The Role of Ultra Sound in Diagnosis of Intussusceptions in Children in Baghdad 2012_2013

Hassan Kareem Gata1,Amer Abdulla Ejrish
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Keywords : Intussusception,Ultrasound, Children
Medical Journal of Babylon  13:1 , 2016 doi:1812-156X-13-1
Published :15 April 2016

Abstract

Intussusceptions’ is the acquired invagination of one portion of the intestine into the adjacent bowel. It is described by the proximal, inner segment of intestine (intussusceptum) first and the outer distal, receiving portion of intestine (intussuscipience). This study of 50 cases of intussusceptions in the children welfare teaching hospital at medical city in BaghdadSeptember2012-September2013.All patient underwent history, physical examination and investigation(radiological include plain abdominal x-ray and ultrasonagraphy.the patient divided into two age groups(infant younger than 10 months age, infant older than 10 months age).Thirty eight patients(79.17%) were equal or below 10 months and ten patients(20.83%) were above 10 months. Female to male ratio was1.2:1.The diagnostic tool used was the ultrasound for fifty patients, in forty three cases diagnosis was made by characteristic ultrasonic findings of intussusceptions(target sign or pseudo kidney sign),all of them had a classical intussusceptions mass during operative procedure. The remaining 7 patients had negative ultrasonic findings for intussusceptions,2 of them were truly negative ultrasonic findings on laparotomy,while the other 5patients had an intussusceptions mass during laparotomy .the ultra sound sensitivity was 90%. For that reason the ultrasound still the good diagnostic tool for diagnosis of intussusceptions.

Introduction

Intussusception is the acquired invagination of one portion of the intestine into the adjacent bowel. It is described by the proximal, inner segment of intestine (intussusceptum) first and the outer distal, receiving portion of intestine (intussuscipiens) last[1,2]. This disease had been recognized since the last three centuries, It was firstly described by Poul Babette of Amsterdam in 1674 and suggested operative reduction [1,2]. In the 19th century, reductions from below by means of enema, injection of air or gas or manipulation were all attempted. By the mid-19th century, the disease remained fatal in most infants and children but occasionally responded to inflation of the intestine with bellows or to enemas[3]. Jonathan Hutchinson reported the 1st successful operation for intussusception in a 2 years old child in 1873Ravitc[3] and McCune popularized hydrostatic reduction of intussusception with barium enema in 1948. The 1st successful resection of an intussusception in a child was by Clubbe in Australia in 1897 and the 1st successful resection in US was reported by Peterson in 1908[1]. It is usual to speak about two types of intussusception: 1. A primary type in which no lead point is identified. 2. A secondary type in which a lead point is identified [1].The most common pathologic lead point is a Meckel’s diverticulum followed by polyps and duplications. Other benign lead points are the appendix, hemangiomas, foreign bodies, ectopic pancreas or gastric mucosa. Lipomas[5], Leiomyoma [6],Adenoma[6], Juvenile polyposis syndrome, diffuse juvenile polyposis of infancy[7], juvenile polyposis col[8], hamartoma (Peutz-Jegher syndrome) and lymphoid polyps[9]. Malignant causes, which are very rare, include lymphomas[2,5],lymphosarcomas[10,11], small bowel tumors, and melanomas. carcinoid tumors[5]. some studies suggest that the incidence of a lead point increase with age[12]. It can be diagnosed by Plain abdominal film,Barium enema, Abdominal ultrasonography,Computed tomography (CT) and MR.I[13]. Between 55% and 95% of intussusception are reducible by hydrostatic or pneumatic methods (Non-operative management) under fluoroscopic control.Laparatomy is required in children with signs of shock or peritonitis and in those who have incomplete reduction by either technique[14-17]. The Aim of studywas to determine the accuracy and reliability of ultrasound in diagnosis of intussusception by a comparison between diagnosingIntussus-ception by ultrasound with and operative findings.

