|Year : 2022 | Volume
| Issue : 5 | Page : 739-745
Bedside hydrostatic saline enema reduction of pediatric intussusception: Our experience
Rahul Gupta, Bhairu L Gurjar
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
|Date of Submission||03-Nov-2021|
|Date of Decision||07-Jan-2022|
|Date of Acceptance||09-Feb-2022|
|Date of Web Publication||11-Jul-2022|
Dr. Rahul Gupta
Associate Professor, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Context: The ultrasound-guided reduction by saline enema is a preferred nonsurgical procedure for intussusception. In a government setup where bedside ultrasound and round-the-clock trained radiologist facilities are unavailable, bedside saline enema reduction (without ultrasound guidance) may be an option. Aims: To evaluate the efficacy of bedside hydrostatic saline enema reduction in the treatment of pediatric intussusception; the secondary aim was to identify the patient subset in which it is more useful. Settings and Design: A retrospective study was conducted from January 2019 to May 2021 in all children with ultrasound-confirmed intussusception at our center. Subjects and Methods: All children were considered for non-operative bedside reduction with saline enema, excluding those with signs of peritonitis and shock. We allowed a maximum of three attempts of saline enema reduction. Results: There were 375 patients admitted with the diagnosis of intussusception in our institute. Out of these, 42 patients were subjected to bedside hydrostatic saline enema reduction. The patients in this group were in the age range of 5 months to 14 years. The success rate of bedside hydrostatic saline enema reduction was 90.47% (38 out of 42 cases). No perforations occurred during the procedure. The duration of symptoms and age of the patients did not influence the successful reduction in our series (p > 0.05). The duration of admission attained a statistically significant difference (p < 0.05) between those who had a successful non-operative reduction and those who subsequently had an operative intervention, that is, reduction or resection. There was no mortality. Conclusion: Bedside hydrostatic normal saline enema reduction of intussusception is a suitable non-operative technique of managing childhood intussusception in the carefully selected subset of patients. The technique is simple, safe, and cost-effective in a resource-limited setup.
Keywords: Bedside, hydrostatic, intussusception, pediatric, recourse limited, saline enema
|How to cite this article:|
Gupta R, Gurjar BL. Bedside hydrostatic saline enema reduction of pediatric intussusception: Our experience. Med J DY Patil Vidyapeeth 2022;15:739-45
|How to cite this URL:|
Gupta R, Gurjar BL. Bedside hydrostatic saline enema reduction of pediatric intussusception: Our experience. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Nov 26];15:739-45. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/739/350687
| Introduction|| |
Intussusception is the most frequent pediatric abdominal emergency. Intestinal spasms, ischemia, necrosis, and even death may occur without prompt diagnosis and treatment. Ultrasound (Color Doppler) and/or radiographs suggestive of the presence of ischemic bowel, perforation, and/or complete intestinal obstruction necessitate operative management., The ultrasound-guided reduction by saline enema is a preferred nonsurgical procedure for intussusception., In our center, bedside/portable ultrasound facilities and round-the-clock skilled radiologists are not available. We have been performing bedside saline enema reduction and would like to share here our experience of using this simple technique that can be used in centers like ours where resources are limited and a skilled radiologist isn't available.
| Aims and Objectives|| |
Primary objective: To evaluate the efficacy of hydrostatic saline enema reduction in the treatment of pediatric intussusception.
Secondary objective: The secondary aim was to identify a patient subset in which it is more useful.
| Material and Methods|| |
This retrospective study was conducted in the Department of Paediatric Surgery of our tertiary care teaching institute. The study was conducted over a period of nearly 2.5 years, from January 2019 to May 2021. The paper was presented by the junior author (Dr. B.L. Gurjar) at the 47th Annual Conference of the Indian Association of Pediatric Surgeons, which was held as a virtual event (E-IAPSCON 2021) on 23rd October 2021.
- All children with ultrasound-confirmed intussusception were considered for non-operative bedside reduction with saline enema.
- Transient intussusception.
- Intussusception with clinical and radiological signs of peritonitis, perforation, intestinal prolapse, complete intestinal obstruction, and shock.
- Postoperative intussusception.
- Lead-point intussusception (complex mass in the center of the intussusception in various sections on ultrasound, distinct from primary intussusception suggestive of secondary intussusception with a lead point).
- Previous ultrasound suggestive of complete intestinal obstruction, echogenic peritoneal fluid, effusion inside the intussusception, and lack of blood flow by color Doppler in the intestinal wall of intussuscipiens.,
A thorough clinical evaluation of all the patients was performed, including their clinical history, complete clinical examination, and comorbidities. In all patients, baseline blood investigation including complete blood counts and renal and liver function tests was performed. Abdominal radiographs were performed in all the patients to exclude complete intestinal obstruction before saline enema reduction.
