Invagination in children]

Although rare, childhood intussusception is one of the most common causes of small bowel obstruction in infancy. In these very young patients it can sometimes be difficult to interpret the clinical signs and symptoms correctly. This retrospective study comprises 79 children (median age 7.5 months; 24% girls and 76% boys) who experienced 83 episodes of intussusception. At admission the diagnosis made by the referring physicians could be confirmed in only about one-third of the cases. A barium enema was part of the inhospital diagnostic process. Non-operative treatment was attempted in 70 patients (89%), and barium enema reduction was successful in 64%. Laparotomy was required in 33 (42%) of the patients. No mortality, bowel perforation, or any other major complications were encountered. The diagnosis of childhood intussusception seems difficult to achieve in many cases, and the interpretation of, at times vague clinical signs and symptoms remains a challenge for all clinicians who are involved in the care of these very young patients.     

Insulin-like growth factor system in serum and cerebrospinal fluid in patients with multiple sclerosis

Perforation during attempted gas-enema reduction of intussusception is more common than during a barium enema. In a review of 650 consecutive attempted gas enemas, perforation occurred in 7 infants (1.1%). Gross abdominal distension from the pneumoperitoneum may be rapid and cause splinting of the diaphragm, which leads to acute respiratory distress. This complication is readily recognised at the time of the gas enema, and may require immediate intervention by paracentesis using a 14-gauge needle. A review of 7 children with intussusception in whom perforation occurred revealed that all had radiologic evidence of bowel obstruction (air-fluid levels) prior to the enema, and the patients had had a relatively long history since the onset of symptoms. No perforation occurred during a delayed repeat enema reduction. Perforation during gas enema produces minimal peritoneal contamination. No pathological lesion at the lead point of the intussusception was identified in any of the children in whom perforation occurred.     

Indications for laparotomy after hydrostatic reduction for intussusception

A criterion for successful hydrostatic reduction of intussusception is reflux into the terminal ileum. In our practice, absence of reflux into the terminal ileum is not an indication for laparotomy if the radiographic appearances suggest edema of the ileocecal valve. The aim of this study was to validate our approach. We reviewed the case notes of patients with a diagnosis of intussusception (n = 107; age 11.74 +/- 1.48 months; mean +/- SEM) treated from 1987 to 1991. Eleven required primary laparotomy for peritonitis. Ninety-six patients who had a contrast enema were studied. Edema of the ileocecal valve was defined as a persistent filling defect in the cecum after apparently complete hydrostatic reduction, without reflux of contrast into the distal small bowel. In 59 patients hydrostatic reduction was successful: 11 (18.6%) had edema of the ileocecal valve and no reflux contrast into the terminal ileum (group B). All improved clinically after the enema and needed no further treatment. In 37 patients hydrostatic reduction of the intussusception was unsuccessful and an operation was performed: 26 (70.3%) required manual reduction of the intussusception (group C) and 11 (29.7%) underwent bowel resection (group D). None of the patients with edema of ileocecal valve required further treatment or developed recurrent intussusception. In none of the patients who had an operation was the intussusception found to have been reduced by the contrast enema. There were no deaths.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reliability of color Doppler and power Doppler sonography in the evaluation of intussuscepted bowel viability

In two similar cases of irreducible intussusception with wall necrosis and perforation, symptoms had begun 24 h before admission and the plain radiographs showed signs of small-bowel obstruction. The sonographic (US) appearances, however, were different: color Doppler (CD) US showed vascular flow in the intussuscepted bowel in one case and no flow in the other. After radio-clinical assessment, both children underwent surgery and an intestinal resection had to be performed, manual reduction being impossible. The reliability of the US findings and the prognostic value of CD and power Doppler US in determining the viability of the intussuscepted bowel are discussed with a review of the literature.     

