INTUSSUSCEPTION
IN CHILDHOOD
A City-wide
Study
M. Moreno Robins, M.D., and Henry P. Plenk, M.D.,
M.S.
Department of Radiology, St. Mark’s Hospital and University of Utah School of Medicine, Salt Lake City
592
I
NTUSSUSCEPTION is an invagination of asegment of the gastrointestinal tract
into an adjacent segment. It is a disease
primarily of infancy and childhood. Eighty
per cent of recorded cases occur in children under the age of 2 years and 69% under the
age of 1. It is the most frequent cause of
intestinal obstruction in childhood2 and
ranks second only to appendicitis as the
most common acute abdominal condition
after the first months of life.1 It has been
known to occur throughout the
gastrointes-final tract from the stomach to the anus. The disease entity was first described by Hippocrates. Pathologic specimens of the
involved bowel were demonstrated as early
as 1789 by John Hunter and in 1873
Jona-thon Hutchinson reported a successful
op-eration on an infant with intussusception.
Reduction of tile intussusception by barium
enema in 107 cases was described as early
as 1905. By 1927 barium enema under
fluoroscopic guidance was used widely as a therapeutic method.’
The signs and symptoms of the disease
in childhood are so classic that a careful
history should suggest the correct diagnosis
in most cases. In a typical case a well baby
suddenly develops acute, recurrent colicky
abdominal pain, frequently associated with
passage of bloody stools or the presence of
blood on rectal examination. An abdominal
mass may or may not be palpable.
Despite the importance of the clinical
syndrome and the classic symptomatology,
a review of the literature still reveals
con-siderable disagreement regarding the ideal
method of treatment. It is also apparent that lack of early diagnosis still results in
need-less morbidity and mortality. The lack of
(Accepted September 17, 1959; submitted June 6.)
ADDRESS: (Fl.P.P.) Department of Radiology, St.
agreement as to management centers around
the use of barium enema for reduction
versus primary surgical treatment. Orloff’s
statement in a recent comprehensive review
of the subject1 characterizes the prevalent problem regarding treatment: “In the past we have not advocated attempts at reduc-tion of acute intussusception in children by
barium enema under roentgenologic
con-trol. However, we cannot continue to ignore the excellent results of the hydrostatic
pres-sure method reported by workers in
Aus-tralia, in the Scandinavian countries, and
more recently, in the United States.” Nor-dentoft and Hansen5 report that barium
enema is used in 96.7% of suspected cases
in Denmark with over half of the
intussus-ceptions being successfully reduced by this means. In this country the prime advocate
of the use of hydrostatic pressure has been Ravitch3’ 6-9 who reports 74% of his cases reduced by barium enema. Other
au-10, 11 have more recently reported
good results with the therapeutic use of
barium enema. However, the majority of
authors in this country12’#{176} continue to
ad-vocate the surgical approach. They report
reduction by barium enema as an incidental finding only and do not propose its use as primary treatment.
The importance of early recognition of
symptoms and of an awareness by the medi-cal profession of this syndrome is brought
out by the fact that cases treated within 24 hours after onset of symptoms have a
rela-tively low mortality rate while after 72
hours the mortality rate is high. Various
authors report from 2 to 11% mortality if the
syndrome is treated within 24 hours of
on-set of symptoms while the mortality rises to
Mark’s Hospital, Salt Lake City 16, Utah.
TABLE I
SIGNS AND SYMvroIs IN 6 PATIENTS
WITH INTUMMUSCEI’TION
Age of patient (mo) Less than 6
6-1 1-4 Over 24 9 35 4 15 7 6 23 CASE REPORTS
38 to 75% if symptoms persist longer than 72
hours.1 Packard and Allen10 report only 1 (leath in 67 cases treated within 24 hours
of onset. However, American authors have
reported very few series of cases in which
the average duration of symptoms has been
less than 30 hours and most reports contain
many cases receiving treatment after 2 to 3
days. The decreased mortality rate of recent
years must 1)e attributed to advances in
un(lerstanding of childhood physiology,
improved surgical technique, and better
anesthesia rather than to early recognition
of the disease. Of significance is the
state-ment by Nordentoft and Hansen5 that 80% of cases in Denmark are now admitted
within 24 hours of onset of symptoms. The
extensive literature on the subject in that
country has resulted in increased early
recognition of the syndrome by physicians.
