allowing the fluid to descend by gravity intrarectally. The attempt of hydrostatic reduction was repeated maximally for three times, each attempt lasted for 15–20 min with a latent period of 2–3 h between the trials.

Successful reduction was achieved when the US reveals disappearance of the mass and free passage of fluid into the terminal ileum in association with the disappearance of signs and symptoms. Patients were followed up until the passage of stools as well as tolerating oral intake with a free abdominal US before discharge.

The outcome of hydrostatic reduction was reported and the patients were divided into group A (successful reduction) and group B (failed reduction). These groups were compared according to the previously mentioned parameters. Statistical description and analysis of data were done by appropriate statistical tools with the Software SPSS version 10.0 (SPSS Inc., 233 South Wacker Drive, 11th Floor, Chicago, Illinois, USA).

The study was designed in accordance with the ethical standards of our responsible committee on human experimentation in our institute and with the Helsinki Declaration of 1975, as revised in 2000.


  Results Top


The study included 140 patients and the procedure was successful in 91 patients (group A; 65%) and failed in 49 patients (group B; 35%). About 73 (52.1%) patients were men; the difference in sex distribution between the two groups did not show statistical significance as shown in [Table 1].
Table 1 Sex distribution among the studied groups

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Personal data

The age at presentation ranged between 6 and 36 months with a mean of 17.69±11.32 months. Patients of group A had an older age (20.05±11.39 months) than patients of group B (13.31±9.89 months); this difference showed a statistically significant effect on the success of hydrostatic reduction (Student’s t test: 3.49, P=0.001).

The BMI ranged between 11.23 and 33.13 kg/m2with a mean of 17.48±3.59 kg/m2; it was significantly higher in patients of group A (18.±3.94 kg/m2) than in patients of group B (16.51±2.58 kg/m2) (Student’s t test: 2.383, P=0.019).

Clinical presentation

The period between the onset of the complaint and the presentation to our institute ranged between 5 and 70 h with a mean of 16.44±11.45 h; it was shorter in patients of group A (11.42±7.96 h) than in patients of group B (25.78±11.15 h); this difference was statistically significant (Student’s t test: 8.812, P=0.000).

Symptoms

The presenting symptoms included abdominal colic, vomiting, and the passage of red currant jelly stools. Abdominal colic was present in all of the studied patients; however, the frequency of the attacks varied among them being repeated every 5, 10, or 15 min without showing statistical significance. Vomiting was the second presenting symptom in frequency which developed in 54 (38.6%) patients without affecting the outcome significantly. The least common symptom was the passage of red currant jelly stool which developed in 45 (32.1%) patients; the passage of red currant jelly stool was the only statistically significant factor as shown in [Table 2].
Table 2 Relationship between presenting symptoms and success of hydrostatic reduction of primary intussusception

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Clinical examination

All the studied patients had been subjected to general examination, local abdominal examination, and digital rectal examination.
  1. General examination: general examination showed that 33 patients (23.6%) were dehydrated, 16 patients (11%) were drowsy, and 43 patients (31%) were feverish. These signs did not show statistically significant effect on the success of hydrostatic reduction as shown in [Table 3].
    Table 3 Relationship between signs of general examination and success of hydrostatic reduction of primary intussusception

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  2. Local abdominal examination: abdominal examination showed distension in 30 patients (21.4%), rigidity in 10 patients (7.1%), tenderness in 13 patients (9.3%), and a palpable abdominal mass in 53 patients (37.9%). The only abdominal sign which affected the outcome significantly is the presence of a palpable abdominal mass which reduced the success rate of hydrostatic reduction significantly as shown in [Table 4].
    Table 4 Relationship between signs of abdominal examination and success of hydrostatic reduction of primary intussusception

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  3. Digital rectal examination: digital rectal examination revealed the presence of the head of intussusception in 24 patients (17.1%) being prolapsed from the anus in four patients. This finding did not change the outcome significantly as shown in [Table 5].
    Table 5 Relationship between prolapsing rectal mass and success of hydrostatic reduction of primary intussusception

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Imaging evaluation

All of the studied patients had been evaluated by PXR abdomen standing and by US of the abdomen.

