Dr. Jose Campos is back, this time helping us review some of the latest literature on the diagnosis and management of intussusception in children. In this podcast, we're reviewing a typical case with Dr. Todd Ponsky and incorporating literature from the last few years.
Hosts: Rod Gerardo and Ellen Encisco
Tsou, Po-Yang, et al. "Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: a systematic review and meta-analysis." The American Journal of Emergency Medicine 37.9 (2019): 1760-1769. Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis
Liu, Shu Ting, et al. "Ultrasound-guided hydrostatic reduction versus fluoroscopy-guided air reduction for pediatric intussusception: a multi-center, prospective, cohort study." World Journal of Emergency Surgery 16.1 (2021): 1-7. Ultrasound-guided hydrostatic reduction versus fluoroscopy-guided air reduction for pediatric intussusception: a multi-center, prospective, cohort study - World Journal of Emergency Surgery
Patel, Dhruv M., et al. "Radiographic findings predictive of irreducibility and surgical resection in ileocolic intussusception." Pediatric Radiology 50.9 (2020): 1249-1254. Radiographic findings predictive of irreducibility and surgical resection in ileocolic intussusception
Gondek, Andrea Soria, et al. "Ileocolic intussusception: Predicting the probability of success of ultrasound guided saline enema from clinical and sonographic data." Journal of Pediatric Surgery 53.4 (2018): 599-604. doi.org/10.1016/j.jpedsurg.2017.10.050
Feldman, Oren, et al. "Success rate of pneumatic reduction of intussusception with and without sedation." Pediatric Anesthesia 27.2 (2017): 190-195. doi.org/10.1111/pan.13045
van de Bunt, Jascha A., et al. "Effects of esketamine sedation compared to morphine analgesia on hydrostatic reduction of intussusception: A case‐cohort comparison study." Pediatric Anesthesia 27.11 (2017): 1091-1097. doi.org/10.1111/pan.13226
Litz, Cristen N., et al. "Outpatient management of intussusception: a systematic review and meta-analysis." Journal of pediatric surgery 54.7 (2019): 1316-1323. doi.org/10.1016/j.jpedsurg.2018.09.019
Vo, Andrea, et al. "Management of intussusception in the pediatric emergency department: risk factors for recurrence." Pediatric Emergency Care 36.4 (2020): e185-e188. Pediatric Emergency Care
Ferrantella, Anthony, et al. "Incidence of recurrent intussusception in young children: A nationwide readmissions analysis." Journal of pediatric surgery 55.6 (2020): 1023-1025. doi.org/10.1016/j.jpedsurg.2020.02.034
Type: podcast · 20 min · posted 2022-02-15 Canonical: https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092 ## Chapters - [0:00](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=0) Case Presentation and Initial Diagnostic Approach - [2:12](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=132) Point-of-Care Ultrasound for Diagnosis - [4:51](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=291) Reduction Techniques: Air Enema vs Saline Enema - [7:05](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=425) Predictors of Failed Reduction - [9:33](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=573) Sedation and Analgesia During Reduction - [12:32](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=752) Post-Reduction Disposition and Recurrence - [17:06](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=1026) Summary and Clinical Implications ## Statements - "Point-of-care ultrasound for intussusception diagnosis has approximately 95% sensitivity and 99% specificity" — Rod Gerardo (clinical) [2:12](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=132) - "Ultrasound-guided hydrostatic reduction has a 95.8% success rate versus 93.1% for fluoroscopy-guided air reduction" — Rod Gerardo (clinical) [5:50](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=350) - "Obstructive gas pattern on radiograph is associated with decreased success of air enema and increased need for bowel resection" — Rod Gerardo (clinical) [7:58](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=478) - "A prediction model using clinical and sonographic data can identify 80% of failed ultrasound-guided saline enema reductions before the procedure" — Rod Gerardo (clinical) [8:50](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=530) - "Free fluid and extension beyond the splenic angle are sonographic predictors of failed reduction" — Rod Gerardo (clinical) [9:06](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=546) - "Altered Doppler signal is a predictor of failed enema reduction" — Rod Gerardo (clinical) [9:06](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=546) - "Sedation during pneumatic reduction has slightly better success rate than no sedation, but the difference is approximately 7%" — Jose Campos (clinical) [10:12](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=612) - "Bowel perforation occurred in 3 patients in the sedation group and none in the non-sedation group, but this was not statistically significant" — Jose Campos (clinical) [10:12](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=612) - "Recurrence rate was 5.1% with sedation versus 1.3% without sedation, not statistically significant but concerning" — Jose Campos (clinical) [10:12](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=612) - "Ketamine sedation had 90% success rate versus 70% for morphine analgesia during hydrostatic reduction, but difference was not statistically significant" — Rod Gerardo (clinical) [11:27](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=687) - "Recurrence rates were 10% for ketamine and 15% for morphine, not statistically