In the present study the records from all
four general hospitals in Salt Lake City over the period 1950 to March 1959 were
reviewed. Twenty-six cases (Table I) in
children under 10 years of age were found among approximately 330,000 hospital
ad-missions.
RESULTS
In general the present findings agree with
those of other authors. The ratio of males to
females is almost exactly the classic 2 to 1 reported in the literature and the other
Iliajor manifestations (Table I) were
re-ported in the 26 patients in proportions
similar to those reported by other authors.
It is significant that 62% of cases in this
series were treated within 24 hours after
onset of smptorns. However, four patients
(
15%) had symptoms for more than 72 hoursPrior to hospital admission. N’Ioore’5 reports
that the course of the disease is more
pro-longed and less dramatic in patients over
the age of 2 years. It was not possible to
observe aiiy decisive (Ii iference according
to age iii the I)resent series.
A review of tile treatment received is
given in Table
II.
Tile effectiveness ofbarium enema in reducing intussusception
in relation to tile duration of symptoms is
demonstrated in Table III.
.\o. (‘ases Per (‘eat
Male Female 17 9 65 35 Total 6
l)uration of symptoms (hr) O-’4
24-48
48-7
7’2 an(l over
16 5 1 4 6Z 19 4 15 Symptoms Vomiting Abdominal pain Bloody stools Abdominal distention () 1 15 5 77 SI 58 19 Signs Abdominal mass Abdominal tenderness 11 14 4 54 Case 1
A 14-month-old female infant entered with
the complaint of abdominal pain of 12 hours
duration, without a history of vomiting or
bloody stools. Barium enema disclosed an
in-tussusception to the midportion of the trans-verse colon which was apparentli’ reduced.
Twenty-four hours after discharge she entered
again with a 5-hour history of recurrent
ab-dominal pain. Barium enema again revealed
intussusception localized to the cecum. She
was operated on immediately amid a 2-cm
ileo-colic intussusception was reduced.
Case 2
A 6-month-old male infant entered with a
24-hour history of vomiting. No blood stools
‘s’ere noted. Physical examination revealed a
temperature of 38#{176}Cand al)domninal
disten-tion. An intussusception was demonstrated by
barium enema but could i)e reduced only
par-tially. The patient went to surgery without
de-lay. An ileoiieocecal intussusception with
1\O. Patients
Completely
Barium Reduced
Enemas (jo. Patients)
Total
17 9 56*
2 1 50
1 0
4 1 25
24 11 48
43t
I I
17%
TABLE 11
TREATMENT OF 2(1 PATIENTS VITII INTUSSITM(EI’FION
Bariumi, emien a:
Total number of patients 23
‘I’otal number of barium enemimas 24
Reduced, flO surgery 8
Reduced, recurred after 24 hours, surgery I (Case 1)
Followed by surgery 15
P05111(1 reduce(l 2
Found not re(luced 13
lotal re(luce(l by l)ariunm (neImmiI I I (487j)
Surgery:
‘I’otal cases receiving surgery IS
Surgery alone 3
After hariumim emenma 15
Ite(lu(ed l nanipulat ion 16
Resection 2
Average hospital stay (days):
After barium enema alone Meami I .3
Median I.0
Bariumn enemna PIUS surgery iiIean 8 .6
Median 5.0
Surgery alone Mean 5.0
Me(liaII 6.0
Complications (See ease reports):
After barium enema alone I
Barium enema plus surgery I
Surgery alone 1
Mortality 0
During the operative procedure the patient
de-veloped spasticit secondary to cerebral edema
amid anoxia although the patient was not
cya-notic. Postoperatively the child developed
VOUIld dehiscence twice. Twenty-four hours
after the initial operation he developed bowel
obstruction secondary to adhesions. Resection of the involved bowel was performed at this time. Forty-four days after admission the child
was discharged apparently well, although
some residual spasticit was apparent.
Case 3
A 2-year-old boy entered with a 6-day
his-tory of abdominal pain, bloody stools and
tem-peratlire of 37.8#{176}C. An abdominal mass was
palpable. Barium enema was performed
with-out attempt to reduce the demonstrated
intus-simsception. An ileocecal intussusception was
reduced surgically. Postoperatively he
devel-oped an abscess of the incision which healed
vithout further incident.
