Intussusception

Background. Intussusception remains a frequent cause of bowel obstruction in children and typically is treated by reduction via enema. Controversy persists regarding the optimal reduction technique to maximize success while minimizing morbidity. Methods. We reviewed our institutional data comparing outcomes of enema reduction that use contrast medium versus air. A systematic review also was undertaken of comparative studies evaluating pneumatic (oxygen or air) versus hydrostatic (any contrast medium) reduction. Critical appraisal was performed with the Methodological Index for Non Randomized Studies scale for observational studies, Jadad score for randomized trials. Meta-analysis was performed with REVMAN 5.1. Results. Institutional data revealed a failed reduction rate of 20.4% (20/98) with air and 29.6% (8/27) with contrast reduction. Nineteen studies were included in the systematic review. The cumulative failure rate favored pneumatic reduction (odds ratio [OR] 0.45; 95% confidence interval [95% CI] 0.34-0.60); sensitivity analysis of prospective studies demonstrated similar results (OR 0.39; 95% CI 0.24-0.63). The number needed to treat to eliminate one failed reduction was nine pneumatic reductions. No difference was noted in reported perforations (OR 0.98; 95% CI 0.48-2.03). Conclusion. Pneumatic reduction is more likely to successfully reduce intussusception in children without evidence of increased morbidity. In the context of available expertise, pneumatic reduction should be the method of choice for the treatment of intussusception barring an indication for immediate operative intervention. (Surgery 2013;154:328-34.)

The widespread application of computed tomography (CT) in different clinical situations has increased the detection of intussusception, particularly non-lead point intussusception, which tends to be transient. Consequently, determining the clinical significance of intussusception seen at CT poses a diagnostic challenge. Patients with intussusception may or may not be symptomatic, and symptoms can be acute, intermittent, or chronic, making clinical diagnosis difficult. In most cases, radiologists can readily make the correct diagnosis of intestinal intussusception by noting the typical bowel-within-bowel appearance at abdominal CT. However, the CT findings that help differentiate between lead point and non-lead point intussusception have not been well studied. Nevertheless, although there is considerable overlap of CT findings, when a lead mass is seen at CT as a separate and distinct entity vis-à-vis edematous bowel, it can be considered a reliable indicator of a lead point intussusception. Differentiating between lead point and non-lead point intussusception is important in determining the appropriate treatment and has the potential to reduce the prevalence of unnecessary surgery.

Intussusception of the appendix is a rare condition. Most cases are diagnosed during operation of the patients suspected to have appendicitis. In this report we present a seventy one year-old man with a history of periumbilical intermittent abdominal pain for several months. None of the paraclinical tests were useful for determining the diagnosis. Colonoscopy performed during the last episode of abdominal pain revealed the prolapsed appendix in the cecum and the patient was sent to the operating room. Macroscopic appearance of the appendix was normal and microscopic examination revealed follicular hyperplasia and acute focal appendicitis. Appendiceal intussusception should be considered in differential diagnosis of intermittent abdominal pain and colonoscopic diagnosis could be very important to avoid dangerous or unnecessary decision making.

Duodenal obstruction caused by ileocolic intussusception in the absence of intestinal malrotation is extremely rare. We present and discuss the imaging findings in an infant with an intussusception secondary to a duplication cyst in whom sonography also showed inversion of the orientation of the mesenteric vessels and a distended stomach. A contrast medium study revealed a proximal duodenal obstruction with a beak appearance suggestive of midgut volvulus. At surgery, an ileocolic intussusception causing duodenal obstruction without concomitant malrotation or volvulus was found. The combination of duodenal obstruction and abnormal relationship of the mesenteric vessels as a result of ileocolic intussusception has not previously been reported in the literature.

