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Intussusception in infancy and childhood: evaluation of a prognostic scoring pattern.
Correspondence Address:
This is a retrospective analysis of 82 patients of intussusception in infancy and childhood. Males were more than females in the ratio 2.4 : 1, the ages varied from 2 months to 12 years. Majority (73%) were less than 1 year old. Commonest presentations were pain, vomiting, distension, palpable lump and blood and mucus in stools. The management of these patients varied from barium enema reduction (3 cases), reduction by surgery and manipulation (59 cases) and resection with primary anastomosis (20 cases). We analysed our patients by giving scores based on clinical criteria. We concluded that the patients in our circumstances do not show any correlation of the scoring pattern with morbidity or mortality, chances of reduction by barium enema or manually. Resection, however, did correlate with a high incidence of death (75%). Resections were required slightly more in ileo-ileal intussusceptions than in those having a colonic involvement, morbidity in the form of wound dehiscence, and sepsis was higher in those patients who had undergone resections.
Intussusception, the invagination of a portion of the intestine into itself, is one of the emergencies in infancy and childhood. The etiology may be idiopathic or secondary to some pathology within the wall of the bowel. Children may present at any age but this occurs most commonly in the first year. The mode of presentation may vary depending upon the time of presentation. A modified scoring system based on clinical criteria has been used as an indicator of prognosis[4]. The following presentation comprises our experience in the treatment of 82 cases of intussusception in children, and the value of a scoring pattern based and modified from that advocated by Guo et al[4]. The main debate in the therapy options pertains to the reduction of intussusception by hydrostatic pressure[2],[5],[7] versus operative reduction. Recently air has been used for reduction[4],[6].
This is a study based on a retrospective analysis of 82 cases of proved intussusception over a span of 3 years from 1985 to 1987. There were 58 boys and 24 girls in this series and their ages ranged from 2 months to 12 years. The commonest mode of presentation was pain in the abdomen, vomiting, distension, a palpable abdominal lump and blood and mucus in stools [Table - 1]. The presence of coexisting diarrhoea was present in only 23% of cases. Moderate to severe dehydration was also present in 65%. Plain X-ray of the chest and abdomen in the vertical position was taken in all cases. The diagnosis of intussusception was proved in all cases either by barium enema (13 cases) or at operation. Reduction of the intussusception was attempted either by barium enema alone, surgical exploration with manual reduction and if the first two failed, then by resection of the bowel and primary anastomosis. Air pressure reduction of intussusception was not tried in our series to-date. The barium enema reduction was done after keeping the operation theatre ready for surgery. The procedure was done under fluoroscopic control with the barium can suspended 3 feet above the level of the patient for uniform pressure to be exerted[7]. Those patients in whom surgery was decided upon, either primarily due to a delayed presentation, or failure of barium enema reduction, were operated upon under general anaesthesia in a supine position through a right-sided supraumbilical, transverse, muscle-cutling incision; older children were operated upon through a right paramedian incision. Manual reduction of the intussusception was attempted in all cases. After achieving a complete reduction the bowel was inspected to look for any primary lead point like Meckel's diverticulum, polyp, or any other intraluminal pathology which would have to be taken care of. In those cases where manual reduction was not possible, a resection of that part of the bowel with primary anastomosis was done. Mickulicz enterostomy was never done in any case. A scoring pattern based on clinical criteria similar to those described by Guo et al[4] is shown in [Table - 2]. This modified scoring pattern helped us in analysing our 82 cases and subsequently defining their scores for prediction and prognosis as to whether a child coming to us in future had a chance of reduction with barium enema reduction alone, or requires manual reduction and those with a higher score will require resection and anastomosis.