Parental consent form for study
The procedure, including its necessity and risks, was explained in detail to the parents/guardians. Informed written consent was obtained from them about the study. The parents were explained the purpose of the study. The parents were explained that there is no direct anticipated benefit (financial) to the child. All confidential information collected (patient) would not be shared with anyone else. The patient's parents or guardians consented to and approved all the necessary procedures.
All the medical records were carefully recorded in the spreadsheet, and the information obtained was analyzed according to the objectives of the study. Charts were prepared on patients' demography, clinical presentation, and associated comorbidities and complications, including recurrence. All data analyses were carried out using the statistical analytical software SPSS, version 10.0 for Windows. Inferential statistics with Chi-square test was used to establish the association. A P value of less than 0.05 was considered significant.
The procedure of bedside hydrostatic saline enema reduction
The materials for saline enema were prepared, such as sufficient normal saline, an infusion rack, tailored intravenous (IV) set, lignocaine jelly, and bedsheet. IV set is tailor-made after removing the Luer connector [Figure 1]. The treatment room was equipped with an ECG monitor, central oxygen supply, a sphygmomanometer, and so on in case of emergency. Operation theatre was informed regarding the case before the procedure. Adequate hydration was achieved, intravenous antibiotics were initiated, and pre-procedural IV dexamethasone (1-2 mg/Kg IV) was given. The procedure was performed without sedating the patients. A well-lubricated end (injection site end) of the tailored IV set was softly introduced per-rectally. The injection site end is made of rubber material and its proximal part snugly enters into the anal canal preventing its dislodgement. The IV set was connected to the saline bottle. The saline bottle was kept at an extra height of 100 cm above the level of the bed. The parents kept company and held the child meticulously on the thigh to seal the anus against leakage. The child was wakeful in the supine position and observed during the entire procedure. Then transabdominal manual manipulation was performed to assist reduction by gently pressing the abdomen counter-clockwise to drive the liquid from the left to the right abdomen toward the intussuscipiens. The saline infusion was kept at a rate to slowly fill up the colon over a period of approximately 30 minutes. Approximately 200–500 ml of normal saline was infused depending on the age and weight of the child. Strict monitoring of the child was performed during the reduction procedure. Positive endpoints were passage of motion and flatus during the procedure, the disappearance of the palpable lump, or abrupt cessation of crying spells and pain. Negative endpoints were aggravation of symptoms and clinical deterioration necessitating emergency laparotomy. The next morning, ultrasounds were performed for confirmation of reduction/length of the segment. The presence of symptoms and residual length of the intussusception guided further management. In patients with negative endpoints, post-procedure, abdominal radiographs were performed to see the abdominal gas pattern and presence of pneumoperitoneum and level of the obstruction. We allowed a maximum of three attempts of saline enema reduction. Follow-up was performed weekly for 2 weeks, then monthly for 3 months, and then tri-monthly for 1 year.
|Figure 1: Photograph showing tailored intravenous (IV) set after removing the Luer connector (black arrow) from the injection site end (made of rubber material) of the IV set which is introduced per-rectally; infusion rack having normal saline with well-lubricated tailored intravenous (IV) set|
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| Results|| |
There were 375 patients admitted with the diagnosis of intussusception in our institute. Out of these, 42 patients were subjected to bedside hydrostatic saline enema reduction (as per the exclusion criterion). The patients in our study sample were in the age range of 5 months to 14 years; 18 (42.85%) were infants; 22 (52.38%) were aged below 2 years. Out of 20 (47.62%) patients aged above 2 years, 18 (42.86%) were aged between 2 and 5 years. Maximum (18) number of patients were in the 2–5 years age group [Table 1]. The median age group was 1.6 years. There were 34 males and 8 females (M: F = 4.25:1) as depicted in [Figure 2].
|Table 1: Clinical characteristics, including age distribution, presenting complaints, and the type and length of the intussusception, along with attempts with saline enema reduction in our study|
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|Figure 2: Pie chart showing the sex distribution of patients in our study|
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Pain in the abdomen and/or excessive crying spells were presenting complaints in all 42 (100%) patients [Table 1]. Bleeding per rectum was seen in 2 (4.76%) cases. On clinical examination, lump per rectum was palpable in 2 cases. Ileocolic was the most common (92.86%) type [Table 1]. Slightly more than 50% of the patients (n = 22, 52.3%) out of the 42 presented after 2 days of illness; the duration of illness ranged from 1 to 4 days [Table 1].