Simultaneous diagnoses of intussusception and appendicitis in the same patient have rarely been described in the pediatric literature. A case of a 30-month-old boy is presented with an initial diagnosis of intussusception that was successfully reduced by air contrast enema. When the patient's condition deteriorated, a diagnostic search surprisingly revealed a missed perforated appendicitis with an appendicolith that had been part of the intussusception. The patient's hospitalization and surgical course is described along with a discussion of the intermingling of intussusception and appendicitis in a young child. This case illustrates the need to consider alternative diagnoses when a patient's course takes an unexpected and confusing turn.

Objectives -This case series describes 5 dogs with small intestinal intussusception and acute kidney injury due to infection with Leptospira interrogans serovar Australis. Case Series Summary -Small intestinal intussusception was observed in 4 dogs diagnosed with acute kidney injury due to leptospirosis presented between 1997 and 2005. Intussusception was diagnosed at initial presentation or later during hospitalization. An additional dog fulfilling our inclusion criteria was presented to a small animal specialty clinic nearby and was included. Upon admission, all dogs were severely azotemic and thrombocytopenic. All 5 dogs showed the strongest microscopic agglutination test serology reaction to L. interrogans serovar Australis. Two dogs survived with no apparent residual renal damage, 1 survived with subsequent mild chronic kidney disease, and 2 dogs were euthanized at the owners' request due to a guarded prognosis. New or Unique Information Provided -Intussusception can occur or may be seen in dogs with leptospirosis due to L. interrogans serovar Australis and patients should be monitored closely for this potential complication. As all 5 dogs described in this case series showed the highest titer for L. interrogans serovar Australis, these precautions may be especially applied in geographic areas where this particular serovar is seen.

An 82-year-old male presented to the hospital because of acute exacerbation of abdominal pain and biliary vomiting. Contrast-enhanced computed tomography of the abdomen was performed. A left paraduodenal hernia associated with volvulus, intussusception, and bowel wall ischemia were radiologically diagnosed. Surgery confirmed the diagnostic imaging findings. We present the first case of an association of these acute abdominal conditions.

Records of dogs that had abdominal ultrasonography and surgical or pathological diagnosis of intestinal intussusception between February 1992 and June 1997 were reviewed retrospectively. Ultrasound images were reviewed with respect to appearance of the intussusception, suspected location, evidence of predisposing cause and concurrent lesions. Ten intussusceptions were found, affecting a variety of breeds. The mean (range) age of affected dogs was 2.5 (0.3 to seven) years (four females and six males) and the reported duration of clinical signs, 48 (one to 150) days. Intussusceptions were jejunojejunal (five dogs), ileocolic (three), caecocolic (one) and colocolic (one). A concentric ring sign was identified ultrasonographically in each dog and anatomical location predicted correctly in five instances. Additional ultrasonographic findings associated with intussusceptions included intestinal neoplasm in two dogs, enlarged abdominal lymph nodes in two, multiple mesenteric cysts in one and intestinal foreign body in a further dog. Thus, ultrasonography enables accurate diagnosis of intestinal intussusception and is a useful method for searching for concurrent or predisposing lesions.

Aim:  Establishment of baseline epidemiology of intussusception in developing countries has become a necessity with the possibility of reintroduction of rotavirus vaccine. The current study assessed the seasonal trend in cases admitted with intussusceptions and dehydrating acute watery diarrhoea in children aged 2 months to 10 years.Methods:  In a prospective surveillance study, teaching and research hospital sites in India (Lucknow and Nagpur), Brazil (Fortazela), Egypt (Ismailia) and Kenya (Nairobi) established a surveillance where a network of hospitals with surgical facilities catered to a reference population of about 1–2 million for reporting of intussusception. One large hospital per site also recruited admitted cases of acute watery diarrhoea.Results:  From April 2004 to March 2006, 173 and 2346 cases of intussusception and diarrhoea, respectively, were recruited. Cases of intussusception had no apparent seasonality. Most cases of intussusception (61.3%) (107/173) were in the ≤1 year age group, with males comprising 68.8% (119/173) of all cases. Hospital mortality of intussusception was 4.2% (4/96). Cases of diarrhoea peaked in March, with 56.6% (1328/2346) of admitted cases being males. Majority (83.1%) of cases of diarrhoea had received antibiotics, and the hospital mortality was 0.8% (18/2280).Conclusion:  Intussusception in the four participating countries exhibited no seasonal trend. We found that it is feasible to establish a surveillance network for intussusception in developing countries. Future efforts must define population base before the introduction of rotavirus vaccine and continue for some years thereafter.