PXR abdomen standing

PXR abdomen standing revealed the presence of air fluid levels in 56 patients (40%); the presence of air fluid levels reduced the success rate of hydrostatic reduction significantly ([Table 6];χ2=59.911, P=0.000).
Table 6 Relationship between findings in PXR abdomen standing and success of hydrostatic reduction of primary intussusception

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US of the abdomen

The presence of abdominal mass as confirmed by US abdomen affected the outcome significantly (χ2: 55.813, P=0.000). The site of the mass of intussusception as diagnosed by US abdomen varied among the studied patients with the highest frequency in the upper right abdominal quadrant which was detected in 78 patients (55.7%). The difference in the site of the mass affected the outcome significantly as shown in [Table 7] (χ2: 52.439, P=0.000).
Table 7 Relationship between the site of abdominal mass by US and success of hydrostatic reduction

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  Discussion Top


Many conservative and surgical approaches had been used in the treatment of intussusception with an increased popularity of the conservative measures. Conservative measures include hydrostatic reduction under sonographic guidance and pneumatic or barium reduction under fluoroscopic guidance. On the other hand, patients with failed reduction, peritonitis, bowel perforation, or unstable general condition are treated with surgical exploration [3].

Barium enema had been considered as the principal method of reduction of intussusception for a long period of time; however, the risk of severe peritonitis and even death in case of bowel perforation reduced its usage and directed the physicians to replace it with pneumatic and hydrostatic reduction. Regarding pneumatic reduction under fluoroscopic guidance: it is used under a pressure of 80–120 mmHg which carries the risk of tension pneumoperitoneum in case of bowel perforation besides the risk of high radiation exposure. These disadvantages made Kim and colleagues to think about hydrostatic reduction under sonographic guidance in 1982. He described this procedure as installing saline rectally through a Folley’s catheter reducing the invaginated segment of intussusception backwards under a pressure of 90–150 mmHg [4].

Factors affecting the success of hydrostatic reduction of intussusception had been studied by many researchers. These factors included age, sex, presence and duration of vomiting, abdominal pain, and rectal bleeding. Abdominal signs including distension, site of the abdominal mass and presence of peritonitis as well as general signs including the presence of lethargy, fever, and dehydration were also studied. Rectal prolapse of the intussusceptum as detected by digital rectal examination was also studied. The presence and the site of an abdominal mass as detected by US abdomen was also studied as well as the presence of small bowel obstruction and air-fluid level on PXR abdomen [3].

The success rate of hydrostatic reduction of intussusception varied among different studies. This study revealed 65% success rate; other studies like that of Van Den ED et al. [5] showed higher success rate (79%) and Khorana et al. [6] showed a lower success rate (44%).

Difference in sex did not affect the outcome in this study significantly. On the other hand, the effect of age at presentation was variable among different studies. Patients in the older age groups showed a significantly higher rate of successful hydrostatic reduction in this study. This is similar to the findings of Eklof et al. [7] who explained that by the higher competency of ileocecal valve in younger age groups, this highly competent valve does not allow saline to go back through it into the ileum resulting in a lower success rate of hydrostatic reduction in younger age groups. In contrast, Talabi et al. [2] found that the difference in age at presentation does not affect the success of hydrostatic reduction.

BMI affected the success rate in this study significantly. Few researchers confirmed this finding like Khorana et al. [6] who found that patients with a body weight less than 12 kg had a significantly lower rate of successful hydrostatic reduction. This could be explained by the narrower intestinal caliber in patients with smaller body weight which make reduction of intussusception difficult.

This study showed that patients with shorter duration of presentation have a significantly higher rate of successful hydrostatic reduction. This is similar to the findings of He et al. [8] who described a significant effect of early presentation on reducibility and believed that patients with duration of symptoms of more than 24 h should be treated with more cautious and gentle approaches.

Other researchers like Van Den Ende et al. [5] and Wong et al. [9] observed that the duration of symptoms does not affect the outcome of hydrostatic reduction of intussusception.

Neither the presence of abdominal pain nor vomiting at presentation affected the outcome significantly in this study; this is similar to the findings of Avci et al. [3] who did not prove a significant relationship between the presence of vomiting at presentation and the success of hydrostatic reduction.

On the other hand, Khorana et al. [6] and He et al. [8] reported that the development of vomiting as a presenting symptom in intussusception leads to a lower success rates.

Rectal bleeding can develop either early or late during the course of intussusception in about 60% of patients and denotes bowel edema and congestion. Many literatures including this study showed that the development of rectal bleeding in intussusception can significantly reduce the success rate of hydrostatic reduction. Also, XieXiaolong et al. [10] found the same results and explained that by the fact that bleeding per rectum is a late presentation.