In this series as in all series all over the world [1],[2],[7],[8] males (70.7%) were more common than females (29.3%). Of the 82 patients, 60 (73%) were below 1 year at presentation and amongst these, almost 50% were between 3 and 6 months of age. An abdominal lump was palpable in 73% and a mass was felt rectally in 18%. Ninety per cent of X-rays showed signs of intestinal obstruction (See [Figure - 1] and [Figure - 2]). A barium enema reduction was attempted in only 7 patients. It was fully successful and was the only mode of therapy in 3 cases (4.3%). The individual scores in these 3 patients were 10, 5 and 9. However, in the other 4 cases barium enema reduction was not successful; 2 of these had scores of 6 points each and the other 2, of 12 points each. Barring 3 successful reductions, the remaining 79 patients were operated upon. Amongst these 79, manual reduction was possible in 59 cases (74.7%) and resection was done in 20 cases (25.3%). Again, attempting to correlate the scores with successful manual reduction versus resection, we found the average score for patients with successful manual reduction was 11.4 with a lowest of 4 and a highest of 16. In comparison, the average score for resection was only 12, with a lowest of 6 and a highest of 17, thereby leading us to conclude that these clinical criteria in our conditions are highly unpredictable regarding the ultimate prognosis of a patient. We encountered all the types of intussusceptions of which ileo-colic was the most common [Table - 3], followed by ileo-caecocolic. There were 3 patients who had more than one type of intussuseeptions; thus a total of 85 intussuseeptions, were seen in this series [Table - 3]. Comparison of the incidences of reduction or resection with small bowel or colonic intussusception did not show any appreciable difference. We also analysed the data regarding those patients requiring resection and their age and we found that 65% of the patients where resection was done were below the age of 1 year. Mortality and Morbidity: In this series there were 8 deaths in all giving a mortality rate of 9.7%. Further analysis showed that 6 out of the 8 deaths were in those patients who had undergone a resection with primary anastomosis. We attempted to correlate the clinical criteria as risk factors for death by the scoring pattern and fund the average score in the patients who died was 14.5 with a minimum of 12 and a maximum of 17 points. Further analysis showed that 3 out of 16 patients with small bowel intussusceptions expired whilst only 5 out of 66 patients with colonic intussusceptions died giving a higher mortality for patients having small bowel intussusception. Those patients who underwent a resection had an onset of acute symptoms of an average of 3.3 days, before being seen by the surgeon. Other causes of morbidity in the peri-operative period were perforation of the bowel after or during reduction in 4 cases, wound dehiscence in 4 cases, septicemia in 2 infants, superficial wound infection in 6 cases; there were also 2 cases with recurrence of intussusception, giving a peri-operative morbidity of 24.3%. Resection of bowel was done in 20 cases of which 16 were for gangrene and 4 for secondary causes of intussusception i.e. 3 for Meckel's diverticulum and 1 for polyp. In our series, majority of cases were of idiopathic origin (69 out of 79) since 3 cases were reduced with barium enema and the bowel could not be inspected or visualised. In 10 patients (12.6%) we found a specific lead point with 4 patients having a Meckel's diverticulum and 6 patients with polyps of the bowel. Round worms were found in the small bowel of 6 patients but could not be proved to have been the lead point of the intussusception. We also found associated anomalies in 5 patients, there was an umbilical hernia in one case, achondroplasia in one, a horizontal mesentery in one and malrotation in 2 cases.
Intussusception has been differentiated from other forms of intestinal obstruction for less than 300 years. All series report a strong male predominance [1],[7],[8], the incidence varies from 62- 68%. A majority of the patients are below one year[1],[7], - a finding confirmed in our series. Intussusception is said to occur in well-nourished infants[7], though seen in many malnourished children also as happened in our series. Only 10% of these patients have diarrhoea before the onset of intussusception, which was not so in our series where 23% of patients had diarrhoea, and 7 had upper respiratory infection. The patients usually present with symptoms of pain[1],[2],[7] (73% of our cases), vomiting, and blood in the rectal discharge (80.4% of our cases). A palpable mass is felt in majority [1],[7],[8] of cases (73% in our study). Early on, the abdomen is flat or scaphoid, as time passes distension and intestinal loops may obscure the mass. Intussusceptions, can be of various types like the ileo-ileal, ileo-caecal, ileo-colic, ileocaeco-colic, jejuno-ileal, colo- colic of which the ilco-colic was the most common (34%) and only 2-8%[1],[2],[8] of intussusceptions have a recognizable lesion acting as the lead point, the present series has an even higher incidence of 12.2%. Various lesions have been cited like polyp, Meckel's diverticulum, hypertrophied lymphoid patch, human reovirus like agent a