Background There are several causes of obstructed defecation one of which is thought to be internal rectal prolapse. Operations directed at internal prolapse, such as laparoscopic ventral rectopexy, may improve obstructed defecation symptoms significantly. It is not clear whether the obstructed defecation with internal prolapse is a mechanical phenomenon or whether it results changes in rectal sensitivity. This study aimed to evaluate rectal sensory function in patients with obstructed defecation and high-grade internal rectal prolapse. Methods This study represents a retrospective review of a prospectively collected database of patients attending a tertiary referral pelvic floor unit. Patients with high-grade (recto-anal) intussusception formed the basis of this study. Rectal sensory function was determined by intrarectal balloon inflation. Three parameters (sensory threshold, urge to defecate and maximum tolerated volumes) were recorded. Abnormal sensitivity was defined as partial (one or two parameters abnormal) or total (all three abnormal). Key Results Four hundred and eight patients with high-grade internal rectal prolapse both with and without obstructed defecation symptoms were studied. Two hundred and forty one (59%) had normal sensation. Eighteen (4%) had total hyposensitivity and three (1%) total hypersensitivity. A further 96 (24%) had partial hyposensitivity whilst 50 (12%) had partial hypersensitivity. Neither hypersensitivity nor hyposensitivity differed between patients with and without symptoms of obstructed defecation.

Intussusception in children may recur after surgical correction. Ileopexy has popularly been used as a procedure to prevent recurrent intussusception, but its effect has not been well evaluated. The present study compared the incidence of recurrent intussusception after several different surgical procedures for intussusception in children. The charts of 278 children undergoing surgical reduction of ileocolic intussusception over 17 years were retrospectively reviewed. The incidence of recurrent intussusception was compared among the three surgical procedures: simple manual reduction, manual reduction plus ileopexy, and segmental resection. Simple manual reduction was performed in 67 (24.1%) of the 278 patients, manual reduction plus ileopexy in 186 (66.9%), and resection of the involved segment in 25 (9.0%). There were four episodes of recurrence in three (4%) patients who had had manual reduction, nine episodes in eight (4%) patients who had undergone ileopexy, and none after segmental resection. There was no statistical difference in recurrent rate among the three groups (reduction vs. ileopexy, P = 0.95; reduction vs. resection, P = 0.28; ileopexy vs. resection, P = 0.29). Ileopexy is not better than simple manual reduction in preventing recurrence of ileocolic intussusception in children.

Meckel’s diverticulum (MD) has varied presentations and often becomes a diagnostic challenge. The purpose of this study was to review the various presentations of symptomatic MD and to assess the sensitivity of the Meckel’s scan as a diagnostic tool in patients with bleeding MD. The hospital records of 71 consecutive patients with a diagnosis of MD from 1990 to 2005 were retrospectively reviewed. The data was assessed for age at presentation, sex, clinical features, investigations performed, surgical intervention and histopathological findings. There were 71 patients with a diagnosis of MD (age 2 days–14 years). In eight patients, MD was an incidental finding at laparotomy. The remaining 63 patients were symptomatic and presented with various clinical features. Ten patients (15.8%) had clinical features of peritonitis; of these, six had perforated MD and four had Meckel’s diverticulitis at laparotomy. Nine patients (14.2%) were diagnosed as intestinal obstruction, and at laparotomy, a Meckel’s band was found to be the cause of the obstruction. Nine patients (14.2%) had a patent vitello-intestinal duct and presented with umbilical discharge. Thirty-five patients (55.5%) presented with episodes of bleeding per rectum or malaena. Ultrasound scans revealed intussusception in six patients requiring open reduction. Of the remaining 29 patients with bleeding per rectum, 27 underwent a Meckel’s Tc99 scan that showed a positive tracer in 18 patients (66.6%) and negative in 9 (33.3%). All patients with a symptomatic MD underwent resection of the diverticulum. Histology revealed ectopic gastric mucosa in 43 patients (68.3%). MD has various presentations and can be easily misdiagnosed. It is necessary to maintain a high index of suspicion in the paediatric age group. The Meckel’s scan has a poor positive predictive value and cannot be relied upon for a diagnosis in cases of bleeding MD if Tc99 scan is negative.