Materials and methods

A prospective study of 50 cases with suspected intussusception was done in the  Children Welfare Teaching Hospital in Baghdad-medical city complex from September 2012 to September 2013.We collected  a 50cases that present to our hospital with clinical features ofintussusception  in which a clinical trial of cramping abdominal pain, vomiting, and bleeding per rectum were the presenting symptoms. History was taken carefully about an attack of upper chest infection or gastroenteritis preceding this triad. Every patient was examined regarding general condition,hydration status. Also abdominal examination was doneto all patients regarding inspection if there is any distention or asymmetry, if there IS any palpable mass, rectal examination for a palpable mass or bleeding. All patients were fully investigated like general stool examination to exclude a bacterial or amebic  cause of bloody stool& urine exam, blood counts,blood urea, serum electrolytes, chest radiograph, abdominal radiograph and abdominal ultrasono-graphy.
Ultrasound study had been performed for all the included cases in this study  by different  doctors who were in charge in outpatient clinic or emergency room  with different machines.
Collected cases in which the diagnosis of intussusception was done either by Ultrasound or by clinical examination supported by Ultrasound study. We divided the patients into two age groups:
1-    Infants younger than 10 months age.
2-    Infants older than 10 months age.
This study also includes the gender, presenting symptoms, seasonal distribution, type of presentation and results of surgical procedures.
By using SPSS software for windows, data of the 50 cases  were entered and analyzed with appropriate statistical tests. Descriptive statistics were presented as frequencies (number of cases) and percent.Chisquare test was used to assess the significance of differences, Sensitivity, specificity, accuracy; positive predictive value (PPV) and negative predictive value (NPV) were calculated according to the standard equations by using the Epi. Calc 2000 statistical package software. Level of significance of ? 0.05 was considered as significant. The presence of pseudo-kidney sign ,target sign are important finding for Ultrasound diagnosis of intussusceptionsas in figures 2,3




Results

1. Age and gender distribution: A total of 50 cases suspected intussusception were enrolled in this study, 48 of them were truly discovered intussusception intra -operatively. They were 26 females (54%) and 22 males (46%), with a female to male ratio of 1.2:1, figure 4. Thirty eight patients (79.17%) aged ? 10 months and the remaining 10 patients (20.83%) aged > 10 months. From other point of view, among females, those who were aged ? 10 months were 20 represented (76.9%), compared to 81.9% of males, this findings indicates that the intussusception was more prevalent among males under the age of 10 months, however, the difference was statistically not significant in between both sexes, P>0.05.table 1. Seasonal Distribution As it shown in table 2 and figure 5, it had been significantly found that the higher incidence was during Spring; 25 cases ( 52%)followed by Summer; 13 cases (27%), and the lowest incidence was during winter; 4 cases (8.5%), this indicating that the peak incidence of intussusception had been found in Spring and Summer and the lower incidence during Autumn and Winter, P=0.011.