DISCUSSION
Although the present series is too small to
justify comparison with other larger groups
previously reported, the data show that, in 43% of patients who received barium enemas for possible intussusception in Salt Lake
City during the past 9 years, the
intussus-ception was completely reduced, rendering
further surgery unnecessary. Two of these
patients were actually operated on and
re-duction was confirmed.
In
one
additional
patient the lesion was reduced but recurred
after 24 hours. In 41% of patients partial
re-duction facilitated further surgical
meas-ures. In the remaining 17% of cases barium enema helped to establish or confirm the diagnosis.
TABLE III
RESULTS (IF BARIUM ENEMA IN RELATION TO 1)URATION OF SYMPTOMS
I)uratioa of
Symptoms (hr)
Partially Not Reduced Per Cent
Reduced
Reduction (.o. Patients) (No. Patients)
I.ess than 24 24 to 48
48 to 72 More than 72
16
2 I 4
23
* Includes one recurrence. ** Re-examination of Case 1. t Corrected for one recurrence.
6 (7)** 0
1 0
1 2
ARTICLES
595Patients Wil() had barium enema only
staved in tile hospital an average of 1.3
days as compared to 5 to 6 days for those
Patients who underwent surgery, either
with or without Prior i)ariuni enema. There
was no evidence to indicate that barium
enema prior to surgery lengthened iloSpital
stay or ilicreased tile incidence of surgical
complications.
Reduction I)V barium enemas was most
effective \v ithin the first 24 hours after onset
of symptoms wilell 56% of intussusceptions
could be reduced hut 2 of 7 lesions could
still be reduced after a duration of
svrnp-toms of over 24 hours.
Some advocates of hydrostatic, closed
treatment of intussusception” ‘ ‘ ‘ in
in-fants dfl(l children have listed as the
ad-vantages of this method of therapy: 1) Less
trauma to
tue
patient; 2) milderconvales-cence; 3) shortened hospital stay; 4)
de-creased incidence of postoperative
compli-cations; 5) avoidance of dangers of
anesthesia; and 6) greater economy to the
I)1tiemit. It ilas been maintained that a high percentage of lesions will he reduced by
this method.
Those who condemn the use of barium
enemas in intussusception argue that a
p05-5i1)le causatie lesion such as Meckel’s
diverticuluni or intestinal polyp may he
overlooked. However, 94% of children with
intussusception show no demonstrable cause
for tile condition1 and proponents of the
nonsurgical I)r0ce(1ure’ have stated that
such lesions are dangerous only in that they
tend to produce intussusception. NVith this
in mind, barium enema should not be used
as a therapeutic measure in cases of
re-current intussusception. In these cases
stir-gical intervention is indicated. The danger
of perforation of the bowel or reduction of
nonviable bowel has been mentioned.
Although experiments on dogs’ have
shown that the pressures ordinarily used
will not perforate bowel nor reduce
gan-grenous bowel, such a danger must still be
contemplated. Nordentoft and Hansen5
re-ported 4 such instances of perforation in a
series of 2,037 cases.
Because there is a potential danger of
perforation, barium enema should not be
performed if clinical evidence of peritonitis
or gangrene of involved bowel is present. Contraindications to barium enema
there-fore are: 1) Marked abdominal distention;
2) diffuse abdominal tenderness with
mus-cular guarding and rebound tenderness; and 3) roentgenographic evidence of free air
0I fluid in the abdomen.
It is apparent from the literature and from the present study that abdominal
dis-tention and tenderness are sometimes found in uncomplicated intussusception ; however,
these are less severe than are found in true
peritonitis. Previous st1m(1ies#{176}illve shown
that the degree of fever and the amount of
leukocytosis are of no diagnostic or
prog-nostic value in the evaluation of possible complications.
Barium enema should not result in delay
in operation if the operating room is pre-pared at the time the child is admitted;
necessary fluids, nasogastric tube, and other
preparations as indicated, are given while
the roentgenographic procedure is being
performed; the surgeon is in attendance;
and the patient is taken to the operating
room immediately if hydrostatic reduction
of the lesion is not complete.