significant" — Rod Gerardo (clinical) [11:27](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=687) - "There were no bowel perforations in the ketamine versus morphine comparison study" — Todd (clinical) [11:27](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=687) - "Systematic review found no significant difference in emergency department returns, recurrence, need for operation, or mortality between inpatient and outpatient management after successful air enema reduction" — Rod Gerardo (clinical) [13:23](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=803) - "Nationwide database study of 8,289 patients found 3.7% readmission and recurrence rate after intussusception reduction" — Rod Gerardo (epidemiological) [15:31](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=931) - "Single-center study of 200 cases found 13.5% overall recurrence rate with 7.3% recurring within 48 hours" — Todd (epidemiological) [16:17](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=977) - "Fever and female sex are risk factors for early recurrence of intussusception" — Todd (clinical) [16:17](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=977) - "Point-of-care ultrasound results are institution-dependent and require adequate training and volume" — Todd (opinion) [2:52](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=172) - "It would be irresponsible for an institution to adopt emergency department point-of-care ultrasound based solely on published sensitivity/specificity data without adequate local training" — Todd (opinion) [3:50](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=230) - "Standardized point-of-care ultrasound training in residency programs is likely more than 5-10 years away in the United States" — Todd (opinion) [3:50](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=230) - "If obstructive gas pattern predicts bowel resection but not perforation risk, attempted enema reduction is still worthwhile" — Todd (opinion) [7:58](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=478) - "If sedation is equally safe for perforation as no sedation, then sedation should be used for patient comfort" — Todd (opinion) [11:47](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=707) - "COVID-19 hospital resource constraints are forcing reconsideration of traditional admission practices" — Todd (opinion) [13:46](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=826) - "Clinicians should increase tolerance for recurrence risk if it benefits the majority of children by avoiding unnecessary admission" — Jose Campos (opinion) [16:59](https://library.globalcastmd.com/watch/case-based-journal-review-intussusception-in-2022-5092?t=1019) ## Transcript Hey there, everybody. This is Rod Girardo. Ellen Francisco. We're a research resident at Cincinnati Children's Hospital. And over the past six months, we were looking at some of our most popular podcasts. And one of them was a podcast where we basically did like a lit review, but in this format of a case presentation with Dr. Jose Campos, a pediatric surgeon from Santiago, Chile. So we thought, let's do another one. And that's what we're doing today. Yeah. So we had a case again. This time we have an 18 month old male presenting a day of fussiness, abdominal pain, nausea, vomiting, and bloody stools. Of course, he recently recovered from a mild upper respiratory virus. Yeah. He hasn't wanted to eat for the last day. When you see him, his heart rate is in the hundreds. He's normal intensive. He's not febrile. His abdomen is soft. He's tender throughout the abdomen, but not peritonitic. And he does have a palpable mass in the right lower quadrant. Yeah. So let's talk about first impressions. This patient should reasonably go get a workup for intussusception. I would start off with an abdominal x-ray. I work in a limited resourced environment. So we don't have ultrasound at night. Actually, we don't have ultrasound up to 2 p.m. many times. So it's actually difficult to come up with a diagnosis of interception sometimes. Okay. So we get an x-ray, which is suspicious for intussusception. So what would we get next? Ultrasone. If you're thinking specifically intussusception, I think you go for an ultrasound. Would you favor getting an ultrasound in radiology or from one of the ED doctors if they decide to do it just at the bedside? I would only accept radiology. I would only accept radiology because you have to do an intervention after that. So if it's positive, you have to do an intervention, whether it is enema reduction or surgery. And at least I'm not trained in point-of-care ultrasound and neither are the emergency doctors I work with. But I think it's something interesting and worth looking at it. So all the articles we're going to talk about are linked below as usual, if you want to read along. But the one we're talking about now is called Accuracy of Point-of-Care Ultrasound and Radiology Performed Ultrasound for Intussusception. And this one was published in the American Journal of Emergency Medicine in 2019. And basically they want to know like, how is POCUS and how good is it in diagnosing intussusception in children? What they found in their study that it was actually about 90, almost 95% sensitive and 99% specific in diagnosing intussusception. And this was a pretty large sample that they used for it. This is actually a lot better than a lot of us would predict. This study tells me that if you're at a high volume center and other people other than the radiologist have gotten good at doing ultrasounds, whether that's the surgeons, whether that's the emergency room