1. 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

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

3. 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

4. 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.

5. 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.

6. Pathogenesis
Greater than 75% thought to be idiopathic, related to viral illness
Lead points
Meckel’s diverticulum
Lymphoma
Cystic fibrosis

7. 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

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

9. Recurrence

10. Timing of recurrence

11. 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)

12. 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 ( ), 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.

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

15. Complications associated with recurrence

16. Pathologic lead points by Age

17. 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

18. When to resume re-feeding?

19. 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.

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

21. 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

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

23. 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 ( ), 42 (3), p. 158.