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PubMed1998

Is rectal intussusception a cause of idiopathic incontinence?

PURPOSE: The cause of rectal intussusception in patients primarily dominated by symptoms of anal incontinence has not been fully elucidated, especially for patients with idiopathic incontinence. METHODS: Between 1991 and 1996, 51 patients referred with a diagnosis of idiopathic incontinence were prospectively evaluated by standard questionnaire, clinical examination, defecography, and anal manometry. Fourteen female patients were identified with rectal intussusception and were treated by transabdominal rectopexy. Postoperatively, clinical assessment and anal manometry were performed at regular intervals. RESULTS: Continence was improved after rectopexy (P < 0.01). The postoperative increases in the anal resting pressure, maximum squeeze pressure, and maximum tolerated volume were not statistically significant. CONCLUSIONS: Rectopexy improved anal incontinence in patients with rectal intussusception. The cause of rectal intussusception in anal incontinence could not be explained by functional improvement of the internal anal sphincter tone or an increase in the maximum tolerated volume. Rectal intussusception may be a cause of idiopathic incontinence in patients; however, larger prospective studies are required to support this concept.

Aged↗
PubMed2000

Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction.

PURPOSE: The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback. METHODS: From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent). RESULTS: Whereas 65 patients failed to complete the course of biofeedback therapy, 108 (62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5 (8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P = not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups. CONCLUSION: Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.

Aged↗
PubMed1989

Gas reduction of intussusception.

Efforts to improve the non-surgical management of childhood intussusception centre around (a) reassessment of selection criteria used to ensure as many children as possible have the advantage of hydrostatic reduction, and (b) improvements and modifications of enema technique to ensure successful and safe reductions without increased morbidity. Reports that pneumatic reduction was highly successful in treating childhood intussusception prompted the authors to evaluate this technique over an 18 month period using our previously reported technique of oxygen at 2 litres/minute and a pressure of 80 mm Hg. Pneumatic reduction was attempted in 114 of 129 consecutive cases of intussusception, and was successful in 85 (75%). Fifteen patients (8.6%) were considered unacceptable risks for gas reduction using our current selection criteria and had primary surgery. The overall success rate considering all cases of intussusception managed at our institution over this period was 66% (85/129). As with any form of hydrostatic reduction, pneumatic reduction of intussusception requires careful selection of patients, meticulous technique, and awareness of complications and their appropriate management. Because of its simplicity and improved success rate, pneumatic reduction has replaced traditional barium reduction at our institution. It may be that with further evaluation of selection criteria, higher pressures, and prolonged attempts that results will improve further.

Barium Sulfate↗
PubMed2002

Intussusception. Part 1: a review of diagnostic approaches.

The vast majority of symptomatic intussusceptions in children arise in the ileum and are either ileocolic or ileoileocolic. The clinical diagnosis of these "idiopathic" intussusceptions may be difficult to make. Failure to make a prompt diagnosis and initiate appropriate treatment may lead to bowel ischemia, perforation, peritonitis, shock and even death. The clinician, therefore, may have to rely on imaging procedures to diagnose or exclude the presence of intussusception promptly and accurately. The imaging diagnosis of intussusception can be made with sonography or plain abdominal radiographs or by contrast (including air) enema examinations of the colon. This article highlights the current concepts and some controversial issues related to the imaging diagnosis of intussusception.

Colon↗
PubMed2003

Adult intussusception due to lymphangioma of the colon.

We present herein a case report of adult intussusception due to lymphangioma of the colon. On May 27, 2000, a 39-year-old woman with right lower abdominal pain was admitted to our hospital. Preoperative imaging studies, by ultrasonography, computed tomography (CT), and barium enema examination, showed right colon intussusception with a multilocular cystic tumor as a leading point. Emergency operation was performed. During the operation, normograde ileocecal intussusception with a 9 x 6-cm soft submucosal tumor of the cecum was recognized. Ileocecal resection was performed, and the patient's postoperative course was uneventful. Pathological diagnosis of the resected specimen was a cystic type lymphangioma of the cecum. Recently, lymphangioma of the colon has been diagnosed more frequently by colonoscopy and endoscopic ultrasonography. However, only a few cases of colon intussusception due to lymphangioma have been reported in the literature to date. Large lymphangioma of the colon is rare, but it should be taken into consideration that it is one of the organic lesions that causes adult intussusception.