doctors, that if they do enough of something, they have good enough results. Other than that, I don't think this paper should change anyone's practice because it's totally institution dependent. To me, this article changed a lot because sometimes we do unnecessary laparotamins in the middle of the night just to just to make a diagnosis because we don't have a radiologist at night at our institution and we don't have any formal training in point of care ultrasound. I agree with what you said that anyone that does it, it becomes good at it. But from an institution that doesn't have it, I feel very keen on getting trained on point of care ultrasound after reading this. I think it would be irresponsible, I'm going to be that bold to say, irresponsible for an institution to look at this study and say, see, we can use our ER data now. The second point you said, I think is a great point. And so maybe this does have a little more practice changing capability in that an institution like yours that is limited in radiology ultrasound should then present this to the hospital and say, hey, look, if we get enough volume, we may get to the point where we can make these diagnoses on our own. And so the program should be initiated to start putting more emphasis and use of point of care ultrasound. I think we're more than five or 10 years from this being the standardized part of residency training in the United States, whether it's an emergency medicine or general surgery or whatever. So what are we going to do next and for this patient? Here, the options are fluoroscopy guided air enema, ultrasound guided saline enema, laparoscopy or laparotomy. I would do an air enema, but that's because that's what we do at our institution. We're doing a lot of laparotomies. We only have radiologists during the daytime and the radiologist is the one that does our enemas, but we many times end up doing laparoscopies or laparotomies for these children. So to help answer this question, we have another article published in the World Journal of Emergency Surgery in 2021. This one's titled, Ultrasound Guided Hydrostatic Reduction versus fluoroscopy guided air reduction for pediatric intussusception. For this particular question was looking at ultrasound guided hydrostatic reductions versus fluoroguided air reductions. So this was a prospective study from a few years ago, 2017 and 2018 in China. The results they found that ultrasound guided hydrostatic reduction had a higher success rate, but you can see, as Jose pointed out, that there's like a 2% difference, so 95.8% success rate versus 93.1% success rate of the air enema. After reading this, well, it's an interesting paper, it's well done, but I don't think anyone should change from air, doing air enema. So again, I'm going to disagree with Jose, which is why it's good we have multiple opinions here. I agree that this study should not change your management out of a hope of having improved outcomes. However, it validates an alternative method of reducing the intussusception that shows at least equivalent results if you know how to do it. Yeah, that makes sense. I mean, if it's basically equivalent in results and outcomes, then yeah, I agree why I switch, but I'm not sure that's a good question about the radiation. They do point that out. All of this culminating together, the one common question that needs to be asked is, could we change paradigm where we do a lot of this strictly in the emergency department? They learn how to do the ultrasound, they may be able to learn how to do the reduction as well. All right, Ellen, we gotta keep moving here. We asked the radiologists to do the air enema, um, iliocolic insusception, but they tell us that on the x-ray, the bowel gas pattern appears obstructive, you know, therefore, they predict the reduction will be unsuccessful. I have had radiologists say to me, by the look of the ultrasound, they think that the chance of reduction is low and they would be concerned about perforation. My answer is go for it. I share the same opinion. I would just go for it. Regarding the obstructive view, I think it depends on how many hours the patient has presented to the emergency. So this article is titled Radiographic Findings Predictive of Irreducibility and Surgical Resection in Iliocolic Intusception, and it was published in Pediatric Radiology in 2020. They looked at the radiographs of patients with intusception and tried to look for findings that would, that were more associated with, um, failed air enema reduction. And then the ones that they found, if they had a obstructive gas pattern, as opposed to a normal bowel gas pattern on the radiographs, and they had a decreased success of the air enema and increased complicated surgical co-reductions, meaning they had to resect bowel. But I'm still not convinced that this single co-hole retrospective study is enough for me to, to trust this idea. But actually you're making a really good point, Todd. If it's not related to, to bowel resection, it's still worth trying. Just to summarize that, I did not know that, and it makes total sense, that if you see a bowel obstruction, it's been there long enough that the chances are low and that what to do with that, I don't know, but it is interesting. All right. So we had a second article discussing this topic. It's called Iliacolic Intusception, predicting the probability of success of ultrasound guided saline enema from clinical and sonographic data. This one was published in the Journal of Pediatric Surgery in 2018. Yeah. And this one created a model to try to predict who would fail ultrasound guided saline enema. Yeah. This