cause of gastroenteritis in children[7], enteric cysts, ectopic pancreatic tissue, Henoch-Schonlein purpura[7]. It can occur after abdominal operative manipulations Eke resection of coarctation of aorta, resection of Wilms tumour (1 case in this study), biopsy for neuroblastoma. Due to the pathogenesis of this disease, the mesentery of the invaginated bowel is corn pressed between the layers of the intussuscepturn, hence the longer it remains unreduced the higher the chances of gangrene setting in and lesser chances of reduction (of the intussusception). Thus, based on clinical criteria, Guo et al[4] set up a scoring pattern. The higher the score, the higher the chances of requiring resection. Along the same lines, we analysed our data but found it difficult to correlate with reduction, resection or death. In 1871, Hutchinson successful operated upon an infant with intussusception[7]. Shortly afterward Hirschsprung[5] reported a series of children whose intussusceptions was reduced by retrograde hydrostatic pressure. Since that time the mode of therapy has become controversial. More and more institutions are shifting to barium enema reduction as primary treatment in most of their patients. To achieve success with this method, certain principles must be vigorously observed[7]. The pre-requisites before attempting a barium enema are that duration of symptoms should be less than 2 days, there should not be signs of intestinal obstruction on abdominal radiography, and there should be no signs of localised or generalised peritonitis. The technique of barium enema reduction is the same and reduction is confirmed if there is free flow of barium into the terminal ileum, expulsion of faeces and flatus with barium, disappearance of the mass, and clinically child becomes comfortable. Reduction attempts are abandoned[8] if the intussusception does not move for more than 10 minutes, there is partial reduction, a poor ileal reflux, a persistent mass in the ileum, or leak of barium suggesting colonic perforation [3]. In our series, very few patients came to us within 2 days of onset of symptoms, besides, there were patients in this series who did not show any evidence of intestinal obstruction on radiography where a resection had to be done, many patients had no clinical signs of a localised or generalised peritonitis yet required a resection. Even our scoring pattern was found erroneous in many respects, since even with a low score of 6, patients required resection whereas a patient with a high score of 16 could also be manually reduced; so also the average score for resection to reduction was not significantly apart. It also implies that very few of these 82 patients in this study were fit for attempting a barium enema reduction. The benefits of this procedure are complete reduction without surgery, no anaesthesia is required, no morbidity, early ambulation, less stay in the hospital, no scar. The disadvantages are its uselessness in ileodeal intussusception, recurrence rate is higher (11%) than after operative reduction (3%)[3], specific recognizable lead points can be missed (2-8%), in unsuccessful cases a dangerous delay, colonic perforation[3], and the possibility of reducing nonviable bowel. The standard treatment of intussusception used to be operative reduction. Manual reduction by milking back of the intussusception by progressive compression of the bowel just distal to it. If reduction is not possible, or gangrene has set in, resection of the affected bowel has to be done, followed by either Mickulicz procedure or a primary end-to-end anastomosis. In our series, we attempted a barium reduction in 7 cases and we were successful only in 3 cases, of the remaining 79 patients on whom we operated, 59 were reduced manually, and 20 required resection and primary anastomosis. Our patients are from a low socio-economic strata, a lower literary state, and come to a hospital long after the onset of the symptoms, thus we can hardly offer them a non-operative technique of barium enema hydrostatic pressure reduction. We have also found that a clinical scoring system is not a prognostic predictor in these patients. A newer mode of therapy introduced by the Chinese is the concept of air pressure enema reduction of intussusception[4],[6]. The indications for use of this are similar to that of barium enema reduction, and the new scoring pattern suggests that with a score of more than 15 points, this technique cannot be used. This technique requires a special mechanical device consisting of a miniature air pump, a system of pressure selection, an indicator of visual alarm. The pump operates for 4 second intervals with an inflation volume of 220 ml until a present value is reached (110 mm Hg for children; 80 mm Hg for infants). The Chinese have claimed a 92.5% rate of reduction currently[4]. As for barium enema reduction, this method too at present cannot be used in our patients and we should continue to go by the older methods until such time we are able to have more accurate predictors for reduction or the patients begin coming much earlier than they now do or both.
We thank Dr GB Parulkar, Dean, King Edward Memorial Hospital and Seth GS Medical College, Mumbai 400 012, for permitting us to report hospital data.
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