Adult↗
PubMed1998

Colonoscopic diagnosis of lymphoid hyperplasia causing recurrent intussusception: report of a case.

This paper describes a 6-year-old boy with recurrent ileocecal intussusception due to lymphoid hyperplasia in the terminal ileum, which was diagnosed preoperatively by colonoscopy. At the age of 3 years, he developed diarrhea and a tender abdominal mass. He was diagnosed as having intussusception by ultrasound and was treated by hydrostatic barium enema. After resolution, he had three recurrent episodes of intussusception. A contrast barium enema revealed a small mass in the ileocecal region. Colonoscopy showed several exaggerated folds of the terminal ileum and a biopsy showed lymphoid hyperplasia. Because the repeated intussusception seemed to have been caused by the lymphoid hyperplasia in the terminal ileum, he underwent an ileocecal resection without any subsequent recurrence. Based on the above findings, we conclude that a colonoscopy may thus be useful both for diagnosing lymphoid hyperplasia in the terminal ileum as a cause of recurrent intussusception and for deciding how to manage it.

Child↗
PubMed1999

Survey of intussusception reduction in England, Scotland and Wales: how and why we could do better.

AIM: The aim of our study was to assess the variation in technique among hospitals in England, Wales and Scotland. In addition, local in hospital variation among paediatric radiologists at our own institution was assessed. METHOD: Postal questionnaires were distributed to the radiology departments of 301 hospitals. RESULTS: 183 (60.8%) replies were received. 122 institutions reduced intussusceptions and 61 did not. A lack of paediatric surgical and/or anaesthetic cover, and a lack of radiological experience were the major reasons cited by the departments which did not attempt intussusception reduction. Sixty-five hospitals use barium for hydrostatic reduction, 43 employ pneumatic reduction, 10 use water-soluble enemas and four use ultrasound. Of the 65 centres using barium 16 (25%) reported a success rate of less than 50%, 24 (37%) had a 50-70% success rate, seven (11%) reduce greater than 70% of intussusceptions and 18 (27%) did not know. In the 43 institutions employing air reduction, one (2%) had a success rate less than 50%, 20 (47%) had a 50-70% success rate, 17 (40%) a success rate greater than 70% and five (11%) did not know. Overall, of the total number of hospitals which replied to our survey, 28 (23%) reported that they were not aware of their success rates. Within the pneumatic reduction group in particular there was marked variation in the methods and duration of attempted reduction - between different hospitals and within the same institution. In six departments the machine used for pneumatic reduction did not measure intraluminal pressure. CONCLUSIONS: Ultrasound is underutilized despite being a sensitive method in diagnosis. There is almost certainly an over-reliance on plain radiographs and on the use of sedation, antibiotics and anti-spasmodics in general. We believe a 70% or greater success rate should be achievable in most institutions whether by pneumatic or hydrostatic reduction, and all departments should strive to achieve success rates in this range. Less than a quarter of centres who replied currently achieve this standard. Successful reduction rates below 50% are unacceptable in our opinion. Not surprisingly, success rates are generally highest in those centres treating more than 20 cases per annum. Twenty-eight (23%) of hospitals performing intussusception reductions did not know their success rates. Regular audits of intussesception figures should take place in all institutions. Unacceptably wide variations in intussusception reduction techniques currently exist. An accurate pressure release valve at least, and preferably intraluminal pressure monitoring should be an integral component of all pneumatic reduction devices. The British Paediatric Radiology and Imaging Group or the Royal College of Radiology should address these issues and introduce some standardization of practice.

Clinical Medicine↗
PubMed1981

Colon perforation during attempted barium enema reduction of intussusception.