The argument that proof of re(Iuction is inaccurate and uncertain can be largely
dis-pelled if the following criteria of reduction
are observed explicitly: 1) Complete filling
of the cecum; 2) a large inflow of barium into the small bowel; 3) a return of barium with flecks of feces and flatus upon
evacua-tion of the enema; 4) disappearance of the palpable abdominal mass; 5) clinical
im-provement of the child; and 6) recovery in
the stool of charcoal given by stomach tube.
The possibility of recurrence has to he kept in mind whether surgical or
hydro-static reduction is employed. Ileoileocolic
intussusceptions cannot usually be reduced
by hydrostatic methods with barium as
demonstrated by Case 2. For this reason it
is believed that all patients should be
ad-mitted to the hospital and observed after
Surgical intervention is indicated if
symp-toms or abdominal tumor persist or even if
any doubt exists regarding completeness of
the reduction.
A few points regarding technique of
barium enema should be emphasized. The
child should first of all be prepared for this
procedure just as he is prepared for an
operation. An unlubricated balloon catheter
is then inserted in the rectum and the
but-tocks taped so as to close the anal orifice.
The barium mixture should be placed at a
height not to exceed 3 feet above the
table. Manual manipulation should be
avoided to reduce the danger of possible
perforation. The intussusception is identified
by the classic semilunar concave obstruction
to the flow of barium. As the intussuscepted portion of bowel is reduced by the pressure
of the barium flow, progress of the
reduc-tion is followed by means of fluoroscopy. If
the receding intussusceptum stops and
re-mains stationary the catheter is then
re-moved and the barium allowed to be
evacu-ated. The catheter can then be re-inserted
and reduction attempted again. If
reduc-tion is not complete (according to the
criteria previously listed) after three
at-tempts surgery is indicated.
SUMMARY
A city-wide study of intussusception in
childhood is reported. The classic signs and
symptoms (vomiting, abdominal pain,
bloody stools, palpable abdominal mass) are
reported in percentages approximating those
previously reported by other authors.
Intus-susception in childhood occurred about
once in every 13,000 admissions to general
hospitals. Of 26 cases, 3 had surgery
with-out barium enema. In 11 of 23 patients who
had roentgenographic examination the
in-tussusception was reduced by enemas (48%).
In one patient the lesion recurred after 24
Ilours.
No deaths were encountered in this small
series.
Provided certain precautions are
fol-lowed, barium enema is a safe procedure
which will save about one-half of the
pa-tients a surgical procedure and unnecessary
prolonged hospitalization.
Acknowledgment
The authors wish to acknowledge the help
given in the search for statistics by Drs.
Mc-Laren Ruesch, Gordon Stagg, Ralph Meyer, Phil Fredericks, and William Christensen as
well as by the Medical Record Librarians of
Holy Cross Hospital, Latter Day Saints
Hos-pital, Salt Lake General Hospital, and St. Mark’s Hospital.
REFERENCES
1. Orloff, M.
J.
: Intussusception in childrenand adults: collective review. Internat.
Abst. Surg., 102:313, 1956.
2. McLaughlin, C. W., Jr. : Acute
intussuscep-tion in infancy and childhood. Am.
J.
Surg., 76:306, 1948.
3. Cited in Ravitch, M. M. : The
non-opera-tive treatment of intussusception; hydro-static pressure reduction by barium enema. Surg. Clin. North America, 36:
1495, 1956.
4. Langlet,
J.
F., and Chance, D. P. :Manage-ment of intussusception in infants and children. Arch. Surg., 75:35, 1957.
5. Nordentoft,
J.
M., and Hansen, H. :Treat-ment of intussusception in children; brief
survey based on 1,838 Danish cases.
Surgery, 38:311, 1955.
6. Ravitch, M. M., and Morgan, R. H.: Reduction of intussusception by barium enema. Ann. Surg., 135:596, 1952.
7. Ravitch, M. M. : Reduction of
intussuscep-tion by barium enema. Surg. Gynec. &
Obst., 99:431, 1954.
8. Idem: Consideration of errors in the
diag-nosis of intussusception. Am.
J.
