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Predictors of failed enema reduction in childhood intussusception
Journal of Pediatric Surgery (2012) 47, 925–927
www.elsevier.com/locate/jpedsurg
Predictors of failed enema reduction in childhood intussusception Frankie B. Fike, Vincent E. Mortellaro, George W. Holcomb III, Shawn D. St. Peter ⁎ The Children's Mercy Hospital, Kansas City, MO 64108, USA Received 11 January 2012; accepted 26 January 2012
Key words: Intussusceptions; Enema reduction
Abstract Background: Initial management of intussusception is enema reduction. Data are scarce on predicting which patients are unlikely to have a successful reduction. Therefore, we reviewed our experience to identify factors predictive of enema failure. Methods: A retrospective review of all episodes of intussusception over the past 10 years was conducted. Demographics, presentation variables, colonic extent of intussusceptions, and hospital course were collected. Extent of intussusception was classified as right, transverse, descending, and rectosigmoid. Episodes were grouped as success or failure of enema reduction and compared using the Student t test for continuous variables and χ2 test for dichotomous variables. Significance was P less than .05. Results: We identified 405 episodes of intussusception and 371 attempts at enema reduction. There were 285 successful enema reductions. There was no difference between groups in age; sex; or the presence of emesis, fever, or abdominal mass. The failed enema group was more likely to have had symptoms over 24 hours before presentation (P = .006), bloody diarrhea (P b .001), and lethargy (P b .001). The chance of success diminished with colonic extent (right, 88%; transverse, 73%; left, 43%; colorectal, 29%; P b .001). Conclusion: Predictors of failed enema reduction of intussusception include presence of symptoms over 24 hours, diarrhea, lethargy, and distal extent of intussusception. © 2012 Elsevier Inc. All rights reserved.
Intussusception is the most common cause of bowel obstruction in the infant and toddler age group [1]. Most frequently, it is a result of lymphoid hyperplasia serving as a lead point, which allows the bowel to telescope upon itself. The classic triad of abdominal pain, emesis, and passage of bloody stools is described but estimated to occur only 30% of the time [2,3]. The treatment of choice is enema reduction, hydrostatic or pneumatic, with operative intervention
reserved for failure of radiographic reduction. Data regarding which patients are likely to fail enema reduction are scarce and conflicting. Therefore, we reviewed the experience at a tertiary children's hospital with intussusception with specific attention to type and duration of presenting symptoms, distal extent of intussusception, and outcome of enema attempt.
1. Methods ⁎ Corresponding author. Center for Prospective Clinical Trials, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA. Tel.: +1 816 983 3575; fax: +1 816 983 6885. E-mail addresses: [email protected], [email protected] (S.D. St. Peter). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2012.01.047
After institutional review board approval, a retrospective review was conducted on all episodes of intussusception treated at our hospital over the past 10 years.
926
F.B. Fike et al.
Demographic data were collected. Charts were reviewed to determine presenting complaints including fever, bloody stools, emesis, lethargy, and presence of a palpable abdominal mass as well as the duration of these symptoms before evaluation. The colonic extent of the intussusception as determined by ultrasound or enema was also evaluated. The colonic extent of intussusception was categorized as follows: right colon, transverse colon, descending colon, and rectosigmoid colon. Episodes of intussusception were divided into 2 groups as successful or failed radiographic reduction. Each predominance of each variable between these 2 groups were compared using the Student t test for continuous variables and χ2 for categorical variables with a P value less than .05 being considered significant. Because failure is the important event, the likelihood of failure was used to calculate odds ratio and relative risk with 95% confidence interval for each categorical variable. Logistic regression was performed for the categorical variables to evaluate independence. The relationship between of colonic extent of intussusception and failure of enema reduction was evaluated using the MantelHaenszel χ2 test using both multigroup comparison for directional trend and 2 by 2 contingency comparison for risk of failure of colonic position relative to the right colon.
Table 2 Odds ratio and relative risk expressed around likelihood of failure in the presence or absence of each variable % Odds 95% Relative 95% failure ratio confidence risk confidence interval interval Male sex Emesis Fever Abdominal mass Symptoms over 24 h Bloody diarrhea Lethargy
26% 26% 34% 33%
1.5 1.7 1.9 1.7
0.9-2.6 0.9-3.1 0.8-4.0 0.4-6.4
1.4 1.5 1.6 1.