one's interesting because it creates a prediction rule. And actually, they tried this prediction rule in real patients and they were able to identify 80% of failure. So before doing the enema, you can actually find out if it's going to be successful or not. So... Also looked at, you know, because all of you just built free fluid as being something to look into and if it's beyond the splenic angle. And whether, if you have an altered Doppler signal, those are also, those are other things to look at. The next question, if we decide they're going to do an air enema to reduce it, what do we think we should give for analgesia or sedation? Mm-hmm. And we give them analgesia based on opioids. That's it. We don't do any sedations or sedation or anesthesia for them. So I was actually very interested in finding out whether the reduction rate is less with sedation or anesthesia. So we have two papers. The first one is called Success Rate of Pneumatic Reduction of Interception with and Without Sedation. And it was published in Pediatric Anesthesia in 2017. The success rate is slightly better for sedation. Bowel proliferation is three on the sedation group, none in the non-sedation group, but that's not statistically significant. But again, the reference rate, it's a bit higher, 5.1 with the sedation group and 1.3 with the non-sedation group. Non-significantly different, but again, it gives you a bit of a red flag about that. Yeah. I don't know if we have a say in that necessarily, but I agree with what Jose is saying. I feel like if it makes the patient more comfortable and the family more comfortable for the procedure, these numbers aren't dramatically different to me. I know that they found significant difference in the success rate, but it's like 7% difference. It's not enough to convince me. I feel like, why not just make this kid comfortable when you're going to do it? But that would lead us then to the next article. I mean, if you are going to use sedation, then which sedation would you use? The next study, which is in Pediatric Anesthesia titled Effects of S-ketamine Sedation Compared to Morphine Analgesia on Hydrostatic Reduction of Intestiception Case Cohort Comparison Study. And what they ended up finding was non-significant differences between ketamine and morphine. So the success rate for ketamine was 90. The success rate for morphine was 70%. And then the recurrence rates were 10 and 15 respectively. So all non-significant. And then Todd, there were no bowel perfs in this one. If we feel that it's equally safe, and you said the first study was not statistically significant. If these studies show that sedation is not any more dangerous for perforation than non-sedation, then I agree with you in sedating them. For me, it's difficult to understand why sedation, analgesia, nothing, or anesthesia would change your risk profile. I agree with Rod. I would love to give sedation for these children. But having a look at this article, the numbers are not significant. I find this interesting, and I want to move forward to sedation from nothing or just analgesia. But I would like to see a bit of a larger study ensuring myself and the families that sedation is as safe as the other one. So we do the eridema in this case, it's successful. The question now is, what do we do with them? Do we send them home from the ED, admit them overnight, or admit them until they can eat a full diet or admit them for 48 hours? So historically, watch them overnight. I know there's recent data to support sending them home. In fact, I think our hospitals have established a new protocol for that. My answer is, I think the data is strong enough that it's okay to send these patients home if they meet criteria. It's going to be a culture shift. I'm open to it. I would keep them overnight. We have a study again. So this one's about outpatient management of interception. This one's a systematic review of meta-analysis from JPS in 2019. And so these authors looked at 10 studies of pediatric patients undergoing air enemas and looked for the outpatient management and if it was safe for these patients. They found no significant difference in the rate of returns to the emergency department, recurrence or need for operation or mortality in patients who were inpatient versus those who were managed on an outpatient and they were sent home from the ED. Now, I will say, interestingly, during COVID, as hospital beds are becoming a scarcity, staff is a scarcity, we're going to be forced to try things we didn't do before. And this is going to be one of those. This is a pure example of looking at the possibility of not just admitting because we used to. And if we have a study that shows that it's safe, that should be compelling enough for us to consider sending these patients home. I would also be willing to change my practice up to looking at these results. And I agree with the comment you made. I think we've all seen the benefits of the ERAS protocols and it's really nice to see these numbers. I think on our appendicitis podcast that we did in this fashion, just talk about COVID and getting patients out of the hospital or keeping patients from getting admitted and stuff like that. It's unfortunate we're having the same conversation six months later, but you know, it's true. It's happening again. And here we are talking about how to keep patients out. Let's say that this child goes home, they go home. What do you think the recurrence rate is for these patients with intussusception who get reduced successfully? I was always told, and I've been telling patients for years, 15 to 20%. And every time I say