In reviewing the records of almost 1000 infants and children with intussusception in two children's hospitals over the last 25 yr, there have been seven bowel perforations during attempted hydrostatic barium enema reduction of an intussusception. Except for one instance, these have all occurred during the last 6 yr. The infants were all 6 mo old or less and most had a preceeding viral illness. Only 4 of the 7 had pain, all vomited, in only 2 was a mass felt and all but 1 had rectal bleeding. The duration of these signs and symptoms was longer than 36 hr with most ill for 3 or 4 days. All seven infants had abdominal x-rays that showed complete small bowel obstruction. Once the intussusception was suspected, barium enema reduction was attempted without excessive hydrostatic pressure and not for a prolonged time; all the ileocolic intussusceptions were met in the transverse colon with only a minimal reduction produced. It was at this time that a perforation was suddenly noted. All infants required immediate right hemicolectomy for the area (s) of colonic necrosis. Postoperatively, there were two wound infections, a volvulus which left the child with a short gut and another infant suffered severe brain damage. These babies seem to fit a pattern in which they are younger and sicker longer than the average infant with an intussusception, and have a complete small bowel obstruction. These facts may be a warning that such infants are at increased risk for a barium enema bowel perforation.

Barium Sulfate↗
PubMed1986

Intussusception due to lymphoma.

Over 1,200 infants and children with an intussusception were treated at our hospital over the last 40 years and from this group, only 11 were found to have a lymphoma as a leading point for the intussusception. This number represents 17% of the 65 pathologic lesions that have caused an intussusception. Three children were under 41/2 years of age. All the children except two were chronically ill with pain for at least 1 week and usually for several months; weight loss and an abdominal mass in many instances provided the suspicion of a possible malignancy. When barium studies were done, there was almost always an ileocolic intussusception present with some obstruction. Reduction of the intussusception was accomplished with hydrostatic barium enema in 10 of the 11 patients; the one reduction, however, had a residual filling defect. Surgery confirmed the above findings and a resection of the leading point lymphoma was carried out in all of the children. In spite of all forms of treatment, death followed in all but three, usually within several months. One of these three survivors was treated with radiotherapy and steroids (after surgical excision) and is alive after 30 years; the second was also given chemotherapy and is alive and well after 6 years, and the third has not had radiotherapy and is alive after 10 months.

Child↗
PubMed1997

Childhood intussusception: ultrasound-guided Hartmann's solution hydrostatic reduction or barium enema reduction?

A comparison was made of the efficacy of ultrasound guided Hartmann's solution hydrostatic reduction on 23 patients (US group) with the same number of consecutive patients in whom hydrostatic reduction was done by barium enema (BE group) under fluoroscopy for childhood intussusception. The US group was diagnosed by ultrasound scan and reduction was attempted under the guidance of ultrasonography with Hartmann's solution at 100 mm Hg pressure. Excluded were patients older than 12 years, patients in shock, patients with peritonitis, bowel perforation, and gross abdominal distension as well as recurrent intussusception of more than three episodes. There were three patients excluded in this group. The diagnosis of intussusception and complete reduction were confirmed by gastrografin enema. This US group had three recurrences (3 of 26, 11.5%), one lead point (1 of 23, 4.4%), and 19 successful reductions (19 of 26, 73%). Incidentally, there were also three patients excluded in this period of barium enema reduction. There was only one recurrence (1 of 24, 4.2%), one leadpoint (1 of 23, 4.4%), and 12 successful reductions (12 of 24, 50%) in these 23 BE patients. The success rates for the ileo-colic intussusceptions with Hartmann's solution reduction and barium enema reduction were 91% (19 of 21) and 55% (12 of 22), respectively (P = .00865). There was no complication in either group, and the accuracy of diagnosing a complete reduction was 100% in both forms of reduction. Hence, ultrasound-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

Barium Sulfate↗
PubMed1999

Idiopathic intussusception: the role of laparoscopy.

BACKGROUND: The use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical complete reduction of the intussusception, which must be proven by adequate reflux of barium into the distal ileum. If this does not occur, it is assumed that the intussusception has not been reduced, and the infant is taken straight to the operating room for laparotomy and surgical treatment. The aim of this study is to limit unnecessary surgical explorations by the diagnostic and the therapeutic policy of laparoscopy with assisted hydrostatic saline reduction under general anesthesia. METHODS: Over a period of 3 years, 90 patients with intussusception were treated. Twenty patients in whom hydrostatic reduction was contraindicated were treated initially by surgery. In the remaining 70 patients, hydrostatic reduction was successful in 50 (71%), and laparoscopy was performed in 20 patients before laparotomy. Hydrostatic saline reduction was used when there was failure of reduction seen by laparoscopy. RESULTS: In 20 patients, laparoscopy showed reduction of intussusception in eight patients (40%), and saline hydrostatic reduction was successful in six patients (30%), with failure of reduction in six patients (30%) necessitating laparotomy. CONCLUSION: The use of laparoscopy for diagnosis of failure of reduction of intussusception and the hydrostatic reduction by saline enema during laparoscopy saved 14 patients from unnecessary laparotomy.

