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Intussusception in Children Presenting to the Emergency Department Ailie Lochhead, Roaa Jamjoom and Savithiri Ratnapalan CLIN PEDIATR 2013 52: 1029 DOI: 10.1177/0009922813506255 The online version of this article can be found at: http://cpj.sagepub.com/content/52/11/1029
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506255
research-article2013
CPJXXX10.1177/0009922813506255Clinical PediatricsLochhead et al
Article
Intussusception in Children Presenting to the Emergency Department
Clinical Pediatrics 52(11) 1029–1033 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813506255 cpj.sagepub.com
Ailie Lochhead, MBBS1, Roaa Jamjoom, MD1, and Savithiri Ratnapalan, MBBS, MEd, MRCP, FRCPC, FAAP1
Abstract A retrospective chart review of children diagnosed with intussusceptions from March 2005 to March 2007 was conducted at a tertiary care pediatric hospital. There were 152 children with 170 episodes of intussusceptions during the study period. Around one third (30%) of children diagnosed with intussusceptions had a concurrent infection. There were 114 large bowel intussusceptions, with a mean age of 27 months (SD = 25) and a success rate of 91% for air enema reductions. Bowel resection was performed in 8.8% of children with large bowel intussusceptions. Small bowel intussusceptions (n = 38) were associated with gastrostomy tubes in 42% (n = 16) of patients, and 81% needed tube shortening. The varying age range of many children diagnosed with intussusceptions and the high incidence of intercurrent illnesses and fever in our study alert health professionals to suspect intussusceptions in children presenting with abdominal pain or crying. Keywords intussusceptions in children, small bowel intussusceptions, large bowel intussusceptions, presentation, recurrence, air enema reduction
Background Intussusception is a potentially life-threatening bowel obstruction usually presenting in children under 1 year of age.1 Although intussusceptions associated deaths have declined, intussusceptions cause significant morbidity in children.1 The annual hospitalization rates for intussusceptions in the United States has declined 25% from 1993 to 2004 but have remained stable at approximately 35 cases per 100 000 infants since 2000.2,3 The rates vary by age and peak at 62 per 100 000 at 6 to 7 months of age.2 In a study from Switzerland children of with intussusception, infants under 12 months were the largest single group and the mean age of the patients was 2.7 years.4 This study showed that the yearly mean incidence of intussusceptions was 38, 31, and 26 cases per 100 000 live births in the first, second, and third year of life, respectively, with no apparent seasonality.4 The intussusceptions rates for Japanese children was found to be rather high at 180 to 190 cases per 100 000 infants.5 These studies collected hospitalization data and mentioned that the spontaneous reduction rate for intussusceptions was low and that the reduction in the incidence of intussusceptions cannot be attributed to reduced hospitalization rates of children with intussusceptions. The hospitalization rates have also changed significantly in recent years and there is an increasing trend of
sending children home from in the emergency department after successful reduction of intussusceptions.6-9 As such, the incidence, mean age of presentation, and outcome may not be truly captures if data examined are from hospitalized children only. The objective of this study was to analyze the presentation, treatment, and outcome of children with intussusceptions in a tertiary care emergency department.
Methodology This study is a retrospective chart review of children presenting to a tertiary care emergency department with intussusceptions from March 2005 to March 2007. Children were selected as having intussusceptions using the ICD-10 classification code of 7131020 (K56.1). All identified charts were reviewed and children diagnosed with intussusceptions during the study period were included in the study. Data on demographic 1
University of Toronto, Toronto, Ontario, Canada
Corresponding Author: Savithiri Ratnapalan, Divisions of Emergency Medicine, Clinical Pharmacology & Toxicology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada. Email: [email protected]
Downloaded from cpj.sagepub.com at University of Waikato Library on July 11, 2014
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Clinical Pediatrics 52(11)
information, presentation, investigations completed, treatments performed, and outcome were collected and entered into a database. If the children had more than 1 visit for intussusceptions, the information from the first visit was collected for final analysis and the children were counted only once. Ethical approval was obtained from the Hospital for Sick Children research ethics board before the study commenced.