Length of the intussusception on ultrasound ranged from 1.5 cm to 7.5 cm; for the maximum number of patients, 11 of them, the length of the intussusception was in the range of ≥5 cm to <6 cm [Table 1]. Overall, in 30 (71.43%) patients, reduction of the intussusception was attempted in one or two attempts. In 12 (28.57%) cases, reduction was attempted with a maximum of three attempts. In 10 cases (23.81%), reduction was successfully achieved in only one attempt with hydrostatic saline enema. In 18 out of 20 patients, reduction was accomplished with only two attempts with hydrostatic saline enema. For the remaining 2 patients, no further attempt was made as there was ongoing bleeding per rectum. In 10 out of 12 patients, reduction was accomplished with three attempts with hydrostatic saline enema. In all 4 cases with failed saline enema reduction, duration of admission to the hospital (admission in the medical ward) was more than 48 hours. The success rate of bedside hydrostatic saline enema reduction was 90.47% (38 out of 42 cases). There were no complications (perforations, peritonitis) during the procedure; there was no mortality. In all 4 failed cases, an exploratory laparotomy was performed. Per operative manual reduction was performed in 3 cases, while resection anastomosis was performed in 1 case. No lead point was observed in any of the patients with failed hydrostatic saline enema reduction (exploratory laparotomy). The reasons for the failure of hydrostatic saline enema in 3 out of 4 patients were marked bowel edema, congestion, and tight intussusception. In 1 patient, terminal ileum remained markedly dusky (after application of 15 minutes of warm saline sponges) after per-operative reduction precipitating resection anastomosis of the ileum.
As many as 38 patients (managed successfully with saline reduction) were discharged within 24 to 72 hours of admission. In the other group, the post-operative stay ranged from 3 days to 8 days. Duration of symptoms and age of the patients did not influence the successful reduction in our series (p > 0.05) [Table 2]. Duration of admission attained a statistically significant difference (p < 0.05) between those who had a successful non-operative reduction and those who subsequently had an operative intervention, that is, reduction or resection. There was no recurrence in our series on a one-year follow-up.
|Table 2: Percentage of successful reduction with saline enema as per the duration of illness in our study (p = 0.89)|
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| Discussion|| |
Intussusception is defined as the invagination of one portion of the intestines (intussusceptum) into the contiguous distal segment (intussuscipiens). It is a common (incidence of 1 to 4 per 2,000) surgical emergency and the most common cause of bowel obstruction in infants and toddlers. Most (90%) of the intussusceptions are ileocolic type., Common symptoms and signs include colicky abdominal pain, vomiting, palpable abdominal mass, and currant jelly stool.
Different methods of non-operative reduction are preferred as per the institutional policy and experience. A barium enema is the standard procedure for both the diagnosis and therapeutic reduction of intussusception; it has its risks and complications. The ultrasound-guided reduction of intussusception by saline enema has gradually become a preferred nonsurgical procedure worldwide for pediatric intussusception since first described by Kim et al. in 1982. The other non-operative methods of intussusception reduction are fluoroscopy-guided barium or air contrast enema. Recently, stethoscope-guided pneumatic reduction in resource-limited setup with non-availability of ultrasound has been published.
Successful reduction can rapidly alleviate symptoms in children and evade surgery and its complications. It is reported that the reduction rate of saline enema is high, and complications such as perforation were rare, generally less than 1%. The success rate of hydrostatic saline enema may be as high as 90%. In addition, hydrostatic saline enema reduction is associated with less patient discomfort and shorter hospital stay as compared to the surgical modality of treatment.
In a similar series of 51 children with 56 intussusceptions from Nigeria, the success rate of sonographic-guided hydrostatic saline enema reduction was 84.4%; however, in our series, the success rate was 90.47% (38 out of 42 cases) even without sonographic guidance. The high success rate in the present series was due to carefully selected patients as per the inclusion criteria, while the success rate was lower in the earlier series because only consecutive patients were selected for reduction. In their series (18 months duration), the perforation rate during the procedure was 4.4%, while it was nil in the present series. Also, no patient in our series suffered from recurrence of intussusception within the 6-month to 1-year follow-up, while in the earlier series, the recurrence rate was 7.5%. The duration of the procedure ranged between 3 and 25 minutes in one series, while in the present study saline infusion was kept at a rate to fill up the colon over a 30-minute duration. This fill-up process was slowed down to prevent complications, especially perforation, as the reduction was carried out without ultrasound guidance.
The duration of symptoms is an important predictor of the outcome of hydrostatic saline enema reduction of intussusception in children. Longer duration of symptoms (>24 hours) has been associated with failure of non-operative reduction of intussusception. In the present series and also in some previous studies, the duration of symptoms did not influence the successful reduction of intussusception., Longer duration of admission to the hospital (>48 hours) were associated with failure of non-operative reduction and subsequently warranted operative intervention.