Discussions

The current study was conducted during a period of one year. In this study enrolled 50 cases, 48 patients were truly discovered intussusception during surgery. In this study seventy nine percent of the cases aged ? 10 months, and about 21% aged > 10 months. The total gender distribution was nearly equal in the present study in which 26 female patients (54%) is nearly equal to 22 male patients (46 %) with a female to male ratio of 1.2:1. However, the difference was statistically not significant in between both genders, P>0.05. [ Table 1]. This is coincide with west African study in 1994 by Magnete and Allison [18], however, American study in 2010 by Paul M. Columbani and Stefan Scholz[1], does not agree with that when they stated preponderance of male over female in a ratio 3:2 . In the current study cases were collected in one year and we got females who were aged ? 10 months represent 76.9% compared to 81.9% males. Regarding seasonal variation, we found that a significant incidence of intussusception was during Spring and Summer 52% and 27% respectively. These results coincide with other studies in united states and Africa by Arnold Coran Scott Azickayne Eli [19], and SigmundEin[20]. This seasonal variation might be attributed to that; in spring and summer babies are more vulnerable for upper respiratory tract infection or gastroenteritis due to viral infection like Rota virus or Adenoviruses[4]. Classically, a previously healthy infant presents with colicky abdominal pain and vomiting. Between episodes the child initially appears well, Later on, the patient may pass a bloody stool. Rectal exam may reveal red currant jelly stool or rarely the apex of intussusceptum may be felt[1]. Classical picture of abdominal pain, vomiting and bleeding per rectum (red currant jelly stool) of intussusception in this study was as follows pain 100%,bleeding 90% and vomiting 78%. These results were similar to the findings of Momoh[21]in Nigeria 1987 and Akram Jawad[22] in Saudi Arabia 1997 [Table 3]. All of our patients were fully investigated like general stool examination and it was negative for bacterial or amebic cause of bloody stool. All the 50 patients were subjected to abdominal ultrasound examination. Laparotomy was done for all of them with positive and negative findings on abdominal ultrasound, because both groups had the classical clinical picture of intussusception. Among 50 patients who were undergone laparotomy, 43 cases have positive findings (true positive). So ultrasound was highly sensitive (about 90% sensitivity).Two patients had clinical picture of intussusception but negative ultrasound finding and negative laparotomy for intussusception, in one of them we found an appendicular mass and the other one was a case of malrotation with volvulus, so ultrasound was correctly identified them as negative, giving specificity of 100%.Unfortunately the rest 5 cases had been diagnosed as a negative ultrasonic findings but an intussusception mass were discovered during laparotomy.The PPV results was 100%, while the NPV results was about 29 % and accuracy of ultrasound in was 90%. [Table 4]. In the current study we see that ultrasound has high sensitivity 90% which is slightly lower than that of results done by Lewis Spitz & Arnold Coran [1], with a sensitivity of 98%-100%in United States of America[14]. This may be related to the well trained personnel and good ultrasound equipment in western countries, while in our study we depended on different ultrasono-graphists and different machines. According to the final diagnosis by laparotomy, among the 48 cases with primary intussusception, the most frequent type of intussusception was Ileo-colic, it was present in (70.83%), followed by Ileo-ileal in (18.75%) then Colo-colic type in (6.25%) and the least frequent type was the Ileo-Ileo-colic in only (4.16%) [Table 5]. The most common specific lead point causing intussusception was meckel`s diverticulum found in 3cases (6%) distributed as 1 case 6 months old and the other 2 cases in more than 2 years. The other common lead points were polyps in age group of more than 2 years, they were found in 2 cases (4%), one of them was having multiple polyps along the large bowel and presented as acute abdomen with delayed presentation and the patient died immediately after operation. The other sporadic cases were due to volvulus 2 cases (4%) and duplication of the bowel 1 case (2%). [Table 6]. Ultrasound didn’t diagnose any lead points per se but only as a target or pseudo-kidney signs. These results were similar to studies done by:Al-Khalidi[23] in Iraq-Mosul city 2001 and British study by Ein [24]and Park, et al[25], in 2007 In this study, we focused on the role of ultrasound in diagnosing intussusception regardless the causes of intussusception whether primary or secondary or the association with lead points or not.

Conclusions

There was no significant difference in incidence between male and female patients in our study.There is seasonal predominance during summer and spring. Ultrasound is a good diagnostic tool for detection of an intussusception mass with a sensitivity of 90%. Different ultrasound machines and different ultrasonographists may influence the accuracy of results, so if well trained personnel with good ultrasound machine, a diagnosis of intussusception may not be missed.

References

1. Paul M. Columbani and Stefan Scholz , Intussusceptions, Arnold G. Coran, N.ScottAzick,Saunders Elsevier, 7th edition 2012 vol.1 chapter 85 p.1093-1110
2. John G. Raffensperger MD, Idiopathic intussusception, Swenson s pediatric surgery, vol.2, p.1182-1185.
3. Mark M.Ravich, Kenneth J. Welch, Clifford D. Benson G. Randolf, Intussusception, Pediatric surgery, 4th edition, vol. 3 ,2004 , p533-542.
4. Romeo C. Ignacio, Jr., and Mary E.Fallat,MD. Intussusception Keith Ashcraft, J. Patrick Murphy,Saunderselsevier: chapter 39, 5th edition, 2010, p. 508 -516.
5. Joanna Hicks FRCS, Intussus-ception, Baily and love s short practice of surgery, Hodder Arnold, 25th edition,2008,p. 79-81.
6. James Shapiro, Intussusception, Seymour.I. Schwartz Principles of Surgery, Mosby, 7th edition,1999, p.1239- 124.
7. Sachatello CR: gastro intestinal polypoid disease, J. Ky. Med. association, 70:540, 1972.
8. MA ManfrediandJass JR, Williams CB, Bussey HJ, Morson BC,juvenile polyposis syndrome, Pub Med., 2009, 48(4): 405–411.
9. Atwell. J.D., Burge D. ,Wright D.,Nodular lymphoid hyperplasia of the intestinal tract in infancy and childhood, Journal of pediatric surgery. 1985, 20(1):25-29.
10. Wayne E. R, et al., Intussus-ception in the older child-suspect lymphosarcoma, J. pediatric surgery,1976 11(5): 789-794.
11. Dunnick N.R., Reaman G.H., Head G.L., et al: Radiographic manifestation of Burkitt s lymphoma in american patients, AJR, 2009,volo 192,5, 1304-1315.
12. Behrman RE; Intussusception in pediatrics: Nelson textbook of pediatrics . Philadelphia, EB Saunders,16th ed., 2000, sec. 11:57
13. Goldstein A, White R, Akuse R, et al: long term follow up of childhood Henoch -Schonlien nephritis Lancet 339:280,1992.
14. MelaniHiorns, Joe Curry, Intussusception; Operative pediatric surgery by Lewis Spitz & Arnold G. Coran ; Hodder Arnold 6th edition 2006 ,chap.47, p.446.
15. Lazar J. Green field, Michael W. Mulholland, Keith T. Oldham, et al : intussusception in scientific principles and practice, 2nd. Edition, 1997, p. 2007.
16. Ong N., Beasleg SW: the lead point in intussusception. J. Pediat. Surg. 25:640-643, 1990.
17. Rose de Bruyn, Abdominal ultrasound July 1, 2010 paediatric ultrasound, How, Why & When, 2nd edition 2010.
18. Magnete - ED, & Allison - AB. Intussusception in infancy & childhood: an analysis of 69 cases. West Afr. J.med., vol. 13, no. 2,1994, p.87(abstract).
19. Eli R. Wayne, John B. Campbell, Ann M. Kosloske& John D. Burrington, intussusception in older children suspect lymphosarcoma, Journal of pediatric surgery, vol. 11, no. 5,1976.
20. Sigmund H. Ein, leading points in childhood, Journal of pediatric surgery,1997, vol. 11, no.2.
21. J.T.Momoh, intussusception in infants & older children: a comparison, pediatric unit, Ahmadu Bello unv. Hospital, Zaria, Nigeria, Annals of tropical pediatrics, 1987,7, 118-121, printed in Great Britain.
22. Akram J. Jawad, Sabah Y. Shibli;Prem S. Sahni; and TajuddinMalabarey. Chronic intussusception. Annals of Saudi Medicine, vol. 17, no. 5, 1997, p.545.
23. Alkhalidi . J.N., Mosul college of medicine, childhood intussusceptions, a study of 32 cases (thesis), p. 15,2001 .
24. Ein SH, Stephens CA. Leading points in childhood intussusception. PubMed; 1991; 26(3):271-4
25. Park NH, Park SI, Park CS, Lee EJ, Kim MS, Ryu JA, Bae JM Ultrasound findings of ileocolic intussusception in comparison to clinical and surgical findings, British J Radiol.2007,80(958):798-802.


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