Results There were 152 children with 189 emergency department visits and 170 episodes of intussusceptions during the study period. Half of them were transferred from other hospitals. Six of these children have had a previous episode of intussusceptions prior to the study period. Of the 152 children, 114 had large bowel intussusceptions and 38 had small bowel intussusceptions of which 13 were associated with gastrojejunal (GJ) tubes. Eleven children had recurrent large bowl intussusceptions and 2 recurrent small bowel intussusceptions needing air enema reduction and GJ tube shortening, respectively. There was a male preponderance of 68% and the mean age was 32 months (range = 2 months to 17 years). The mean age of children with large bowel intussusceptions was 27 (SD = 25) months. All infants under 12 months of age had large bowel intussusceptions and consisted of 45% of all children with large bowel intussusceptions. There were 16 children under 6 months of age who presented with intussusceptions (see Table 1 and Figure 1). Most children were brought in with a history of abdominal pain and or crying (>95%); 66% had vomiting, 28% had fever at presentation, and 27% had a history of blood in stools. All children with signs of bowel ischemia had been symptomatic for more than 24 hours. A significant number of children (30%) had a concurrent infection and 64% of them had documented fever at presentation (see Figure 2). Abdominal tenderness was noted on examination in 24% and a palpable mass in 10%. Rectal examination was recorded in only 20%, and 23% of them were positive for blood in stools. All children except one child transferred from another institution (with a diagnostic computed tomography) had ultrasound scan examinations to diagnose intussusceptions. Lead points were present in 46% of children who had intussusceptions. Twenty-nine percent of children with intussusceptions also had enlarged mesenteric lymph nodes diagnosed on ultrasound scan, which was the most common lead point found in 62% of children with lead points (see Table 2 for details). All small bowel intussusceptions (ileoileal) that were not associated with GJ tubes resoled spontaneously. Symptomatic children with small bowel intussusceptions
Table 1. Age Range. Age Under 1 year 1 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to 10 years 10 to12 years Over 13 years Total
0
Total
51 31 22 8 2
0 6 8 7 3 4 2 3 1 1 2 1 38
51 37 30 15 5 4 2 3 1 1 2 1 152
114
16
15
5
Small Bowel Intussusceptions
infans under 12 months
20
10
Large Bowel Intussusceptions
19
11
Series1 Series2
5
0 to < 4 months
4- to
Intussusception in Children Presenting to the Emergency Department Ailie Lochhead, Roaa Jamjoom and Savithiri Ratnapalan CLIN PEDIATR 2013 52: 1029 DOI: 10.1177/0009922813506255 The online version of this article can be found at: http://cpj.sagepub.com/content/52/11/1029
Published by: http://www.sagepublications.com
Additional services and information for Clinical Pediatrics can be found at: Email Alerts: http://cpj.sagepub.com/cgi/alerts Subscriptions: http://cpj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Oct 17, 2013 What is This?
Downloaded from cpj.sagepub.com at University of Waikato Library on July 11, 2014
506255
research-article2013
CPJXXX10.1177/0009922813506255Clinical PediatricsLochhead et al
Article
Intussusception in Children Presenting to the Emergency Department
Clinical Pediatrics 52(11) 1029–1033 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813506255 cpj.sagepub.com
Ailie Lochhead, MBBS1, Roaa Jamjoom, MD1, and Savithiri Ratnapalan, MBBS, MEd, MRCP, FRCPC, FAAP1
Abstract A retrospective chart review of children diagnosed with intussusceptions from March 2005 to March 2007 was conducted at a tertiary care pediatric hospital. There were 152 children with 170 episodes of intussusceptions during the study period. Around one third (30%) of children diagnosed with intussusceptions had a concurrent infection. There were 114 large bowel intussusceptions, with a mean age of 27 months (SD = 25) and a success rate of 91% for air enema reductions. Bowel resection was performed in 8.8% of children with large bowel intussusceptions. Small bowel intussusceptions (n = 38) were associated with gastrostomy tubes in 42% (n = 16) of patients, and 81% needed tube shortening. The varying age range of many children diagnosed with intussusceptions and the high incidence of intercurrent illnesses and fever in our study alert health professionals to suspect intussusceptions in children presenting with abdominal pain or crying. Keywords intussusceptions in children, small bowel intussusceptions, large bowel intussusceptions, presentation, recurrence, air enema reduction
Background Intussusception is a potentially life-threatening bowel obstruction usually presenting in children under 1 year of age.1 Although intussusceptions associated deaths have declined, intussusceptions cause significant morbidity in children.1 The annual hospitalization rates for intussusceptions in the United States has declined 25% from 1993 to 2004 but have remained stable at approximately 35 cases per 100 000 infants since 2000.2,3 The rates vary by age and peak at 62 per 100 000 at 6 to 7 months of age.2 In a study from Switzerland children of with intussusception, infants under 12 months were the largest single group and the mean age of the patients was 2.7 years.4 This study showed that the yearly mean incidence of intussusceptions was 38, 31, and 26 cases per 100 000 live births in the first, second, and third year of life, respectively, with no apparent seasonality.4 The intussusceptions rates for Japanese children was found to be rather high at 180 to 190 cases per 100 000 infants.5 These studies collected hospitalization data and mentioned that the spontaneous reduction rate for intussusceptions was low and that the reduction in the incidence of intussusceptions cannot be attributed to reduced hospitalization rates of children with intussusceptions. The hospitalization rates have also changed significantly in recent years and there is an increasing trend of
sending children home from in the emergency department after successful reduction of intussusceptions.6-9 As such, the incidence, mean age of presentation, and outcome may not be truly captures if data examined are from hospitalized children only. The objective of this study was to analyze the presentation, treatment, and outcome of children with intussusceptions in a tertiary care emergency department.