pated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0±0.7 before to 0.07±0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1±4.2 before to 4.6±3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group. Conclusions Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long-standing constipation is less effectively cured by biofeedback.

Intussusception, a potentially lethal condition with poorly understood etiology, is the most common cause of acute intestinal obstruction in children younger than 5 years old. In some cases, the condition has been associated with administration of the first licensed rotavirus vaccine, the reassortant rhesus-human tetravalent rotavirus vaccine (RRV-TV; RotaShield). No such association has to date been reported from large phase III safety trials with new rotavirus vaccines. As 2 new, live-attenuated oral rotavirus vaccines are currently under review for approval by the European Union regulatory authorities, a review of the clinical, etiologic and epidemiologic aspects of intussusception in Europe is urgently needed.

Background: Continuous surveillance for intussusception (IS) is important for monitoring the safety of secondgeneration rotavirus vaccines. The present study aimed to assess the incidence of IS in Singaporean children aged < 2 years. Methods: This was a prospective, hospital-based, multi-center surveillance conducted in seven hospitals -two public hospitals and five private medical centers between May 2002 and June 2010 in Singapore. Diagnosis of IS (definite, probable, possible, suspected) was based on the case definition developed by the Brighton Collaboration. Children < 2 years of age who were diagnosed with IS were enrolled in this study. Incidence of IS was calculated per 100,000 child-year with its 95% confidence interval. Results: Of the 178 children enrolled, 167 children with definite IS cases were considered for final analyses; 11 were excluded (six diagnosed as probable IS and four diagnosed as suspected IS; one child's parents withdrew consent). Mean age of children with definite IS was 11.6 ± 6 months; 67.7% were males. The overall incidence of IS was 28.9 (95% CI: 23.0-34.8) and 26.1 (95% CI: 22.2-30.0) per 100,000 child-year in children < 1 year and < 2 years of age, respectively. The majority of IS cases (20 [12.0%]) were reported in children aged 6 months. Most children (98.2% [164/167]) recovered, two (1.2%) children recovered with sequelae and one (0.6%) child died of septic shock. Conclusions: The incidence of IS remained low and stable in Singaporean children aged < 2 years during the study period (

Postoperative idiopathic intussusception is considered to be a distinct entity, and has been reported following different operations. We present a 45-year-old female with postoperative ileoileal intussusception following a transverse loop colostomy for sigmoid volvulus, in which there was a kinked loop of bowel forming the lead point. The pathogenesis and literature review of this disorder is discussed.

Backgrounds:   The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death. Methods:   Literature was collected systematically via internet using key words of intussusception and children. The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-Based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels. Results:   Three criteria of &quot;diagnostic criteria&quot;, &quot;severity assessment criteria&quot;, and &quot;criteria for patient transfer&quot; were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referr...