Female↗
PubMed1998

Ultrasonographic and clinical predictors of intussusception.

OBJECTIVE: The objective of this study was to determine the positive and negative clinical predictors of intussusception and the correlation of ultrasonography and air enema in establishing this diagnosis. STUDY DESIGN: This was a prospective descriptive cohort study. SETTING: This study was performed in a tertiary care pediatric emergency department. PARTICIPANTS: Eighty-eight of 245 candidates were assessed for clinical predictors of intussusception. All 245 cases were examined for correlation between ultrasonography and air enema. INTERVENTIONS: A questionnaire, ultrasonography, and air enema were used. RESULTS: Thirty-five of the 88 patients assessed for clinical predictors were positive for intussusception. Significant positive predictors were right upper quadrant abdominal mass (positive predictive value [PPV] 94%), gross blood in stool (PPV 80%), blood on rectal examination (PPV 78%), the triad of intermittent abdominal pain, vomiting, and right upper quadrant abdominal mass (PPV 93%, p = 0.0001), and the triad with occult or gross blood per rectum (PPV 100%, p = not significant). Significant negative predictors were a combination of > or = 3 of 10 clinically significant negative features (negative predictive value 77%, p = 0.035). Of the total 245 cases, intussusception (as confirmed by doughnut, target, or pseudokidney sign) was ruled out by ultrasonography in 97.4%. Alternate ultrasound findings comprised 27% of negative cases. CONCLUSIONS: Excellent positive predictors of intussusception were identified prospectively. Although no reliable negative predictors were found, patients at low risk may be screened by ultrasonography.

Air↗
PubMed2001

Endotoxin, cytokines and lipid peroxides in children with intussusception.

BACKGROUND: Intussusception is a relatively common paediatric surgical emergency. The aim of this study was to investigate selected inflammatory mediators in children with acute intussusception and to identify potentially useful plasma markers of clinical outcome. METHODS: Clinical, radiographic, operative and pathological details were recorded prospectively of all children presenting to a single institution with a confirmed diagnosis of acute intussusception during 1 year. Paired acute and convalescent venous blood samples were collected in a standard manner for blinded analysis of the following: malondialdehyde, C-reactive protein (CRP), interleukin (IL) 6, neopterin, tumour necrosis factor alpha, endotoxin, and immunoglobulin (Ig) G and IgM antiendotoxin core antibody (EndoCAb). RESULTS: Thirty-two consecutive children (23 boys, nine girls) with a median age of 4 months were studied. Acute ileocolic intussusception was managed by air enema reduction (n = 19), operative reduction (n = 8) or surgical resection (n = 5). Peripheral blood cultures were sterile. Acute levels of plasma IL-6, neopterin and CRP were significantly raised in comparison to both normal laboratory ranges and convalescent samples (P < 0.001). Using stepwise discriminant analysis, CRP was identified as the best variable at distinguishing between the three treatment groups (P < 0.001). IgM EndoCAb concentrations were significantly greater in the convalescent sera of all the patients (P < 0.001). CONCLUSION: Acute ileocolic intussusception in childhood is associated with endotoxinaemia and significantly raised levels of circulating inflammatory cytokines. Plasma CRP at diagnosis showed a statistically significant positive correlation with disease severity.

Biomarkers↗
PubMed2001

Live attenuated polio vaccine and the risk of intussusception.