Spontaneous reduction of intussusception: verification with US

PURPOSE: To report cases of spontaneous reduction of intussusception. MATERIALS AND METHODS: The authors reviewed the clinical and imaging findings in four patients with intussusception. Patients ranged in age from 3 to 7 months and were seen over a 12-year period. RESULTS: Intussusception was diagnosed with ultrasound (US) in all four patients; however, when enema studies were performed, intussusception was not identified. Repeat US also failed to demonstrate the presence of an intussusception, and all four patients showed concomitant rapid resolution of symptoms. CONCLUSION: Spontaneous reduction of intussusception is probably more common than is generally thought, and its documentation was facilitated with US. It is likely that spontaneously reduced intussusception will be documented more frequently in the future.     

Hydrostatic reduction of intussusception under US guidance

The current nonoperative management of ileocolic intussusception includes hydrostatic and pneumatic reduction, both performed under fluoroscopic monitoring. Recently, a new technique--ultrasound-guided reduction--replaced the conventional approach in our institution. Over a 20-month period, 46 intussusceptions were diagnosed sonographically in 40 patients. In all cases, reduction was attempted under ultrasound guidance by means of a normal saline enema. In 42 cases (91%) reduction was successful and only four patients had to be operated (two resections, two manual reductions). Complications did not occur. This technique permits distinct visualization of the entire process, providing a clear and detailed echogram of the fluid-filled large and small intestine. We established the following definite criteria of reduction: disappearance of the target, demonstration of the ileocecal valve, visualization of the fluid reflux, and fluid filling of small bowel loops. The presented technique for the reduction of intussusception without radiation exposure is reliable and safe, and appears to be one of the most promising methods for the nonoperative treatment of ileocolic intussusception.     

Perinatal intussusception in premature infants

Intussusception is common in infants aged 5 to 18 months, but there have been only 12 reports of its occurrence among premature infants. Nine of these previously reported cases with adequate data and one new case are reviewed. Many of the infants were believed to have necrotizing enterocolitis, leading to an average 12-day interval between the onset of signs and the operation. Bilious emesis or nasogastric contents, bloody stool, and intestinal dilation without pneumatosis intestinalis were common. A contrast enema showed the intussusception in only 1 of 7 cases. Most cases were diagnosed in the operating room and underwent successful primary anastomosis, with no recurrences. A pathological lead point was identified in 2 of the 10 cases. The overall mortality rate was 23%; the one death since 1970 was secondary to attempted hydrostatic reduction. These cases may represent what, in the absence of premature delivery, would have been the intrauterine development of intussusception likely leading to small bowel atresia.     

Chronic intussusception in childhood

A rare case of chronic intussusception is reported. Radiological investigation including ultrasound, CT and barium enema provided the correct diagnosis. Ultrasound revealed a solid mass near the transverse colon in the right lower abdomen. CT demonstrated the real nature of the solid mass as being the classical 'coiled spring' of intussusception. The barium enema was unsuccessful as an attempt at hydrostatic reduction, but confirmed the diagnosis by a 'crescent-shaped' filling defect in the ascending colon. The patient was discharged after an uneventful surgery and recovery. No organic lesion that precipitated the chronic intussusception was discovered at operation. Radiological findings, the typical clinical picture and adequate treatment are discussed.     

US-guided hydrostatic reduction of intussusception in children

Over a period of 3 3/4 years, hydrostatic reduction of ileocolic intussusception was performed under sonographic guidance in 47 cases (a total of 41 consecutive patients). The enema consisted of a mixture of isotonic electrolyte solution and water-soluble contrast medium (9:1 ratio) and was given at a hydrostatic pressure of 80-100 cm water. Reduction was successful in 83% of cases (n = 39). Even initially remaining ileo-ileal intussusception could finally be reduced in two cases. No complications were observed. Since, in comparison with other conservative methods of reduction, the success rate was not substantially worse (versus that of pneumatic reduction) or was even higher (versus that of barium enema reduction), the method described can be recommended for wider use because of the substantial reduction in radiation exposure.     