Also, the presence of bloody stool is one of the important risk factors for failure of hydrostatic saline enema reduction or other methods of non-operative reduction.,, Unsuccessful reduction was observed in patients with rectal bleeding compared to those without rectal bleeding with a statistically significant difference. Similar findings were present in our series. A review of the literature also illustrates that rectal bleeding decreases the success rate of non-operative reduction., Rectal bleeding is a pointer toward edema and circulatory impairment of intestines and is seen in 60% of the cases. In our study, rectal bleeding was present in only 4.76% of the patients, which is very low compared to the other series (62% of patients). The low percentage is purported to be due to carefully selected cases in our study.
Infants and children below 2 years of age with intussusception are idiopathic types. Also, patients aged above 2 years may be associated with the pathological lead point of intussusception. It is observed that there is an apparent shift toward an older age (beyond 2 years) in relation to the occurrence of idiopathic intussusception. The shift of cases of idiopathic intussusception in patients older than 2 years of age has been described by research from Taiwan, Singapore, and the USA.,, Saline-enema reduction is suitable for infants or for children younger than 2 years with intussusception, as they are rarely associated with lead points. There is a shift of cases of idiopathic intussusception aged above 2 years; this has been reported by other authors as well as observed in the present study.,, In our series, out of the 20 (47.62%) patients aged above 2 years, 18 (42.86%) were in the age range of 2 to 5 years. This justifies saline enema reduction for older children with intussusception.
As per one study, the success rate of non-operative reduction was lower in patients in whom the invaginated segment length was >7 cm. In other series, this relationship between the length of the invaginated segment and the success of the procedure was absent. In our study, failure of reduction was observed in 2 cases with invaginated segment length >5 cm and also 2 cases with invaginated segment length >6 cm.
Successful reduction was achieved in 55% (50) of patients in the first attempt, according to the latest study published in Turkey. In our series, it was accomplished only in 23.81% of children in the first attempt, while 42.86% and 23.81% got successfully reduced in second and third attempts. Thus, a total of 66.67% and 90.47% cases were successfully reduced after two and three attempts, respectively. A maximum number of reductions were achieved in the second attempt, which was also seen in a study from the USA.
In our study, dexamethasone was used during the procedure to facilitate reduction and prevent recurrence. Steroids have been suggested as a treatment to decrease the chance of recurrence of intussusception., Dexamethasone acts by amelioration of lymphoid hyperplasia. As per Cochrane systematic review, administering steroid medication such as dexamethasone to treat children with intussusception may reduce the recurrence of intussusception.
An Egyptian research study performed a controlled trial in the assessment of using dexamethasone injection in preventing or minimizing the frequency of recurrence during ultrasound-guided saline enema reduction for intussusception. As per their study, the percentage (82.5%) of patients with successful reduction in the dexamethasone group was higher than that of the group who did not receive dexamethasone (77.1%). Though the difference between both groups was statistically insignificant, there was a statistically significant difference between both groups regarding the early recurrence rate, which was significantly higher among the group who did not receive dexamethasone.
The duration of hospital stay was significantly short in the cases managed successfully with saline reduction, as they were discharged within 24 to 72 hours of admission. Also, these patients became asymptomatic immediately after the reduction and pain-free. This is an important factor considering the bedside early reduction rather than waiting for ultrasound-guided reduction next morning, which prolongs the duration of symptoms in these patients and increases the chances of bowel ischemia and/or operative reduction.
In the case of non-availability of round-the-clock bedside ultrasound in a high-volume center and a clinically stable condition after optimization, a bedside saline enema reduction should be considered with a maximum of three attempts. Our series has proven that our technique is safe and effective and can be easily performed at any hospital with resource limitations. Hence, we can avoid unnecessary laparotomy (90.47%) in carefully selected patients at centers where skilled round-the-clock radiologists are not available. The limitation of the present study was its small sample. Thus, a larger cohort of patients for the study is being contemplated in the future.
| Conclusions|| |
In the case of non-availability of round-the-clock bedside ultrasound in a high-volume center and a clinically stable condition after optimization, a bedside saline enema reduction should be considered with a maximum of three attempts. Bedside hydrostatic normal saline enema reduction of intussusception is a suitable non-operative technique of managing intussusception in children. With this technique, we can avoid unnecessary laparotomy (90.47%) in carefully selected patients. The approach is a simple, safe, and cost-effective treatment option in an environment with limited resources.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
We are sincerely thankful to the faculty, especially Dr. Praveen Mathur, HOD of Pediatric Surgery, and Dr. Arun Gupta, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]