Leading Points in Childhood Intussusception By Sigmund H. Ein
ETIOLOGY of most intussusceptions is unknown. However, there are 1 a small number of intussusceptions which are initiated by lesions of the bowel, so-called leading points. The purpose of this paper is to present, analyze, and discuss a series of intussusceptions in children caused by leading points. CLINICAL MATERIAL There
were 569 cases
of intussusception
at the Hospital
for Sick Children,
Toronto,
over
a
16-yr period between 1959 and 1974 exclusive.’ From this group, we have extracted 31 cases of intussusception caused by leading points. The average age of these children was over 2 yr. The youngest patient was 3 days of age; the oldest 16 yr. There were 18 males and 13 females in the series. Excluding the one child who had Henoch-Schonlein purpura, there were three children whose intussusceptions were preceded by a viral illness. Twenty children (64%) had pain, 27 (87%) vomited, 16 (51%) had a palpable abdominal mass, and 17 (55”/) patients passed blood per rectum. It took an average of 38 hr before the diagnosis was made. Hydrostatic barium enema reduction was attempted in 15 patients; it was unsuccessful in ten and successful in five. The remaining 16 children did not have a barium enema because there was a marked degree of bowel obstruction in seven, two were thought to have acute appendicitis, and one child, was considered “too sick.” No reason was given in the remaining six patients for omitting the barium enema. All 31 patients with leading points were operated on and 40% of the intussusceptions involved only small bowel. There was only one patient whose bowel was perforated during the operation. Twelve intussusceptions could be manually reduced at operation. Eight leading points were excised locally; a bowel resection was required in the remaining 23. The commonest leading point was a Meckel’s diverticulum accounting for almost one-half of the lesions. Six of these Meckel’s diverticula contained ectopic gastric mucosa, although none had peptic ulceration with bleeding. Six of the eight polyps were found in the ileum, with one each in the cecum and colon. Two duplications were located in the ileum, two more in the cecum, and one in the jejunum (Table I). Postoperatively there were five wound infections, two small bowel fistulae, and two wound dehiscences. There were no deaths related to the intussusceptions.
DISCUSSION
In this series, 31 intussusceptions caused by pathologic leading points over a 16-yr period have been described. This is 5% of the total number of intussusceptions seen and 7% of all operative cases .2 The average age of the children in this paper was twice that of children whose intussusceptions were idiopathic; no explanation for this has been found. A preceding illness was not more prevalent in our 31 patients than in the entire series of patients. Moreover, no explanation can be made of the fact that a smaller number of patients in this group had
From the Division of General Surgery,
The Hospital for Sick Children. Toronto, Ontario, Canada.
Presented before the Canadian Association of Pediatric Surgeons Meeting, Winnipeg, Manitoba. Canada. January 1975. Address for reprint requests: Sigmund H. Ein. M.D., F.R.C.S. (C), Division of General Surgery, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1x8, Canada. 0 I976 by Grune & Stratton, Inc.
louma/ of Pediatric Surgery, Vol. 11, No. 2 (April), 1976
209
210
SIGMUND
H.
EIN
Table 1. Meckel's ..................................................
.
ileum
...............................................
6
Cecum
..............................................
1
Colon
..............................................
1
Dup~cction ~eum Cecum Jejunum H-SPurpura Sutureline Appendix Tumor
.
................................................
............................................... .............................................. ............................................
.................................................
(lymphosorcoma)
....................................
5
2 2 1
............................................... ................................................
14
8
Polyp .....................................................
1
.
1 1 1
pain, a palpable abdominal mass, and rectal bleeding than in the overall group. Diagnosis was delayed in this type of intussusception and these children were more severely ill. The use of hydrostatic barium enema in the diagnosis and treatment of intussusception caused by a leading point was disappointing as shown by the results with our patients. The barium enema did not reduce the intussusception, it showed no abnormalities, or it wasn’t attempted because there was a marked degree of obstruction. The fact that 12 children had intussusceptions involving only the small bowel explains the large number of small bowel obstructions. In our series, all patients required operation. It is therefore tempting to conclude that all intussusceptions caused by leading points cannot be reduced with hydrostatic barium enema.3 It has been reported that a child in whom an ileal resection was performed for intussusception led by a Meckel’s diverticulum had, 2 yr previously, an initial intussusception which had been reduced by hydrostatic barium enema.2 A similar case was observed in our series. It is quite possible that the first intussusception in each instance was idiopathic and the Meckel’s diverticulum was uninvolved, while the second or recurrent intussusception was caused by the Meckel’s diverticulum as the leading point. During the 16 yr spanned by our series, incidental Meckel’s diverticula were found in five children operated upon for intussusceptions. It is reasonable to conclude that an intussusception can occur with a potential leading point nearby and uninvolved in the intussusception. The high resection rate (74%) and complication rate (29%) in this series parallels a similar large series and is not surprising considering the large number of irreducible and gangrenous intussusceptions encountered.* Fortunately there was no mortality in our series. In the past, it has been assumed that in older children who have an intussusception, or children who have recurrent intussusceptions, laparotomy is mandatory to rule out the possibility of a leading point.4 This report does not support these assumptions. It does indicate that an intussusception caused by a leading point, is unlikely to be reduced by hydrostatic barium enema and will almost certainly require surgical exploration.