AIMS: Since suspicion has been raised that administration of an oral live attenuated rotavirus vaccine may increase the risk of intussusception in young children, there has been concern about the possible effects of oral polio vaccine. The aim of the study was to evaluate the relationship between oral attenuated polio vaccine and intussusception in children below the age of 1 year. METHODS: We conducted a nested case-control analysis based on data from the General Practice Research Database which encompassed 133 children who developed documented intussusception during the first year of life and 515 controls. RESULTS: The time from oral polio vaccine to the index date was similar in cases and controls. Relative risk estimates for intussusception ranged from 0.7 (95% CI 0.2, 2.1) for babies whose last oral polio vaccine was given 29-35 days before their index date to 1.0 (95% CI 0.4, 2.3) for those whose last oral polio vaccine was given 15-21 days before their index date (compared with babies vaccinated more than 43 days before their index date). CONCLUSIONS: There is no suggestion that oral polio vaccine increases the risk for intussusception.

Case-Control Studies↗
PubMed1999

Postoperative intussusception in children.

BACKGROUND: Postoperative intussusception is an uncommon and sometimes forgotten cause of postoperative intestinal obstruction in children. METHODS: Eleven consecutive cases of postoperative intussusception during a period of 16 years (1981-1997) were analysed retrospectively. RESULTS: Symptoms developed after a median period of 5 days after operation. With one exception, postoperative intussusception was not diagnosed before reoperation. In ten of the 11 cases the intussusception was successfully treated with intraoperative manual reduction. CONCLUSION: Postoperative intussusception is a rare but typical complication in the paediatric age group and should be kept in mind.

Child, Preschool↗
PubMed1997

General anaesthesia may improve the success rate of hydrostatic reductions of intussusception.

Intussusception is the most common cause of intestinal obstruction in young children. Hydrostatic enemas result in a successful reduction of intussusception in 50% to 80% of patients. Failure to achieve reduction with hydrostatic enema results in laparotomy, although a frequent finding upon exploration is complete reduction of the intussusception, presumably due to induction of general anaesthesia. Recent paediatric literature suggests that induction of general anaesthesia may improve the success rate of therapeutic hydrostatic enema. We report a difficult case of recurrent intussusception where the induction of general anaesthesia alone did not result in reduction of intussusception, but successful reduction by enema was achieved while the patient was anaesthetized.

Anesthesia, General↗
PubMedDate not supplied

Radionuclide imaging of bowel infarction complicating small bowel intussusception in dogs.

Technetium-99m (99mTc)-pyrophosphate was investigated for use as an indicator of intestinal infarction in intussuscepted bowel. Irreducible intussusceptions were created in eight adult mongrel dogs. Technetium-99m-pyrophosphate was then injected intravenously 24 and 48 hrs later for external scanning. In six of the dogs, infarction developed in the intussusception, and each demonstrated increased uptake of 99mTc-pyrophosphate on in vivo scintiscans. The two dogs without infarction showed no increase uptake of the radionuclide. Well-counting and specimen scanning confirmed increased radionuclide in the infarcted intussusceptions. These observations suggest that 99mTc-pyrophosphate is a reliable indicator of the vascular compromise that sometimes occurs with intestinal intussusception.

Animals↗
PubMed1997

Intussusception: a 9-year survey (1986-1995).

BACKGROUND: Acute intussusception has different clinical features in various parts of the world. The goal of this study was to determine the clinical presentation in different ethnic groups in Israel. METHODS: A retrospective chart review of a 9-year period (1985-1995) was carried out at a university medical center. Data extracted included age, sex, ethnic origin, presenting symptoms and signs, the type of enema (barium or air), and the success rate of non-surgical reduction of the intussusception. RESULTS: Ninety patients suffering from intestinal obstruction due to acute intussusception were admitted. The triad of intermittent screaming attacks, lethargy, and vomiting was observed in 37.5% of study subjects. The majority of patients were admitted during the warmer months of the year. The average age of the patients was 7.8 +/- 3.7 months; 70% of them were between the ages of 4 and 9 months and 92.5% under 1 year of age. The female-to-male ratio was 1:2.1. Air enema was superior to the barium enema in achieving reduction (p < 0.01). The incidence in the Jewish population was similar to that observed in other surveys, and twice that found in the Arab population in our region (p < 0.05). CONCLUSIONS: The overall clinical presentation of acute intussusception found in our study does not differ from other studies. The lower incidence of acute intussusception found in the Arab population can be explained by ethnic, genetic, or nutritional factors.

Acute Disease↗