Trichobezoars

Trichobezoars are accumulations of hair casts in the stomach associated with trichophagia. The typical patient is an adolescent female who presents with alopecia and an upper abdominal mass which on moving can cause intermittent gastric outlet obstruction. Only a minority of patients have severe psychiatric disorders. When hair strands extend from the main mass in the stomach, all along the small bowel and reaching the cecum, the condition is termed the Rapunzel syndrome. In about 5% of patients there are separate hair masses in the stomach. The clinical presentation includes abdominal pain, loss of appetite, weight-loss, vomiting, loose stools, pancreatitis, jaundice, anemia and hypoalbuminemia. These signs and symptoms raise the suspicion of malignancy. Complications of bezoars include ulcers, perforation of the bowel, obstruction and intussusception. Diagnosis can be established either by barium swallow or by CT scan. Ultrasound might suggest the diagnosis, but sonographic features are definitely not pathognomonic. Treatment is surgical, as endoscopic removal is usually unsuccessful. We present 2 children in whom trichobezoars were found.     

Patterns of recurrence of intussusception in children: a 17-year review

PURPOSE: Patterns of recurrence of intussusception (INT) were reviewed to determine whether changes in management have affected the rate and patterns of recurrence as well as long-term outcome in children with multiple (i. e., 2 or more) recurrences. MATERIALS AND METHODS: Review was done of 763 children with 876 intussusceptions, including (1) recurrence rate, (2) patterns of recurrence (number of and interval between recurrences), (3) reducibility, (4) pathologic lead points (PLP), (5) operative findings and (6) long-term follow-up in those with multiple recurrences. RESULTS: Above features (1)-(6) were the same in those managed with barium enema (1979-1985) and those managed with air enema (1985-1996). Overall recurrence rate was 9 %; 11 % with barium enema and 8 % with air enema. Sixty-nine patients had 113 recurrences: 47/69 (68 %) and 1 recurrence and 22/69 (32 %) had multiple recurrences. Multiple recurrences presented as isolated episodes or in clusters up to 8 years. Reducibility was 100 % for initial INT and 95 % for recurrent episodes; there were no perforations. Surgery, in 4 with irreducible recurrence, revealed no PLP. PLP were present in 5 (8 %): 2 (4 %) with 1 recurrence and 3 (14 %) with multiple recurrences. No pattern of recurrence was predictive for PLP. Long-term follow-up (up to 15 years) available in 11 with multiple recurrences revealed a favourable outcome. CONCLUSIONS: Rates and patterns of recurrence did not change with altered management. Because of the high reduction rate of recurrences, lack of perforation and favourable long-term follow-up, we recommend radiological reduction for recurrent INT. Multiple recurrences are not a contraindication. A careful search for PLP is mandatory. Surgery should be reserved for irreducible recurrences or for demonstrated PLP.     

A constipation scoring system to simplify evaluation and management of constipated patients

PURPOSE: Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients. MATERIALS AND METHODS: All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele. RESULTS: A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14-92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P < 0.05). These factors included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal prolapse (9). CONCLUSION: The proposed constipation scoring system correlated well with objective physiologic findings in constipated patients to allow uniformity in assessment of the severity of constipation.     

Intussusception in children and adults in Zaria: a comparison

OBJECTIVES: To compare and contrast the symptomatology and the anatomical type of the intussusception in children and adults in Zaria. DESIGN: Retrospective study. SETTING: Hospital. SUBJECTS: 93 patients with intussusception. MAIN OUTCOME MEASURES: Frequency of intussusception. RESULTS: Colicky abdominal pain featured often enough in both groups with most symptoms and signs decreasing in frequency from infancy to adulthood. The ratio of small bowel to large bowel disease in infants, older children and adults was 1;8:1, 0;6:1 and 1:1 respectively. Infantile intussusception involving the small bowel was more common, and in older children large bowel involvement was commoner, while 50pc of adult intussusceptions were paradoxically small bowel. Overall, small bowel intussusception was most common with the ileocolic variety predominating. CONCLUSIONS: The most common type of intussusception in our environment is the ileocolic variety.     