Methodology This study is a retrospective chart review of children presenting to a tertiary care emergency department with intussusceptions from March 2005 to March 2007. Children were selected as having intussusceptions using the ICD-10 classification code of 7131020 (K56.1). All identified charts were reviewed and children diagnosed with intussusceptions during the study period were included in the study. Data on demographic 1
University of Toronto, Toronto, Ontario, Canada
Corresponding Author: Savithiri Ratnapalan, Divisions of Emergency Medicine, Clinical Pharmacology & Toxicology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada. Email: [email protected]
Downloaded from cpj.sagepub.com at University of Waikato Library on July 11, 2014
1030
Clinical Pediatrics 52(11)
information, presentation, investigations completed, treatments performed, and outcome were collected and entered into a database. If the children had more than 1 visit for intussusceptions, the information from the first visit was collected for final analysis and the children were counted only once. Ethical approval was obtained from the Hospital for Sick Children research ethics board before the study commenced.
Results There were 152 children with 189 emergency department visits and 170 episodes of intussusceptions during the study period. Half of them were transferred from other hospitals. Six of these children have had a previous episode of intussusceptions prior to the study period. Of the 152 children, 114 had large bowel intussusceptions and 38 had small bowel intussusceptions of which 13 were associated with gastrojejunal (GJ) tubes. Eleven children had recurrent large bowl intussusceptions and 2 recurrent small bowel intussusceptions needing air enema reduction and GJ tube shortening, respectively. There was a male preponderance of 68% and the mean age was 32 months (range = 2 months to 17 years). The mean age of children with large bowel intussusceptions was 27 (SD = 25) months. All infants under 12 months of age had large bowel intussusceptions and consisted of 45% of all children with large bowel intussusceptions. There were 16 children under 6 months of age who presented with intussusceptions (see Table 1 and Figure 1). Most children were brought in with a history of abdominal pain and or crying (>95%); 66% had vomiting, 28% had fever at presentation, and 27% had a history of blood in stools. All children with signs of bowel ischemia had been symptomatic for more than 24 hours. A significant number of children (30%) had a concurrent infection and 64% of them had documented fever at presentation (see Figure 2). Abdominal tenderness was noted on examination in 24% and a palpable mass in 10%. Rectal examination was recorded in only 20%, and 23% of them were positive for blood in stools. All children except one child transferred from another institution (with a diagnostic computed tomography) had ultrasound scan examinations to diagnose intussusceptions. Lead points were present in 46% of children who had intussusceptions. Twenty-nine percent of children with intussusceptions also had enlarged mesenteric lymph nodes diagnosed on ultrasound scan, which was the most common lead point found in 62% of children with lead points (see Table 2 for details). All small bowel intussusceptions (ileoileal) that were not associated with GJ tubes resoled spontaneously. Symptomatic children with small bowel intussusceptions
Table 1. Age Range. Age Under 1 year 1 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to 10 years 10 to12 years Over 13 years Total
0
Total
51 31 22 8 2
0 6 8 7 3 4 2 3 1 1 2 1 38
51 37 30 15 5 4 2 3 1 1 2 1 152
114
16
15
5
Small Bowel Intussusceptions
infans under 12 months
20
10
Large Bowel Intussusceptions
19
11
Series1 Series2
5
0 to < 4 months
4- to