Dis. Child., 84:17, 1952.9. Ravitch, M. M., and McCune, R. M., Jr.: Reduction of intussusception by hydro. static pressure; an experimental study. Bull. Johns Hopkins Hosp., 82:550,
1948.
10. Packard, C. B., and Allen, R. P.: Results
in the treatment of intussusception in
in-fants and children. Surgery, 41:567,
1957.
1 1. Santulli, T. V., and Ferrer,
J.
M., Jr.:Intusssusception, appraisal of present
treatment. Ann. Surg., 143:8, 1956.
ARTICLES
5971.3. Cross, R. E. : The Surgery of Infancy
amid Childhood. Philadelphia, Saunders,
1953.
14. Kahle, H. R. : Intussusception in children
under 2 ears of age: an analysis of 54
cases froni Charity Hospital of
Louisi-aria at New Orleans. Surgery, 29:182,
1951.
15. Moore, T. C.: Management of
intussuscep-tion in infants amid children. Ann. Surg.,
135:184, 1952.
16. Snyder, W. H., Jr., Kraus, A. R., and
Chaffin, L.: Intussusception in infants
amid children: a report of 143
consecu-tive cases. Ann. Surg., 130:200, 1949.
17. Thatcher, D. S. : Intussusception in infants
and children. Ann. Surg., 140: 180, 1954.
18. Thurston, D. L., Holowach,
J.,
andMc-Coy, E. E. : Acute intussusception:
anal-ysis of 116 cases at St. Louis Children’s
Hospital. Arch. Surg., 67:68, 1953.
19. Oberhelman, H. A., and Condon,
J.
B.:Acute intussusception in infants and children: an analysis of 95 cases in the
Cook Counts’ Children’s Hospital. Surg. Clin. North America, 27:3, 1947.
20. Ling,
J.:
Intussusception in infants andchildren: with emphasis on the recogni-tion of cases with complications. Radi-ologv, 62:505, 1954.
ANESTHESIA FOR INFANTS AND CHILDREN,
Robert NI. Smith, M.D., St. Louis, The
C.
V.
Mosby
Company,
1959,
418
pp.,
$12.00.
This text is a welcome addition to the small
number of books devoted exclusively to
pedi-atric anesthesia. There have been many
ad-vances made in this field since Pediatric
Anes-thesia l)y Leigh and Belton (1948) and
Stephen’s monograph, Elements of Pediatric
Anesthesia (1956), vere published. Smith has
collected much of this new information from
videly (listributeci articles, organized it, and
added from his own experience of many years
at the Children’s Medical Center, in Boston.
The book covers many aspects of pediatric
anesthesia : basic science, patient preparation,
general amid special techniques, complications,
mortality, etc. It is assumed that the reader is
already familiar with the general principles of
anesthesia, and emphasis is placed upon
con-siderations especiall important for infants and
children. There are chapters on anatomic,
physiologic and pathologic factors of
signifi-cance in anesthesia. Charles Cook has
con-tributed a chapter on the respiratory physiology
of infants amid children. Most of this
informa-tion is simple and practical.
The psychic management of the child is
treated very well, and discussed in many parts
of the text, especially in the chapter on the
preparation of the child for operation. It is
pointed out that the recommended doses of medication will sedate children satisfactorily in
only 75% of the cases. The disadvantages of
heavier medication are discussed. An important
criticism of the medication tables is that the
routes of administration are placed in the
footnotes, rather than in the heading of each
column. It is anticipated that the footnotes on
occasion max’ be neglected, and if so, patients
may be heavily overdosed.
There is a chapter on commonly used equip-ment for pediatric anesthesia. This is based upon actual clinical experience, and should be
useful to the anesthesiologist who is not
fa-miliar with some of the newest equipment.
The discussions on management of general
and special problems of pediatric anesthesia
and on choice of anesthetic agents amld
tech-niques are a detailed account of what works well in the author’s hands. These are especially valuable for the anesthesiologist who only
oc-casionally works with children.
The book ends with an excellent chapter on
the mortality associated with pediatric
sur-gery and anesthesia. This should be of value
to pediatricians amid surgeons as well as
anes-thesiologists.
On the whole the book is highly
recom-mended. The bibliography is excellent and
quite complete up to 1958.