Residential dampness problems and symptoms and signs of bronchial obstruction in young Norwegian children

To assess the role of dampness problems and house dust mite exposure in the development of bronchial obstruction in early life, a cohort of 3,754 children born in Oslo during 1992 and 1993 was followed for 2 yr. Bronchial obstruction was defined as two or more episodes with symptoms and signs of obstruction or one lasting 1 mo or more. A matched case-control study was carried out in 251 cases of bronchial obstruction (response rate: 98%) and their 251 paired controls. Information on home dampness problem(s), house dust mite exposure, and potential confounders was collected during home visits and by questionnaires. Dampness problems were confirmed in the homes of 27% of the cases and 14% of the controls, while a concentration of Dermatophagoides pteronyssinus allergens > 2 microg/g dust was found in the beds of 11 (4.5%) cases and three (1.2%) controls. In conditional logistic regression analysis controlling for potential confounders, confirmed dampness problems increased the risk of bronchial obstruction (adjusted odds ratio: 3.8; 95% confidence interval: 2.0-7.2). Exposure to D. pteronyssinus allergens > 2 microg/g dust increased the risk of bronchial obstruction (adjusted odds ratio: 2.8; 95% confidence interval: 0.7-11.7). Residential dampness problems in Oslo dwellings seem to increase symptoms and signs of bronchial obstruction in young children, apparently without increasing their exposure to house dust mites.     

Diagnostic imaging in the evaluation of constipation in adults

Acute and chronic constipation are common conditions. In most instances, a thorough history and digital rectal examination provide sufficient information to begin treatment. Occasionally, imaging studies can be useful to confirm the presence of a suspected abnormality. The acute onset of constipation suggests colonic obstruction. Plain abdominal radiographs may be sufficient to determine the level and cause of the obstruction, such as sigmoid or cecal volvulus. Barium enema radiographic examination or colonoscopy may also be useful to detect the cause of obstruction. In patients with chronic constipation, plain abdominal radiographs can be used to show the extent of fecal impaction. Colonic transit time can be assessed on serial abdominal radiographs after the patient has ingested radiopaque markers. Evacuation proctography can be used to diagnose a variety of functional disorders of the rectum and anus, such as rectocele, intussusception and abnormal perineum floor descent.     

Bowel obstruction in a pregnant patient with ileal pouch-anal anastomosis

Bowel obstruction is a rare but serious complication of pregnancy for both the mother and the developing fetus. This report describes the case of 17-year-old girl with ileal pouch-anal anastomosis (IPAA). She presented at 36 weeks' gestation with a complete small-bowel obstruction. Because conservative management was unsuccessful, labour was induced to relieve the obstruction or simplify surgery. Soon after spontaneous vaginal delivery she began to pass copious amounts of flatus and stool. The bowel obstruction resolved within hours. This report illustrates how IPAA alters the anatomy of the gastrointestinal tract, placing the ileal pouch at risk from compressive obstruction by the gravid uterus. Induction of labour in a near-term fetus is a reasonable initial method of management in such women.     

Manual reduction with the index finger for infantile intussusception. A modification of Hutchinson's maneuver

Manual reduction with the index finger (modified Hutchinson's maneuver) enabling simple and safe manual reduction of infantile intussusception is described. The procedure was used in four patients, two boys and two girls, ranging in age from 2 to 15 months, as greater than normal compression was necessary and/or serosal splitting occurred during conventional reduction. The technique is as follows: in addition to the proximal bowel compression with Hutchinson's maneuver, the surgeon inserts his index finger into the intussusceptum via its neck. The finger enables the surgeon to sound a wider space between the intussusceptum and intussuscipiens, which is most likely to be responsive to bowel compression. Although the intussusceptions in the four patients were categorized as ileo-ileo-colic (three cases) and ileo-ileal (one case) types, this manual reduction technique was successful in all cases, no bowel rupture occurred, and hospitalization was no longer than with the conventional procedure. We conclude that this modified Hutchinson's maneuver may contribute to successful surgical reduction of infantile intussusception.     

Predominantly gastrointestinal symptoms and signs in 11 consecutive AIDS patients with gastrointestinal lymphoma: a multicenter, multiyear study including 763 HIV-seropositive patients