Background and aimsDefecating proctography has been traditionally used to assess patients with evacuatory dysfunction. More recently, dynamic transperineal ultrasound has been described, defining the interaction between the infralevator viscera and the pelvic floor at rest and during straining. This study compared qualitative diagnosis and quantitative measurement obtained by defecography and dynamic transperineal ultrasonography in patients with evacuatory difficulty.Patients and methodsThirty-three

BACKGROUND: Pneumatic reduction has a higher success rate and lower incidence of complications compared to barium enema and hydrostatic reductions. What is deterrent to its common use is the cumbersome technique. Our aim is to develop a simple technique that can be used in any hospital with locally available facilities. METHODS: An intercostal drainage bottle and an enema can were used to pass air into the rectum at a controlled pressure determined by the height of the enema can. Water running in from the enema can displaces the air in the intercostal drainage bottle into the rectum effecting the reduction of intussusception. RESULTS: This system was tried in 12 patients. Successful air delivery was obtained in all cases. In two cases, the intussusception could not be reduced. Laparotomy revealed these to be ileoileal intussusceptions. CONCLUSION: The technique described is easy to assemble, safe and effective. We recommend it for regular use in pneumatic reduction of intussusception. [Asian J Surg 2006;29(3):170-2]

Introduction: Intussusception is malengagement of the distal
bowel segment into the proximal gastrointestinal tract. It is rare
in adults.
Case Report: Here, we reported a 41-year-old woman with
complaints of writhing abdominal pain and vomiting whose
physical examination revealed varying findings. Abdominal
tomography with venous contrast showed a target lesion and
sausage-shaped mass that were characteristic for invagination.
Exploration showed invagination of a part of the terminal ileum,
10 cm in length, into the ascending colon. Operation was ended
with resection and anastomosis. Histopathologic examination of
the specimen showed no lesion that would lead to invagination.
Conclusion: In patients with intermittent abdominal pain and
vomiting, if abdominal examination shows that the tenderness
changes place and if the pain does not respond to hydration
and medication, the physician should suspect invagination. It
is important to recognize the target lesion and sausage-shaped
mass that are pathognomonic in the abdominal tomography.

CARTAS AL DIRECTOR 589 6. Theodoropoulos J, Krecioch P, Myricks S, Atkins R. Delayed presentation of a splenic challenge. Int J Colorectal Dis. 2010;25:1033---4. 7. de Vries J, Ronner HR, Oomen APA, Linkskens RK. Splenic rupture following colonoscopy, a rare complication. Neht J Med. 2009;67:230---3. 8. Prowda JC, Trevisan SG, Lev-Toaff AS. Splenic injury after colonoscopy: conservative management using CT. AJR. 2005;185:708---10. 9. Capellani A, di Vita M, Zanghi A, Cavallero A, Alfano G, Piccolo G, et al. Splenic rupture after colonoscopy: report of a case and review of literature. World J Emerg Surg. 2008;3:8. 10. Lalor PF, Mann BD. Splenic rupture after colonoscopy. JSLS.

Background: According to the clinical literature, intestinal intussusception in adults is rare, is associated with a pathologic lead point, and is usually treated surgically. Nonobstructing small bowel intussusception has been reported as a transient finding on computed tomographic (CT) studies. Methods: We evaluated the radiographic and clinical findings in 24 patients who were found to have 26 proximal small bowel intussusceptions on abdominal CT scans performed for a variety of indications. Results: Twenty patients with intussusceptions had no evidence of small bowel obstruction. The transient and clinically insignificant nature of 22 intussusceptions in these 20 patients was proven radiologically (n ϭ 14), surgically (n ϭ 1), or by clinical follow-up (n ϭ 7). These patients demonstrated a bowel-within-bowel pattern on multiple contiguous images and absence of strangulation or intestinal dilatation. No lead points were demonstrated in these patients. Three other patients had symptoms of low-grade small bowel obstruction and were treated conservatively. Extensive follow-up investigations showed no recurrence of intussusception or a lead point. One patient had high-grade obstructive intussusception with intestinal ischemia and required surgical resection of necrotic bowel. Conclusions: Proximal small bowel intussusceptions are likely to be transient and nonobstructive and unlikely to have a significant lead point.