On the other hand, Avci et al. [3] found that the presence of rectal bleeding does not affect the success of hydrostatic reduction of intussusception.

This study did not show a statistically significant relationship between body temperature and the outcome. On the other hand, Khorana et al. [6] concluded in their study that fever might be a systemic response to intra-abdominal infection or to a compromised intestinal vascular supply and hence its presence is directly related to the reduced frequency of successful hydrostatic reduction.

The presence of air fluid levels in PXR abdomen standing reduced the rate of successful hydrostatic reduction in this study significantly; this finding was similar to the findings of Fragoso et al. [11] and Khorana et al. [6].

The presence of the mass of intussusception on the left side of the abdomen as confirmed by US reduced the success rate of hydrostatic reduction significantly in this study. This is similar to the findings of He et al. [8] and XieXiaolong et al. [10] who found the same results in their studies and explained that by the fact that the presence of the mass on the left side of the abdomen denotes long-segment intussusception and as the most common starting point in intussusception is the ileocecal region; this reduces the chance of successful hydrostatic reduction.


  Conclusion Top


Hydrostatic reduction of intussusception is a safe and effective method of management of intussusception whenever indicated. Factors that might reduce the chance of its success include young age group, low BMI, long duration of symptoms, passage of red currant jelly stool, presence of a palpable abdominal mass, left side abdominal mass in US abdomen, and the presence of air fluid levels in PXR abdomen standing.

Acknowledgements

The research was supported by Alexandria Faculty of Medicine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jiang J, Jiang B, Parashar U, Nguyen T, Bines J, Patel MM. Childhood intussusception: a literature review. PLoS One 2013; 8:e68482.  Back to cited text no. 1
    
2.
Talabi AO, Famurewa OC, Bamigbola KT, Sowande OA, Afolabi BI, Adejuyigbe O. Sonographic guided hydrostatic saline enema reduction of childhood intussusception: a prospective study. BMC Emerg Med 2018; 18:46.  Back to cited text no. 2
    
3.
Avci V, Agengin K, Bilici S. Ultrasound guided reduction of intussusception with saline and evaluating the factors affecting the success of the procedure. Iran J Pediatr 2018; 28:e62442.  Back to cited text no. 3
    
4.
Goo KY, Choi BI, Yeon KM, Kim JW. Diagnosis and treatment of childhood intussusception using rea-time ultrasonography and saline enema: preliminary report. J Korean Soc Med Ultrasound 1982; 1:66–70.  Back to cited text no. 4
    
5.
Van Den Ende ED, Allema JH, Hazebroek FWJ, Breslau PJ. Success with hydrostatic reduction of intussusception in relation to duration of symptoms. Arch Dis Child 2005; 90:1071–1072.  Back to cited text no. 5
    
6.
Khorana J, Singhavejsakul J, Ukarapol N, Laohapensang M, Siriwongmongkol J, Patumanond J. Prognostic indicators for failed nonsurgical reduction of intussusception. Ther Clin Risk Manag 2016; 12:1231–1237.  Back to cited text no. 6
    
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Eklöf OA, Johanson L, Löhr G. Childhood intussusception: Hydrostatic reducibility and incidence of leading points in different age groups. Pediatr Radiol 1980; 10:83–86.  Back to cited text no. 7
    
8.
He N, Zhang S, Ye X, Zhu X, Zhao Z, Sui X. Risk factors associated with failed sonographically guided saline hydrostatic intussusception reduction in children. J Ultrasound Med 2014; 33:1669–1675.  Back to cited text no. 8
    
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Wong CWY, Chan IHY, Chung PHY, Lan LCL, Lam WMW, Wong KKY et al. Childhood intussusception: 17-year experience at a tertiary referral centre in Hong Kong. Hong Kong Med J 2015; 21:518–523.  Back to cited text no. 9
    
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Xiaolong X, Yang W, Qi W, Yiyang Z, Bo X. Risk factors for failure of hydrostatic reduction of intussusception in pediatric patients. Medicine (Baltimore) 2019; 98:e13826.  Back to cited text no. 10
    
11.
Fragoso AC, Campos M, Tavares C, Costa-Pereira A, Estevão-Costa J. Pneumatic reduction of childhood intussusception. Is prediction of failure important? J Pediatr Surg 2007; 42:1504–1508.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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