OBJECTIVES: Gastrointestinal lymphoma is a distinct subgroup of lymphoma in HIV-seronegative patients. This study analyzes whether gastrointestinal lymphoma similarly forms a distinct clinical subgroup in HIV-seropositive patients. METHODS: Case control study of medical records of 763 human immunodeficiency virus-seropositive patients admitted to three university hospitals from 1986 through 1992, including 22 with non-Hodgkin's lymphoma. Eleven patients (50%) had gastrointestinal lymphoma, and 11 controls had extraintestinal lymphoma. RESULTS: The clinical presentation in patients with gastrointestinal lymphoma was dominated by gastrointestinal symptoms and signs and gastrointestinal complications. Common symptoms and signs included: change in bowel habits, gross or occult blood per rectum, involuntary weight loss, abdominal pain, abdominal tenderness, peripheral lymphadenopathy, cachexia, and hepatosplenomegaly. Significant gastrointestinal complications during the presenting admission included gastrointestinal bleeding in five, intestinal obstruction in one, and dysphagia from an esophageal stricture in one. Subsequent complications included a walled-off perforating gastric ulcer in one and obstructive jaundice in one. In contrast, the control patients with extraintestinal lymphoma had significantly fewer gastrointestinal symptoms and gastrointestinal complications (p < 0.001 and p < 0.01, respectively, Fisher's exact test). Upper gastrointestinal series or barium enema identified lymphomatous gastrointestinal lesions in all seven patients undergoing these tests. The pathologic diagnosis was made from endoscopic biopsies in six of six patients undergoing panendoscopy, and two of three patients undergoing lower endoscopy. Tumor sites included stomach in six, colon in three, ileum in two, esophagus in two, and duodenum in one. Eight patients had extraintestinal lesions at diagnosis, including four with extraabdominal extranodal lesions. The outcome of gastrointestinal lymphoma was poor with all therapies (mean combined survival = 3.6 +/- 2.2 months), and was not significantly different from that for the controls (mean survival = 4.1 +/- 2.7 months, Student's t test). CONCLUSIONS: This study suggests that gastrointestinal lymphoma in AIDS shares the poor prognosis and aggressive features of extraintestinal lymphoma in AIDS, but has unique localizing features at presentation of predominantly gastrointestinal symptoms and signs, and frequent gastrointestinal complications.     

Effects of conjugated estrogens with or without medroxyprogesterone acetate on mammary carcinogenesis, uterine adenomyosis and femur in mice

The Authors report their experience in the treatment of twenty-one patients with intussusception operated in the Paediatric Surgery Division ASL FG/3 between January 1988 and December 1994. Eighty-nine percent of the patients were between 2 and 12 months of age, with a peak between 2 and 6 months (60%). Ultrasound allowed to identify the pathological picture in forty-two percent of the cases and diagnosis was confirmed by barium enema. In 8 patients a pathology more or less responsible of the intussusception or associated with it was detected. The time between the onset of symptoms and admission as well as the relation between intestinal resection and duration of symptomatology were analyzed. The resection rate was maximal (55%) in those patients presenting symptoms beyond 25 hours. Intestinal resection was performed in 9 patients (47%): 6 ileo-colic; 1 ileo-colic resection extended to the splenic flexure; and 2 ileo-ileal ones. In this series no postoperative complications or recurrences or deaths were registered. Long term results proved that ileo-colic resection, even in few-months old infants, is well tolerated.     

The natural course of anterior disc displacement without reduction in the temporomandibular joint: follow-up at 6, 12, and 18 months

PURPOSE: The purpose of this study was to examine the natural course of anterior disc displacement without reduction in the temporomandibular joint (TMJ). PATIENTS AND METHODS: The subjects were patients who had been diagnosed as having anterior disc displacement without reduction in the TMJ, but who had not undergone any treatment. Forty-four patients were followed for 6 months, 38 for 12 months, and 22 for 18 months. Clinical signs and symptoms were evaluated at each follow-up, and the incidence of successful resolution was determined using the criteria established in 1984 by the American Association of Oral and Maxillofacial Surgeons. RESULTS: The range of motion increased at each time during the follow-up period. Tenderness in the TMJ and the masticatory muscles was alleviated, but the noise in the TMJ remained unchanged at each follow-up time. The incidence of successful resolution was 34.1% at 6 months, 50.0% at 12 months, and 68.2% at 18 months. CONCLUSIONS: The clinical signs and symptoms of anterior disc displacement without reduction tend to be alleviated during the natural course of the condition. This should be taken into consideration when anterior disc displacement without reduction is treated.