Mithulan jegapragasan pGy-1 1/19/2012 Is a hospital admission required after non-operative reduction of an intussusception? Mithulan jegapragasan pGy-1 1/19/2012

Outline Background Current management practices Potential complications Recommendations Questions for future research

Case Presentation HPI: B.O. is a previously healthy 2 y/o male with one week history of abdominal pain, non-bloody diarrhea and bilious emesis with ultrasound at OSH concerning for intussusception PMH: Uncomplicated birth, full-term Meds/Allergies: None/None SH/FH: Non-contributory ROS: As above

Case Presentation Continued Physical Exam: Vitals: Temp 36.9, RR 24, blood pressure 96/83, HR 108 Gen: No-apparent distress CV: RRR Resp: Non-labored breathing, no accessory muscle use, clear Abdomen: Soft, slight distention, no rebound tenderness, no guarding Labs: WBC: 8.6, H/H: 11.7/34.8, Plts: 299, Polys: 23.2%, Bands: 0% ED Course: Air enema attempted. Subsequent, barium enema reduction without reflux into the small bowel. Confirmed with ultrasound.

Background Most common cause of obstruction in children between the age of 6 months and 36 months 60% of cases are under 1 year old 80% are under 2 years old Slight male predominance 3:2 male to female ratio Incidence 1st year of life: 38 out of 100,00 children 2nd year of life: 31 out of 100,000 children 3rd year of life: 26 out of 100,00 children Buettcher M, Baer G, Bonhoeffer J, et al. Three-year surveillance of intussusception in children in Switzerland. Pediatrics 2007; 120:473.

Pathogenesis Greater than 75% thought to be idiopathic, related to viral illness Lead points Meckel’s diverticulum Lymphoma Cystic fibrosis http://www.chop.edu/healthinfo/intussusception.html

Current Management Post-reduction If not reduced on repeated attempts Admit for overnight observation Start IV cefoxitin q6hours till discharge NPO till AM, if no further symptoms start liquid diet If not reduced on repeated attempts To OR

Potential complications with early discharge Recurrence Enema-associated Perforation Sepsis Bowel ischemia Missed pathologic lead point

Recurrence

Timing of recurrence

Success Managing Recurrences 108 episodes Barium enema (n=26) Successful Reduction n=25 (96.2%) Air enema (n=62) Successful Reduction n=57(92%) Surgery (n=24) Conservative txt failure (n=6) Primary surgical (n=18)

Predicting Recurrence? No difference in sex, race, gender, duration of symptoms, and physical examination Presents with less vomiting, less rectal bleeding and shorter duration of abdominal pain, perhaps because increased parent recognition Pathologic lead point? Yang, C M (05/2001). "Recurrence of intussusception in childhood". Acta paediatrica Taiwanica = Taiwan er ke yi xue hui za zhi (1608-8115), 42 (3), p. 158. Intussusception. Part 3: Diagnosis and management of those with an identifiable or predisposing cause and those that reduce spontaneously. AU Navarro O, Daneman A SO Pediatr Radiol. 2004;34(4):305.

Methods: 10 year review of cases with intussusception in a single institution

Complications associated with recurrence

Pathologic lead points by Age

Considerations in Designing a Protocol Exclusion criteria Identified lead points Family lacks access to medical care Associated medical problems: cystic fibrosis, HSP When to discharge? When to feed? How long to observe feeding? Benefits to patients Risks to patients

When to resume re-feeding?

When to feed? Methods: Retrospective analysis of children seen at Texas Children’s Hospital ED observation unit during a six-year interval. Annual ED census of 80,000.

Proposed proposal Most conservative inclusion criteria Minimize outpatient complications in the three categories discussed Patient should be watched in ED observation unit

Suspected Intussusception (stable pt) Reccurrence Reduction Admission First episode Successful enema reduction with reflux into small bowel Age >3 years old or <3 months Immediate oral feeds Tolerate feeds, vitals stable, and nl physical exam Discharge Unable to reduce radiographically Surgical intervention

Future investigations How to manage recurrence of intussusceptions? Cost/benefit analysis Antibiotics?

References Buettcher M, Baer G, Bonhoeffer J, et al. Three-year surveillance of intussusception in children in Switzerland. Pediatrics 2007; 120:473. Yamaguchi M, Takeuchi S, Awazu S, “Meckel's diverticulum. Investigation of 600 patients in Japanese literature,” American Journal of Surgery, vol. 136, no. 2, pp. 247–249, 1978. Yang, C M. "Recurrence of intussusception in childhood". Acta paediatrica Taiwanica (1608-8115), 42 (3), p. 158.