0.9-2.1 0.9-2.5 0.9-2.5 0.5-1.9
30%
2.0
1.8-3.3
1.7
1.1-2.5
37%
2.7
1.5-4.6
2.0
1.4-3.0
56%
5.1
2.3-11.2
2.8
1.8-3.9
(P = .06), whereas lethargy (P = .01) and symptoms over 24 hours (P = .006) were. The likelihood of successful enema reduction of intussusception dramatically decreased with distal extent of the intussusception; the directional trend was significant (P b .0001) (Table 3).
3. Discussion 2. Results We identified 405 episodes of intussusception in 352 patients. Median age at presentation was 17 ± 65 months, and median weight was 10.7 kg ± 23.3 kg. Sex distribution was 62% male. A total of 371 enemas were attempted, of which 285 were successful and 86 failed. Comparing successful and failed enemas, there were no differences in age, sex, presence of emesis, presence of fever, or documented abdominal mass on physical examination. The failed enema group was more likely to have had symptoms over 24 hours, bloody diarrhea, and documentation of lethargy (Table 1). The same variables demonstrate odds ratio and relative risk of enema failure that do not overlap with 1 (Table 2). However, from the regression model, bloody diarrhea was not an independent predictor Table 1
Demographic data and presenting symptoms
Age (mo) Sex (% male) Emesis Fever Abdominal mass Symptoms over 24 h Bloody diarrhea Lethargy
Success (n = 285)
Failure (n = 86)
P
17 59.3% 67.4% 8.8% 2.8% 42.5% 22.1% 5.3%
9 68.6% 77.9% 15.1% 4.7% 59.3% 43.0% 22.1%
.11 .13 .06 .09 .61 .006 b.001 b.001
Intussusception is frequently encountered in the infant and toddler population and is recognized as the most common cause of bowel obstruction in this age group [1]. The diagnosis is usually made via ultrasound interrogation because of its high sensitivity and specificity as well as the lack of radiation [4]. Typical management begins with reduction via fluoroscopic-guided enema with an operation reserved for failures. Success of radiographic reduction of intussusception is reported with wide variability ranging from 40% to more than 90% [3,5-8]. These studies also vary in the symptoms associated with failure of enema reduction. Although some reports demonstrate an increased likelihood of enema failure with longer duration of symptoms, others have found no association [3,6,7,9-11]. Likewise, the presence of bloody diarrhea is associated with outcome in some studies and insignificant in others [3,9,12]. One study suggested that age is predictive of enema failure with patients younger than 6 months holding higher failure rates [13]. A recent study documented a significant difference in reduction rate for intussusceptions located proximal to the splenic flexure vs those more distal [8]. There is no study to our knowledge that has examined the distal extent of intussusception in 4 separate areas of the colon. Our data support the rather intuitive notion that more distal intussusceptions are less likely to be reduced with an enema. Predicting patients likely to fail enema reduction is clinically relevant because it may help clinicians identify which patients are less likely to benefit from a second attempt at enema reduction. However, because of our practice
Predictors of failed enema reduction Table 3
927
Likelihood of failure based on extent of intussusception
Right colon (n = 191) Transverse colon (n = 138) Descending colon (n = 14) Rectosigmoid (n = 21)
% failure
Odds ratio
95% confidence interval
Relative risk
95% confidence interval
P
12% 27% 57% 71%
2.7 9.8 18.4
1.5-5.0 2.8-35.6 5.9-59.8
2.2 4.8 6.0
1.4-3.7 2.2-7.8 3.5-8.5
.001 b.001 b.001
Right colon is used as the reference standard for other locations for establishing odds ratio and relative risks. The Mantel-Haenszel χ2 test for trend was also significant (P b .0001).
pattern, only 6 patients underwent repeat attempt at enema reduction. Of these, 4 were successfully reduced with the second attempt. Other studies have shown a decreased operative rate in patients who undergo a second attempt at enema reduction positing that the partial reduction on the first attempt decreases the bowel wall edema significantly enough to facilitate complete reduction on the second attempt. In the group of 4 patients successfully reduced with a second attempt, none had the presence of all 3 predictive symptoms of lethargy, bloody diarrhea, and duration more than 24 hours in combination. There were 2 patients who had symptoms for over 24 hours, and 1 had bloody diarrhea, whereas no patient was lethargic. The data in this small subset of patients would lend further support to the notion that the presence of all 3 symptoms is predictive of failure. In addition, 2 of the 3 were independent predictors from the regression analysis. However, all 3 symptoms are surrogates for the length of illness. Therefore, it appears clear from these data that the length of illness and the anatomical extent of intussusception both decrease the likelihood for successful enema reduction.