CHILDHOOD
INTUSSUSCEPTION
211
SUMMARY
Children whose intussusception is caused by a specific pathologic lesion are harder to diagnose and have a higher morbidity than those with the idiopathic variety. We have collected and analyzed 31 such cases found in a series of over 500 intussusceptions. The average age of these children was greater than is usually found in most cases, and the duration of the signs and symptoms was also longer than is usually seen. Almost 50% presented with a picture of advanced small bowel obstruction. Fewer barium enemas were done (SO”/,) and none was successful in reducing the intussusception. There was a higher number of ileo-ileal intussusceptions in this group. The commonest leading points were Meckel’s diverticula, polyps, and duplications. All patients with leading points required operation; three-fourths had a bowel resection performed. This study of 569 cases suggests that older children with intussusception and children with recurrent intussusception do not necessarily have leading points causing their intussusceptions. REFERENCES 1.
Ein SH,
Stephens
CA:
Intussusception:
354 cases in 10 years. J Pediatr Surg 6, 1971
3. Ravitch
MM:
and children.
Intussusception
Springfield,
Ill..
in infants
Thomas,
1959,
p 116 2. MacPherson
WA,
nant nature of pediatric dary to specific etiologic 667. 1963
Hays
DM:
The malig-
intussusception lesions.
Am
seconSurg 29:
4. Ravitch
MD: The non-operative
of intussusception-hydrostatic tion by barium 36:1495-1500,
enema. 1956
Surg
treatment
pressure reducClin
North
Am
ETIOLOGY of most intussusceptions is unknown. However, there are 1 a small number of intussusceptions which are initiated by lesions of the bowel, so-called leading points. The purpose of this paper is to present, analyze, and discuss a series of intussusceptions in children caused by leading points. CLINICAL MATERIAL There
were 569 cases
of intussusception
at the Hospital
for Sick Children,
Toronto,
over
a
16-yr period between 1959 and 1974 exclusive.’ From this group, we have extracted 31 cases of intussusception caused by leading points. The average age of these children was over 2 yr. The youngest patient was 3 days of age; the oldest 16 yr. There were 18 males and 13 females in the series. Excluding the one child who had Henoch-Schonlein purpura, there were three children whose intussusceptions were preceded by a viral illness. Twenty children (64%) had pain, 27 (87%) vomited, 16 (51%) had a palpable abdominal mass, and 17 (55”/) patients passed blood per rectum. It took an average of 38 hr before the diagnosis was made. Hydrostatic barium enema reduction was attempted in 15 patients; it was unsuccessful in ten and successful in five. The remaining 16 children did not have a barium enema because there was a marked degree of bowel obstruction in seven, two were thought to have acute appendicitis, and one child, was considered “too sick.” No reason was given in the remaining six patients for omitting the barium enema. All 31 patients with leading points were operated on and 40% of the intussusceptions involved only small bowel. There was only one patient whose bowel was perforated during the operation. Twelve intussusceptions could be manually reduced at operation. Eight leading points were excised locally; a bowel resection was required in the remaining 23. The commonest leading point was a Meckel’s diverticulum accounting for almost one-half of the lesions. Six of these Meckel’s diverticula contained ectopic gastric mucosa, although none had peptic ulceration with bleeding. Six of the eight polyps were found in the ileum, with one each in the cecum and colon. Two duplications were located in the ileum, two more in the cecum, and one in the jejunum (Table I). Postoperatively there were five wound infections, two small bowel fistulae, and two wound dehiscences. There were no deaths related to the intussusceptions.
