1. Case Discussion
R1 吳宗祐
R4 呂筱涵
VS 楊燿榮
2017/05/03
Nelson 1812 (2620)

2. Patient Profile Name: 張X妍 Chart number: 181675xx Age: 2-year-old
Gender: Female
Date of admission: 2017/04/22~04/26
Informant: Parents and medical records

3. Chief Complaints
Abdominal pain since 4 days ago

4. Present Illness 2017/04/18 Intermittent pain
Inconsolable crying and bend-over position during pain
Returned to usual activity and appetite when the pain ended
No fever, no diarrhea, no vomiting, no bloody stool
No fever/URI/UTI/AGE in recent 2 weeks
Constipation: denied

5. Past History Birth Hx: Growth and development: Vaccination:
G2P2, GA 34-35wks, NSD, BBW: 2640g
Uneventful perinatal hx
Growth and development:
BL: 83 cm = 3-15th percentile
BW: 10.6 kg = 15-50th percentile
Developmental milestone: within normal limits
Vaccination:
As Taiwan schedule, Rotavirus: (+). Influenza (2016): (-)
Contact history: denied
Family history
Older brother had 2 episodes of intussusception (2 years old and 3 years old, s/p Barium enema reduction)

6. PE Vital Signs: T: 36.0°C(04/22 20:20); P: 118/min(04/22 20:20)
R: 24/min(04/22 20:20); BP: 124/75mmHg(04/22 20:20)
Consciousness: clear, General appearance: fair
HEENT: conjunctiva: not pale, sclera: anicteric
Neck: supple, no JVE, no LAP
Chest: symmetric expansion, bilateral clear breath sounds
Heart: regular heart beat, murmur(-)
Abdomen: flat and soft, normo-active bowel sound, tenderness (- ), rebound pain (-), palpable mass (-)
Extremities: warm, pitting edema (-)
Skin: no edema, petechiae or ecchymosis

7. Lab

8. Impression Intussusception Constipation Pancreatitis Herniation
Acute abdomen
The patient was brought to 奇美H on 2017/04/19

9. Image
04/19 19:24 灌 灌

10. Image
04/20 10:26

11. Image
04/20 13:05 再灌 再灌

12. Image
04/21 09:27

13. Image
04/21 10:52
灌x3
灌x3

14. Image
04/22 02:06 灌 灌 灌 灌 灌 灌 灌 灌

15. Treatment course 2017/04/19 @ 奇美H Intussusception
Repeated Barium reduction up to 4 times due to recurrence
04/19 19:24
04/20 13:05
04/21 10:52
04/22 02:06
Transferred to our emergency department on 2017/4/22

16. Treatment course 2017/04/22 @ NCKUH ER
Initial vital signs: T/P/R 37.2/108/20
Abdominal sonography
Target lesion at RUQ of abdomen without significant bowel swelling or local fluid accumulation
Multiple enlarged lymph nodes
Recurrent intussusception and mesenteric lymphadenitis were favored
May try Barium reduction again

17. Image
04/22 13:32

18. Image
04/22 15:54 灌

19. Treatment course 2017/04/22 @ NCKUH ER Steroid + IV hydration
Hydrocortisone 20mg IVD STAT (2mg/kg/dose)
5th Barium reduction  FAILED
Surgery at 04/22 18:05
Ileocolic type intussusception about 2 cm
Manual reduction
Ileum congestion, hyperemia thickened about 15 cm
Appendectomy
Mesenteric side with enlarged multiple LN up to 1 cm
biopsy and sent for pathology and viral isolation

20. Final Diagnosis
Intussusception, status post barium reduction, status post surgical manual reduction on 2017/04/22

21. Discussion – Intussusception
Most common cause of intestinal obstruction between 5m/o to 3y/o
Most common abd emergency in < 2y/o
90% idiopathic
Seasonal incidence peaks in fall and winter
Respiratory adenovirus (type C)
Slightly increased risk after receiving rotavirus vaccine

22. Discussion – Intussusception
2~8% of cases has a recognizable leading point

23. Discussion – Intussusception
Clinical manifestations
Sudden onset, severe paroxysmal colicky pain, recurs frequently
Straining efforts, legs/knees flexed
Loud crying
Plays normally between the episodes
Vomiting  vomit with bile content
Currant jelly stool (only 60% of cases)
Sausage-shaped abdominal mass (most often at RUQ)
Recurrent intussusception: 5~8%
Classic triad
(<30%)