References [1] Justice FA, Auldist AW, Bines JE. Intussusception: trends in clinical presentation and management. J Gastroenterol Hepatol 2006;21:842-6. [2] Macdonald I, Beattie T. Intussusception presenting to a paediatric accident and emergency department. J Accid Emerg Med 1995;12: 182-6.
[3] McDermott VG, Taylor T, Mackenzie S, et al. Pneumatic reduction of intussusception: clinical experience and factors affecting outcome. Clin Radiol 2009;64:655-63. [4] Saxena AK, Hollwarth ME. Factors influencing management and comparison of outcomes in paediatric intussusceptions. Acta Paediatr 2007;96:1199-202. [5] Menor F, Cortina H, Marco A, et al. Effectiveness of pneumatic reduction of ileocolic intussusception in children. Gastrointest Radiol 1992;17:339-43. [6] Shapkina AN, Shapkin W, Nelubov IV, et al. Intussusception in children: 11-year experience in Vladivostok. Pediatr Surg Int 2006;22: 901-4. [7] Lehnert T, Sorge I, Till H, et al. Intussusception in children—clinical presentation, diagnosis and management. Int J Colorectal Dis 2009;24: 1187-92. [8] Curtis JL, Gutierrez IM, Kirk SR, et al. Failure of enema reduction for ileocolic intussusception at a referring hospital does not preclude repeat attempts at a children's hospital. J Pediatr Surg 2010;45: 1178-81. [9] Gorenstein A, Raucher A, Serour F, et al. Intussusception in children: reduction with repeated, delayed air enema. Radiology 1998;206: 721-4. [10] Kaiser AD, Applegate KE, Ladd AP. Current success in the treatment of intussusception in children. Surgery 2007;142:469-75. [11] Tareen F, Ryan S, Avanzini S, et al. Does the length of the history influence the outcome of pneumatic reduction of intussusception in children? Pediatr Surg Int 2011;27:587-9. [12] Sandler AD, Ein SH, Connolly B, et al. Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile? Pediatr Surg Int 1999;15(3-4):214-6. [13] Shekherdimian S, Lee SL. Management of pediatric intussusception in general hospitals: diagnosis, treatment, and differences based on age. World J Pediatr 2011;7(1):70-3.
www.elsevier.com/locate/jpedsurg
Predictors of failed enema reduction in childhood intussusception Frankie B. Fike, Vincent E. Mortellaro, George W. Holcomb III, Shawn D. St. Peter ⁎ The Children's Mercy Hospital, Kansas City, MO 64108, USA Received 11 January 2012; accepted 26 January 2012
Key words: Intussusceptions; Enema reduction
Abstract Background: Initial management of intussusception is enema reduction. Data are scarce on predicting which patients are unlikely to have a successful reduction. Therefore, we reviewed our experience to identify factors predictive of enema failure. Methods: A retrospective review of all episodes of intussusception over the past 10 years was conducted. Demographics, presentation variables, colonic extent of intussusceptions, and hospital course were collected. Extent of intussusception was classified as right, transverse, descending, and rectosigmoid. Episodes were grouped as success or failure of enema reduction and compared using the Student t test for continuous variables and χ2 test for dichotomous variables. Significance was P less than .05. Results: We identified 405 episodes of intussusception and 371 attempts at enema reduction. There were 285 successful enema reductions. There was no difference between groups in age; sex; or the presence of emesis, fever, or abdominal mass. The failed enema group was more likely to have had symptoms over 24 hours before presentation (P = .006), bloody diarrhea (P b .001), and lethargy (P b .001). The chance of success diminished with colonic extent (right, 88%; transverse, 73%; left, 43%; colorectal, 29%; P b .001). Conclusion: Predictors of failed enema reduction of intussusception include presence of symptoms over 24 hours, diarrhea, lethargy, and distal extent of intussusception. © 2012 Elsevier Inc. All rights reserved.
Intussusception is the most common cause of bowel obstruction in the infant and toddler age group [1]. Most frequently, it is a result of lymphoid hyperplasia serving as a lead point, which allows the bowel to telescope upon itself. The classic triad of abdominal pain, emesis, and passage of bloody stools is described but estimated to occur only 30% of the time [2,3]. The treatment of choice is enema reduction, hydrostatic or pneumatic, with operative intervention
reserved for failure of radiographic reduction. Data regarding which patients are likely to fail enema reduction are scarce and conflicting. Therefore, we reviewed the experience at a tertiary children's hospital with intussusception with specific attention to type and duration of presenting symptoms, distal extent of intussusception, and outcome of enema attempt.