DISCUSSION
In this series, 31 intussusceptions caused by pathologic leading points over a 16-yr period have been described. This is 5% of the total number of intussusceptions seen and 7% of all operative cases .2 The average age of the children in this paper was twice that of children whose intussusceptions were idiopathic; no explanation for this has been found. A preceding illness was not more prevalent in our 31 patients than in the entire series of patients. Moreover, no explanation can be made of the fact that a smaller number of patients in this group had
From the Division of General Surgery,
The Hospital for Sick Children. Toronto, Ontario, Canada.
Presented before the Canadian Association of Pediatric Surgeons Meeting, Winnipeg, Manitoba. Canada. January 1975. Address for reprint requests: Sigmund H. Ein. M.D., F.R.C.S. (C), Division of General Surgery, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1x8, Canada. 0 I976 by Grune & Stratton, Inc.
louma/ of Pediatric Surgery, Vol. 11, No. 2 (April), 1976
209
210
SIGMUND
H.
EIN
Table 1. Meckel's ..................................................
.
ileum
...............................................
6
Cecum
..............................................
1
Colon
..............................................
1
Dup~cction ~eum Cecum Jejunum H-SPurpura Sutureline Appendix Tumor
.
................................................
............................................... .............................................. ............................................
.................................................
(lymphosorcoma)
....................................
5
2 2 1
............................................... ................................................
14
8
Polyp .....................................................
1
.
1 1 1
pain, a palpable abdominal mass, and rectal bleeding than in the overall group. Diagnosis was delayed in this type of intussusception and these children were more severely ill. The use of hydrostatic barium enema in the diagnosis and treatment of intussusception caused by a leading point was disappointing as shown by the results with our patients. The barium enema did not reduce the intussusception, it showed no abnormalities, or it wasn’t attempted because there was a marked degree of obstruction. The fact that 12 children had intussusceptions involving only the small bowel explains the large number of small bowel obstructions. In our series, all patients required operation. It is therefore tempting to conclude that all intussusceptions caused by leading points cannot be reduced with hydrostatic barium enema.3 It has been reported that a child in whom an ileal resection was performed for intussusception led by a Meckel’s diverticulum had, 2 yr previously, an initial intussusception which had been reduced by hydrostatic barium enema.2 A similar case was observed in our series. It is quite possible that the first intussusception in each instance was idiopathic and the Meckel’s diverticulum was uninvolved, while the second or recurrent intussusception was caused by the Meckel’s diverticulum as the leading point. During the 16 yr spanned by our series, incidental Meckel’s diverticula were found in five children operated upon for intussusceptions. It is reasonable to conclude that an intussusception can occur with a potential leading point nearby and uninvolved in the intussusception. The high resection rate (74%) and complication rate (29%) in this series parallels a similar large series and is not surprising considering the large number of irreducible and gangrenous intussusceptions encountered.* Fortunately there was no mortality in our series. In the past, it has been assumed that in older children who have an intussusception, or children who have recurrent intussusceptions, laparotomy is mandatory to rule out the possibility of a leading point.4 This report does not support these assumptions. It does indicate that an intussusception caused by a leading point, is unlikely to be reduced by hydrostatic barium enema and will almost certainly require surgical exploration.
CHILDHOOD
INTUSSUSCEPTION
211
SUMMARY
Children whose intussusception is caused by a specific pathologic lesion are harder to diagnose and have a higher morbidity than those with the idiopathic variety. We have collected and analyzed 31 such cases found in a series of over 500 intussusceptions. The average age of these children was greater than is usually found in most cases, and the duration of the signs and symptoms was also longer than is usually seen. Almost 50% presented with a picture of advanced small bowel obstruction. Fewer barium enemas were done (SO”/,) and none was successful in reducing the intussusception. There was a higher number of ileo-ileal intussusceptions in this group. The commonest leading points were Meckel’s diverticula, polyps, and duplications. All patients with leading points required operation; three-fourths had a bowel resection performed. This study of 569 cases suggests that older children with intussusception and children with recurrent intussusception do not necessarily have leading points causing their intussusceptions. REFERENCES 1.
Ein SH,
Stephens
CA:
Intussusception:
354 cases in 10 years. J Pediatr Surg 6, 1971
3. Ravitch
MM:
and children.
Intussusception
Springfield,
Ill..
in infants
Thomas,
1959,
p 116 2. MacPherson
WA,
nant nature of pediatric dary to specific etiologic 667. 1963
Hays
DM:
The malig-
intussusception lesions.
Am
seconSurg 29:
4. Ravitch
MD: The non-operative
of intussusception-hydrostatic tion by barium 36:1495-1500,
enema. 1956
Surg
treatment
pressure reducClin
North
Am