In the last two decades, there has been substantial development in the diagnostic possibilities for examining the small intestine. Compared with computerized tomography, magnetic resonance imaging, capsule endoscopy and double-balloon endoscopy, ultrasonography has the advantage of being cheap, portable, flexible and user-and patient-friendly, while at the same time providing the clinician with image data of high temporal and spatial resolution. The method has limitations with penetration in obesity and with intestinal air impairing image quality. The flexibility ultrasonography offers the examiner also implies that a systematic approach during scanning is needed. This paper reviews the basic scanning techniques and new modalities such as contrast-enhanced ultrasound, elastography, strain rate imaging, hydrosonography, allergosonography, endoscopic sonography and nutritional imaging, and the literature on disease-specific findings in the small intestine. Some of these methods have shown clinical benefit, while others are under research and development to establish their role in the diagnostic repertoire. However, along with improved overall image quality of new ultrasound scanners, these methods have enabled more anatomical and physiological changes in the small intestine to be observed. Accordingly, ultrasound of the small intestine is an attractive clinical tool to study patients with a range of diseases.

pated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0±0.7 before to 0.07±0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1±4.2 before to 4.6±3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group. Conclusions Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long-standing constipation is less effectively cured by biofeedback.

Background and Objective: Intussusception is one of the most common causes of intestinal obstruction in children 5 months to 3 years, which is the most common cause of acute abdominal pain and its prevalence increases as a result of viral infection. In this report, were present a case of intussusception in a 17-years-old boy following COVID-19.
Case Report: A 17-year-old adolescent boy with a known case of steroid-dependent nephrotic syndrome from the age of two has been referred to the emergency department with severe abdominal pain and vomiting. On ultrasound, renal mass and free fluids were shown. Ileocecal intussusception was observed and was repaired without any complications.
Conclusion: Based on the results of this study, intussusception should be considered in every patient with nephrotic syndrome with COVID-19 infection.

Although ectopic pancreas and intussusception are not unusual conditions, intussusception caused by ectopic pancreas is extremely rare. Its presence along with a ruptured congenital mesenteric vascular band raises the possibility of an anomaly of the vitelline vascular system. We report the case of a 26year-old man presenting with acute abdominal pain, vomiting, and diarrhea. CT scan showed a large amount of free fluid in his abdomen and an ileo-ileal intussusception. At laparotomy he was found to have hemoperitoneum with a ruptured, actively bleeding congenital band attached to the ileal mesentery, which was ligated, with ileo-ileal intussusception that was resected. Histopathology showed ectopic pancreatic tissue as the lead point for the intussusception. It was likely to be a ruptured mesodiverticular band and along with other findings suggested a constellation of anomalies of the vitello-intestinal tract. Clin. Anat. 24:128-132, 2011. V V C 2010 Wiley-Liss, Inc.

Intussusception in adults is relatively rare. Here we report a 52-year-old man with an extensive colo-colonic intussusception caused by a polypoid mass in the ascending colon. The mass, which was 10 x 8 x 5 cm in size, had been palpated preoperatively and was suspected to be a sigmoid tumor. The patient was treated successfully by reduction of the invagination and subsequent right hemicolectomy.

Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome. Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception &gt; or = 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surg...

Worldwide, rotaviruses account for more than 125 million cases of infantile gastroenteritis and nearly 1 million deaths per year, mainly in developing countries. Rather than other control measures, vaccination is most likely to have a major impact on rotavirus disease incidence. The peak incidence of rotavirus diarrhea occurs between 6 and 24 months of age. In developing countries, however, cases are not uncommon among children younger than 6 months. G serotypes 1 to 4 are responsible for most disease, but there are indications that in Brazil that G type 5 is of emerging epidemiological importance. Both homotypic and heterotypic responses are elicited during natural rotavirus infection, and the immunological response at the intestinal mucosal surface is probably the more consistent predictor of clinical immunity. With the primary objective of protecting children against life-threatening dehydrating diarrhea, many approaches to rotavirus vaccine development have been attempted. One v...