1. Methods ⁎ Corresponding author. Center for Prospective Clinical Trials, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA. Tel.: +1 816 983 3575; fax: +1 816 983 6885. E-mail addresses: [email protected], [email protected] (S.D. St. Peter). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2012.01.047
After institutional review board approval, a retrospective review was conducted on all episodes of intussusception treated at our hospital over the past 10 years.
926
F.B. Fike et al.
Demographic data were collected. Charts were reviewed to determine presenting complaints including fever, bloody stools, emesis, lethargy, and presence of a palpable abdominal mass as well as the duration of these symptoms before evaluation. The colonic extent of the intussusception as determined by ultrasound or enema was also evaluated. The colonic extent of intussusception was categorized as follows: right colon, transverse colon, descending colon, and rectosigmoid colon. Episodes of intussusception were divided into 2 groups as successful or failed radiographic reduction. Each predominance of each variable between these 2 groups were compared using the Student t test for continuous variables and χ2 for categorical variables with a P value less than .05 being considered significant. Because failure is the important event, the likelihood of failure was used to calculate odds ratio and relative risk with 95% confidence interval for each categorical variable. Logistic regression was performed for the categorical variables to evaluate independence. The relationship between of colonic extent of intussusception and failure of enema reduction was evaluated using the MantelHaenszel χ2 test using both multigroup comparison for directional trend and 2 by 2 contingency comparison for risk of failure of colonic position relative to the right colon.
Table 2 Odds ratio and relative risk expressed around likelihood of failure in the presence or absence of each variable % Odds 95% Relative 95% failure ratio confidence risk confidence interval interval Male sex Emesis Fever Abdominal mass Symptoms over 24 h Bloody diarrhea Lethargy
26% 26% 34% 33%
1.5 1.7 1.9 1.7
0.9-2.6 0.9-3.1 0.8-4.0 0.4-6.4
1.4 1.5 1.6 1.
0.9-2.1 0.9-2.5 0.9-2.5 0.5-1.9
30%
2.0
1.8-3.3
1.7
1.1-2.5
37%
2.7
1.5-4.6
2.0
1.4-3.0
56%
5.1
2.3-11.2
2.8
1.8-3.9
(P = .06), whereas lethargy (P = .01) and symptoms over 24 hours (P = .006) were. The likelihood of successful enema reduction of intussusception dramatically decreased with distal extent of the intussusception; the directional trend was significant (P b .0001) (Table 3).
3. Discussion 2. Results We identified 405 episodes of intussusception in 352 patients. Median age at presentation was 17 ± 65 months, and median weight was 10.7 kg ± 23.3 kg. Sex distribution was 62% male. A total of 371 enemas were attempted, of which 285 were successful and 86 failed. Comparing successful and failed enemas, there were no differences in age, sex, presence of emesis, presence of fever, or documented abdominal mass on physical examination. The failed enema group was more likely to have had symptoms over 24 hours, bloody diarrhea, and documentation of lethargy (Table 1). The same variables demonstrate odds ratio and relative risk of enema failure that do not overlap with 1 (Table 2). However, from the regression model, bloody diarrhea was not an independent predictor Table 1
Demographic data and presenting symptoms
Age (mo) Sex (% male) Emesis Fever Abdominal mass Symptoms over 24 h Bloody diarrhea Lethargy
Success (n = 285)
Failure (n = 86)
P
17 59.3% 67.4% 8.8% 2.8% 42.5% 22.1% 5.3%
9 68.6% 77.9% 15.1% 4.7% 59.3% 43.0% 22.1%
.11 .13 .06 .09 .61 .006 b.001 b.001
Intussusception is frequently encountered in the infant and toddler population and is recognized as the most common cause of bowel obstruction in this age group [1]. The diagnosis is usually made via ultrasound interrogation because of its high sensitivity and specificity as well as the lack of radiation [4]. Typical management begins with reduction via fluoroscopic-guided enema with an operation reserved for failures. Success of radiographic reduction of intussusception is reported with wide variability ranging from 40% to more than 90% [3,5-8]. These studies also vary in the symptoms associated with failure of enema reduction. Although some reports demonstrate an increased likelihood of enema failure with longer duration of symptoms, others have found no association [3,6,7,9-11]. Likewise, the presence of bloody diarrhea is associated with outcome in some studies and insignificant in others [3,9,12]. One study suggested that age is predictive of enema failure with patients younger than 6 months holding higher failure rates [13]. A recent study documented a significant difference in reduction rate for intussusceptions located proximal to the splenic flexure vs those more distal [8]. There is no study to our knowledge that has examined the distal extent of intussusception in 4 separate areas of the colon. Our data support the rather intuitive notion that more distal intussusceptions are less likely to be reduced with an enema. Predicting patients likely to fail enema reduction is clinically relevant because it may help clinicians identify which patients are less likely to benefit from a second attempt at enema reduction. However, because of our practice
Predictors of failed enema reduction Table 3
927
Likelihood of failure based on extent of intussusception
Right colon (n = 191) Transverse colon (n = 138) Descending colon (n = 14) Rectosigmoid (n = 21)
% failure
Odds ratio
95% confidence interval
Relative risk
95% confidence interval
P
12% 27% 57% 71%
2.7 9.8 18.4
1.5-5.0 2.8-35.6 5.9-59.8
2.2 4.8 6.0
1.4-3.7 2.2-7.8 3.5-8.5
.001 b.001 b.001
Right colon is used as the reference standard for other locations for establishing odds ratio and relative risks. The Mantel-Haenszel χ2 test for trend was also significant (P b .0001).
pattern, only 6 patients underwent repeat attempt at enema reduction. Of these, 4 were successfully reduced with the second attempt. Other studies have shown a decreased operative rate in patients who undergo a second attempt at enema reduction positing that the partial reduction on the first attempt decreases the bowel wall edema significantly enough to facilitate complete reduction on the second attempt. In the group of 4 patients successfully reduced with a second attempt, none had the presence of all 3 predictive symptoms of lethargy, bloody diarrhea, and duration more than 24 hours in combination. There were 2 patients who had symptoms for over 24 hours, and 1 had bloody diarrhea, whereas no patient was lethargic. The data in this small subset of patients would lend further support to the notion that the presence of all 3 symptoms is predictive of failure. In addition, 2 of the 3 were independent predictors from the regression analysis. However, all 3 symptoms are surrogates for the length of illness. Therefore, it appears clear from these data that the length of illness and the anatomical extent of intussusception both decrease the likelihood for successful enema reduction.
References [1] Justice FA, Auldist AW, Bines JE. Intussusception: trends in clinical presentation and management. J Gastroenterol Hepatol 2006;21:842-6. [2] Macdonald I, Beattie T. Intussusception presenting to a paediatric accident and emergency department. J Accid Emerg Med 1995;12: 182-6.
[3] McDermott VG, Taylor T, Mackenzie S, et al. Pneumatic reduction of intussusception: clinical experience and factors affecting outcome. Clin Radiol 2009;64:655-63. [4] Saxena AK, Hollwarth ME. Factors influencing management and comparison of outcomes in paediatric intussusceptions. Acta Paediatr 2007;96:1199-202. [5] Menor F, Cortina H, Marco A, et al. Effectiveness of pneumatic reduction of ileocolic intussusception in children. Gastrointest Radiol 1992;17:339-43. [6] Shapkina AN, Shapkin W, Nelubov IV, et al. Intussusception in children: 11-year experience in Vladivostok. Pediatr Surg Int 2006;22: 901-4. [7] Lehnert T, Sorge I, Till H, et al. Intussusception in children—clinical presentation, diagnosis and management. Int J Colorectal Dis 2009;24: 1187-92. [8] Curtis JL, Gutierrez IM, Kirk SR, et al. Failure of enema reduction for ileocolic intussusception at a referring hospital does not preclude repeat attempts at a children's hospital. J Pediatr Surg 2010;45: 1178-81. [9] Gorenstein A, Raucher A, Serour F, et al. Intussusception in children: reduction with repeated, delayed air enema. Radiology 1998;206: 721-4. [10] Kaiser AD, Applegate KE, Ladd AP. Current success in the treatment of intussusception in children. Surgery 2007;142:469-75. [11] Tareen F, Ryan S, Avanzini S, et al. Does the length of the history influence the outcome of pneumatic reduction of intussusception in children? Pediatr Surg Int 2011;27:587-9. [12] Sandler AD, Ein SH, Connolly B, et al. Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile? Pediatr Surg Int 1999;15(3-4):214-6. [13] Shekherdimian S, Lee SL. Management of pediatric intussusception in general hospitals: diagnosis, treatment, and differences based on age. World J Pediatr 2011;7(1):70-3.