it, I feel like I'm kind of lying because I know I've been told that number. Anecdotally, it certainly does not seem to me to be 15 to 20%. I share that same feeling. I feel like I lie when I'm saying the number I have in my mind, but actually my number is 10%. That's the number I tell residents, not the number I tell families, 10%. Okay. So this study, Incidents of Recurrent Intussusception in Young Children, Nationwide Readmissions Analysis from Journal of Pediatric Surgery in 2020. This study is done on a database. It's a retrospective search of 8,289 patients. Comes out from University of Miami, Middle School of Medicine. And the readmission and recurrence rate is 3.7%. The thing about this article is that our group on this Zoom call was surprised, maybe you are too, that the readmission and recurrence rate was so low at 3.7%. But to contrast that, we have another study. This one's called the Management of Intussusception in the Pediatric Emergency Department Risk Factors for Recurrence. This is from Pediatric Emergency Care in 2020. And it looked at possible risk factors for recurrence after an air enema. And they had a sample size of 200 cases. And they found a 13.5% recurrence rate with a 7.3% recurrence rate within 48 hours. And they looked at specific factors to predict who might recur. They found that fever and being a female were two factors associated with early recurrence. Both of these articles, whether you go with the smaller study or the larger study out of Miami, both of them have a smaller or a, what do you call it, a much less recurrence rate than what you and Todd were talking about. I think we have to be okay with sending patients home if we can become more tolerant of recurrence and really understand, do they really need to stay in the hospital just because there's a chance of recurrence? That's the question that we need to ask. And here also, the number I've given is 48 hours. I don't know anyone that's going to keep an intussusception for 48 hours. So really, it's how much happens in 12 hours. Because when you admit them, you send them home the next morning. I think for me, it depends on the risk of sending them home, not just the recurrence. And for me, that wouldn't stop me from sending them home. Increasing our recurrence or failure tolerance, it benefits the vast majority of children with lower chances of getting a complication. Okay, so in summary, we have this patient with intussusception. We talked about first how to diagnose intussusception, whether or not, you know, some in some centers are using a point of care ultrasound. And some are using radiology, ultrasound guided. And that one, we kind of figured it's really up to you and your institution. Not everyone's going to be really good at point of care ultrasounds. So maybe play that one by ear. Right. And then the next thing is, if we do see illicolic interception, what do you do next? How do you intervene? And we had some differences in where Jose and Todd were from, meaning that Jose's in the middle of the night often finds themselves doing laparotomies for this. Whereas here, frequently, you know, we do air or saline enemas. Yeah, which I think brings to light, not just how international our zoom call was, but how international our audience, I think is. And, you know, I think that this might vary depending on where you practice as well. It seems like the take home point here was, if there is a way that we could reduce the amount of unnecessary surgery that a child is subjected to, then we should at least try to move in that direction. So then we talked about possible criteria for irreducibility with either an air enema or a saline enema. We talked about two different articles here. If you can take a moment and read these so you can kind of get an idea of what to keep an eye out for when you have these patients with illicolic interception. If you have some new signs, you won't necessarily not try the air enema, but you'll kind of have in the back of your mind, I may need to go to the OR with this patient. So then with radiology for, you know, an air enema or a saline enema, and next question is, or the question was, what should we give the patient for sedation or analgesia? You read a couple of articles about different things, either propofol or ketamine or just some morphine. There may be different opinions out there. But it seems like our group was thinking, whatever your opinion is, just make sure that the child is comfortable for the procedure. So then we get, say our esteriduction was successful, and then we're talking about disposition for the patient. Can we send them home? An article looking at outpatient management, meaning probably safe for these patients who are successfully reduced to be sent home. It seems like it is safe in this day and age to send a child home after successfully reducing their intestinception, if you are comfortable with that recurrence rate. Yeah, that's the last time we talked about is the recurrence rate and maybe some factors to predict recurrence. A quick review of recent literature on how to manage intestinception from when they come into the door to when they're going home or coming back from home. If you like this episode and you want to hear more like this, let us know in the comments. If anyone out there has a topic they might want to see a lit review on, leave a comment, let us know. Follow us on social media, subscribe to our YouTube channel, download the Stay Current Pediatric Surgery app. But until then, I'm Rod. And I'm Ellen. And remember, knowledge should be free. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai