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ORIGINAL ARTICLE Table of Contents   
Year : 2016  |  Volume : 13  |  Issue : 4  |  Page : 166-169
Childhood intussusception: Impact of delay in presentation in a developing country


Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria

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Date of Web Publication24-Nov-2016
 

   Abstract 


Background: The classical cases of intussusception are readily diagnosed clinically, and despite recent improvements in radiological techniques, the diagnosis of intussusception and success in its nonoperative reduction has been suboptimal, thus making operative management a veritable backup. This study examined the impact of delays in presentation on the rate of bowel resection, length of hospital stay, and appraised the outcome of operative treatment. Patients and Methods: This was a retrospective study of consecutive children admitted and treated surgically for intussusception between January 2002 and December 2011 at the University College Hospital, Ibadan, Nigeria. Results: The mean age at presentation was 13.4 months with a male: female ratio of 1.8:1. Fourteen patients (25.5%) presented within the first 24 h of onset of symptoms with majority (36.4%) presenting between 2 and 3 days of onset of symptoms. The primary surgical intervention was performed on 47 patients (85.5%), and the secondary operative intervention was performed on eight patients (14.5%) who had failed initial nonoperative management of intussusception. Manual reduction of intussusception was performed on 27 patients (49.1%), 26 patients had resection of gangrenous bowel with end-to-end anastomosis while two patients (3.6%) had spontaneous reduction of intussusception which was discovered at laparotomy. The mean duration of hospital stay was 12.1 days (range 3–60 days). The overall mortality was 5.5% (three patients), and three patients (5.5%) had recurrence of intussusception. Conclusion: Although mortality is reducing, a high rate of bowel resection is a consequence of delayed presentation and effort should be made to make an early diagnosis of intussusception and make prompt referral to improve outcome.

Keywords: Delayed, intussusception, presentation, reduction, surgical

How to cite this article:
Ogundoyin OO, Olulana DI, Lawal TA. Childhood intussusception: Impact of delay in presentation in a developing country. Afr J Paediatr Surg 2016;13:166-9

How to cite this URL:
Ogundoyin OO, Olulana DI, Lawal TA. Childhood intussusception: Impact of delay in presentation in a developing country. Afr J Paediatr Surg [serial online] 2016 [cited 2017 May 23];13:166-9. Available from: http://www.afrjpaedsurg.org/text.asp?2016/13/4/166/194665



   Introduction Top


Intussusception remains a common cause of bowel obstruction in infants and young children, and it is a major source of significant morbidity and mortality if not promptly treated.[1],[2] The classical cases of intussusception are readily diagnosed clinically with reported accuracy of about 50%, but intussusception may mimic other conditions in children such as gastroenteritis which has a high prevalence in the tropics thus giving a confusing picture.[3],[4],[5] The accepted management of intussusception consists of adequate resuscitation, radiological confirmation of diagnosis, and radiological reduction for uncomplicated cases with surgical intervention as a last resort.[6] Children treated at tertiary hospitals have higher rates of nonoperative reduction than children treated at peripheral hospitals.[7] Despite recent improvements in radiological techniques, the diagnosis of intussusception and success in its nonoperative reduction has been suboptimal in tertiary care facilities in the developed countries.[1] However, reports from some developing countries have shown that surgical management is still routinely performed for intussusception.[8] This study, therefore, examines the impact of delays in presentation on the rate of bowel resection, length of hospital stay, and appraises the outcome of operative treatment.


   Patients and Methods Top


The medical records of 55 consecutive children admitted and treated surgically for intussusception between January 2002 and December 2011 at the University College Hospital, Ibadan were reviewed. Data extracted included the age, and sex of the patients, duration of symptoms before presentation, method of diagnosis, type of surgical procedure performed on the patients, postoperative complications, and the duration of hospital stay.


   Results Top


A total of 55 children were admitted and operated on for intussusception during this period. The mean age at presentation was 13.4 months (range 4 months–8 years). There were 35 boys and 20 girls with a male:female ratio of 1.8:1 [Table 1]. Thirty-four patients (61.8%) presented within the first 3 days of onset of symptoms. Of these, 14 patients (25.5%) presented within the first 24 h. Plain abdominal X-ray and abdominal ultrasound were used to confirm the diagnosis of intussusception for all the patients that were managed for intussusception before January 2005 while abdominal ultrasound was exclusively used to confirm the diagnosis of intussusception after this period. Abdominal ultrasound findings included target sign and pseudokidney appearance in 28 patients (50.9%). The mean hematocrit concentration was 11 g/dl (range 7.7 g/dl–15 g/dl). The primary surgical intervention was performed on 47 patients (85.5%); this included all consecutive patients managed for intussusception between January 2002 and December 2004 (14 patients, 25.5%), and 33 patients (60%) that presented from January 2005 and were not considered for nonoperative management of intussusception while secondary operative intervention was performed on eight patients (14.5%) who had failed initial nonoperative management of intussusception. Intraoperatively, manual reduction of intussusception was performed on 27 patients (49.1%), 26 patients had resection of gangrenous bowel with end-to-end anastomosis while two patients (3.6%) had spontaneous reduction of intussusception which was discovered at laparotomy.
Table 1: Age and sex distribution

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Seventeen patients (30.9%) developed postoperative complications and postoperative pyrexia were seen in nine patients (16.4%). Other complications were surgical site infection in two patients (3.6%), wound dehiscence, and adhesive bowel obstruction in three patients (5.5%) each. The mean duration of hospital stay was 12.1 days (range 3–60 days). The overall mortality was 5.5% (three patients), and three patients (5.5%) had a recurrence of intussusception.


   Discussion Top


The reported mean duration of symptoms before presentation in the hospital varies from 3.5 to 5 days.[4],[9]

This is common to most pediatric surgical centers in this country, and our center is not an exemption. Simon et al.[10] suggested that delay in presentation to the hospital may be due to the parents but mostly from the peripheral hospitals. The practice is to start the children on herbal concoctions and in some cases go to local drug stores to seek for medical advice. This is borne out of the fact that a larger percentage of the population live on <1 USD per day [11] and most parents do not have sufficient funds to take them to the hospital coupled with the fact that there is no effective health insurance system in the country.

However, several authors [4],[11],[12] have shown that about 64%–85% of patients had presented early to primary health-care facilities but were referred very late. The symptom complex of vomiting, abdominal pain, and passage of watery and bloody stool may mimic gastroenteritis, malaria, and other causes of acute abdomen in children. This often leads to initial misdiagnosis and late referral.[4],[12] Conversely, the duration of symptoms is in terms of hours in the developed countries [13],[14],[15] and they do not have delays in referral from the peripheral centers.[15] This may explain why prognosis is poorer in the developing countries because the presentation of patients depends on the availability of quality health care and the possibility to access it easily when the child is in distress without much delay.[15] While it may be difficult to convince individual parents to present their children to the specialist centers early, some authors [12],[15] have suggested improved awareness campaign among doctors and other health-care providers in the peripheral centers to raise the index of suspicion for intussusception and the need for prompt referral.

Ultrasonography has been adopted as the first-line diagnostic tool for intussusception in our center because it is cheap, easily accessible for use, has no risk of radiation, highly sensitive, and specific.[16],[17] It is used to confirm the suitability of the patient for nonoperative management to guide hydrostatic reduction of intussusception.[18]

The definitive management of intussusception has evolved from operative management through hydrostatic reduction to pneumatic reduction of intussusception.[8] Pneumatic and hydrostatic reductions of intussusception have demonstrated a high rate of success in the management of patients with intussusceptions.[19],[20],[21] Operative management is now the accepted back – up for nonoperative management when it fails; however, it is the standard management adopted in the face of suspected bowel gangrene and perforation.[4],[9]

Many studies [8],[12],[22] from Sub-Saharan Africa reported the use of operative intervention to treat every patient presenting with intussusception. Lack of facilities for pneumatic and hydrostatic reductions and delayed presentations have been variously suggested for this.[21],[23] This was the case in our center until January 2005 when ultrasound-guided hydrostatic reduction of intussusception was adopted for all uncomplicated cases of intussusception presenting within the first 72 h of the onset of symptoms.[9] The high rate of bowel resection has been variously attributed to delayed presentation,[12],[24],[25],[26] our study showed that more patients (23.7%) had bowel resection and anastomosis to treat their intussusception and they presented after 3 days of onset of symptoms, although there was no significant difference between the rate of manual reduction and overall resection rate [Table 2]. Overall bowel resection rate of 47.3% is high but still within the reported range of 1.4% and 47.4%.[10],[19],[22],[23],[26],[27] The recorded postoperative complications are not different from the reported complications, and they are due to sepsis and are wound related.[8],[12] The mortality rate of 5.5% is a marked improvement from the earlier reported rate of 8% from this center.[28] Expectedly, hospital stay was prolonged (mean – 12.1 days) in this study and patients (25.5%) who had resection of nonviable bowel stayed longer in the hospital than those (6%) who had a simple manual reduction. This may not be unconnected to the presence of perforation of the bowel and peritonitis that may accompany the gangrenous bowel that necessitated the resection [Table 3].
Table 2: The duration of symptoms and type of surgical procedure performed

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Table 3: The duration of hospital stay and the type of surgical procedure performed

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   Conclusion Top


The duration of symptoms is still largely responsible for the high rate of bowel resection in this study and the high morbidity although the mortality is reducing. A high index of suspicion is needed to exclude conditions such as gastroenteritis and other causes of acute abdomen in children that may mimic intussusception, make prompt diagnosis, and refer the patients promptly for nonoperative management to achieve a better outcome and reduced hospital stay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kaiser AD, Applegate KE, Ladd AP. Current success in the treatment of intussusception in children. Surgery 2007;142:469-75.  Back to cited text no. 1
    
2.
Ogundoyin OO, Ogunlana DI, Onasanya OM. Intestinal stenosis caused by perinatal intussusception in a full-term neonate. Am J Perinatol 2007;24:23-5.  Back to cited text no. 2
    
3.
Ein SH, Duneman A. Intussusception. In: Ziegler MM, Azizkhan RG, Weber TR, editors. Operative Paediatric Surgery. New York: McGraw-Hill Professional; 2003. p. 647-55.  Back to cited text no. 3
    
4.
Kuremu RT. Childhood intussusception at the Moi Teaching and Referral Hospital Eldoret: Management challenges in a rural setting. East Afr Med J 2004;81:443-6.  Back to cited text no. 4
    
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Crankson SJ, Al-Rabeeah AA, Fischer JD, Al-Jadaan SA, Namshan MA. Idiopathic intussusception in infancy and childhood. Saudi Med J 2003;24(5) Suppl 1:18-20.  Back to cited text no. 5
    
6.
DiFiore JW. Intussusception. Semin Pediatr Surg 1999;8:214-20.  Back to cited text no. 6
    
7.
Bratton SL, Haberkern CM, Waldhausen JH, Sawin RS, Allison JW. Intussusception: Hospital size and risk of surgery. Pediatrics 2001;107:299-303.  Back to cited text no. 7
    
8.
Ekenze SO, Mgbor SO, Okwesili OR. Routine surgical intervention for childhood intussusception in a developing country. Ann Afr Med 2010;9:27-30.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Ogundoyin OO, Olulana DI, Lawal TA. Childhood intussusception: A prospective study of management trend in a developing country. Afr J Paediatr Surg 2015;12:217-20.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Simon RA, Hugh TJ, Curtin AM. Childhood intussusception in a regional hospital. Aust N Z J Surg 1994;64:699-702.  Back to cited text no. 10
    