24. Discussion – Intussusception
Diagnosis
Ultrasound: A tubular mass in longitudinal views, a doughnut or target sign in transverse views
Air, hydrostatic (saline), water-soluble contrast enema
Contrast (Barium) enema
Treatment
Hydrostatic reduction
80-95% successful rate in ileocolic type
Bowel perforation rate: %
Air reduction
Perforation rate: %
Surgical intervention
Multiple recurrences
Bowel necrosis, perforation, peritonitis…
Ileoileal type

26. Discussion – Intussusception
Prognosis
Recurrence rate (most within 72hrs)
Reduction: 10%
Surgical reduction: 2-5%
Surgical resection: none
Corticosteroid
Reduce the frequency of recurrence
Multiple recurrences
Suspect a leading point
Consider exploratory laparotomy

27. REVIEW
Intussusception v.s. Steroids

28. Review I

29. Review I -- Abstract
2 cases of recurrent intussusception associated with intestinal lymphoid hyperplasia (ILH)
A short course of steroids
Resolution of symptoms and hyperplasia
Steroids before surgical approach
Recurrent intussusception in association with ILH
No other lead point can be identified

30. Review I -- Case 1 10 m/o female with intussusception
2 previous episodes at 7m/o and 8m/o
No identifiable lead point
Negative Meckel’s scan
Upper GI series & Double-contrast barium enema:
multiple small, round filling defects along the distal small bowel and colon

31. Oral prednisone 1mg/kg/day for 2 weeks, and gradual tapering for 4 weeks
F/u double-contrast barium enema after 2 months
No recurrence during 2-year follow up
Before
After

32. Review I -- Case 2 5y/o male with intussusception
2 previous episode at 1.5y/o and 4y/o
No identifiable lead point
Negative Meckle diverticulum scan
Upper GI series: ILH in terminal ileum and cecum
Suspect recurrence 12hrs after air reduction

33. Oral prednisone 1mg/kg/day for 2 weeks, and gradual tapering for 4 weeks
No recurrence during 18-month follow up

34. Review I -- Conclusion
Steroids before surgical approach or repeat pneumatic or hydrostatic reduction
Recurrent intussusception in association with ILH
No other lead point can be identified

35. Review II
Decreasing early recurrence rate of acute intussusception by the use of dexamethasone
Eur J Pediatr. 2000 Jul;159(7):551-2
Lin SL, Kong MS, Houng DS.
Prospective, randomized, double-blinded study
Pretreated with dexamethasone (0.5mg/kg) before pneumoreduction

36. Review II -- Method Steroid group Normal saline group
122 successful reduction (84.7%)
No recurrence during 72hrs admission
No recurrence during 1st week
1 recurrence in 6 months
No mortality, nor bowel perforation
Normal saline group
117 successful reduction (85.4%)
3 (2.5%) recurrence during 72hrs admission
6 (5.1%) episodes of recurrence during 1st week (P<0.05)
8 (6.8%) recurrence in 6 months

37. Review II -- Conclusion
Amelioration of lymphoid hyperplasia by dexamethasone may be the main mechanism in reducing the recurrence rate of acute intussusception

38. Review III

39. Review III -- Case report
11m/o boy with 3-day abdominal pain, blood and mucus stool  intussusception  gas reduction
In the subsequent 4 months, 9 episodes of recurrence
After the 5th recurrence, diagnostic laparoscopy was performed
Moderate mesenteric lymphadenopathy
Ileo-caecal valve scarring
After the 8th recurrence, oral prednisone (10mg QD) for 2 weeks, and then tapering down in 6 weeks.
No recurrence since then.

40. Review IV

41. Review IV -- Method Aged from 1 week to 18 years, from 1999 to 2014
Idiopathic intussusception, exclusion criteria:
Known underlying intestinal pathology
Underwent surgical intervention
Steroid administration
No randomization
Decision made by the attending pediatric surgeon
Complete pneumatic reduction
Group 1: IV dexamethasone (0.5mg/kg/dose) on diagnosis of immediately after reduction
Group 2: No steroids
Early recurrence
Within 1 week of successful reduction

42. Review IV -- Results & Discussion
Total 174 patients (113M + 61F)
100 steroid: 14 with early recurrence (14%)
74 non-steroid: 4 with early recurrence (5%)
P=0.08
Discussion
Most of the intussusception were idiopathic
This study do not justify the routine use of steroid
Steroid may have a role in lymphoid hyperplasia

43. Thank you for your attention