11.
The World Bank World Development Indicator Database. Available from: http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators. [Last accessed on 2012 Jun 06].  Back to cited text no. 11
    
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Nowshad MA, Moshtaque A, Hafizur R. Management outcome of infancy and childhood intussusception in Rajshahi Medical College Hospital – A prospective study. J Teach Assoc 2009;22:59-63.  Back to cited text no. 12
    
13.
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[PUBMED]  Medknow Journal  
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Eshel G, Barr J, Heyman E, Tauber T, Klin B, Vinograd I, et al. Intussusception: A 10-year survey (1986-1995). J Pediatr Gastroenterol Nutr 1997;24:253-6.  Back to cited text no. 14
    
15.
Ein SH, Alton D, Palder SB, Shandling B, Stringer D. Intussusception in the 1990s: Has 25 years made a difference? Pediatr Surg Int 1997;12:374-6.  Back to cited text no. 15
    
16.
Saxena AK, Höllwarth ME. Factors influencing management and comparison of outcomes in paediatric intussusceptions. Acta Paediatr 2007;96:1199-202.  Back to cited text no. 16
    
17.
Shanbhogue RL, Hussain SM, Meradji M, Robben SG, Vernooij JE, Molenaar JC. Ultrasonography is accurate enough for the diagnosis of intussusception. J Pediatr Surg 1994;191:781-5.  Back to cited text no. 17
    
18.
Daneman A, Navarro O. Intussusception. Part 1: A review of diagnostic approaches. Pediatr Radiol 2003;33:79-85.  Back to cited text no. 18
    
19.
Al-Bassam AA, Orfale N. Intussusception in infants and children: A review of 60 cases. Ann Saudi Med 1995;15:1-4.  Back to cited text no. 19
    
20.
Bai YZ, Qu RB, Wang GD, Zhang KR, Li Y, Huang Y, et al. Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: A review of 5218 cases in 17 years. Am J Surg 2006;192:273-5.  Back to cited text no. 20
    
21.
Sorantin E, Lindbichler F. Management of intussusception. Eur Radiol 2004;14 Suppl 4:L146-54.  Back to cited text no. 21
    
22.
Ugwu BT, Legbo JN, Dakum NK, Yiltok SJ, Mbah N, Uba FA. Childhood intussusception: A 9-year review. Ann Trop Paediatr 2000;20:131-5.  Back to cited text no. 22
    
23.
Justice FA, Auldist AW, Bines JE. Intussusception: Trends in clinical presentation and management. J Gastroenterol Hepatol 2006;21:842-6.  Back to cited text no. 23
    
24.
Ogundoyin OO, Afolabi AO, Lawal TA. Paediatric intussusception in Ibadan, South Western Nigeria. Niger J Surg 2008;14:13-6.  Back to cited text no. 24
    
25.
Meier DE, Coln CD, Rescorla FJ, OlaOlorun A, Tarpley JL. Intussusception in children: International perspective. World J Surg 1996;20:1035-9.  Back to cited text no. 25
    
26.
Adejuyigbe O, Jeje EA, Owa JA. Childhood intussusception in Ile-Ife, Nigeria. Ann Trop Paediatr 1991;11:123-7.  Back to cited text no. 26
    
27.
Archibong AE, Usoro IN, Ikpi E, Inyang A. Paediatric intussusception in Calabar, Nigeria. East Afr Med J 2001;78:19-21.  Back to cited text no. 27
    
28.
Chang HG, Smith PF, Ackelsberg J, Morse DL, Glass RI. Intussusception, rotavirus diarrhea, and rotavirus vaccine use among children in New York State. Pediatrics 2001;108:54-60.  Back to cited text no. 28
    

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Correspondence Address:
Olakayode Olaolu Ogundoyin
Department of Surgery, College of Medicine, University of Ibadan, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.194665

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