Successful treatment of intussusception by hydrostatic reduction in pediatric patients: Is everything okay?

Abstract

Aim: Intussusception, which is defined as telescopic insertion of proximal bowel segment into distal bowel segment, can be cured completely with surgical intervention. Intussusception can be successfully treated by ultrasound guided hydrostatic reduction (USGHR) if there is no necrosis or perforations of intestines. However, misdiagnosing or omitting secondary conditions which can be seen together with intussusception leads to an inevitable rise in morbidity. In this study, we would like to present a retrospective review of the intussusception patients which developed complications due to misdiagnosis within a pediatric surgery clinic in terms of diagnosis and treatment.

Methods: 12 patients who were treated for intussusception using USGHR between May 2014 and September 2017 in Van Yuzuncu Yil University Faculty of Medicine Pediatric Surgery Department were retrospectively reviewed for missed conditions and coincidental pathologies. The data about these case series such as age, sex, patient symptoms, diagnosis and treatment methods, complications and hospitalization periods were evaluated.

Results: 12 (5 Female – 7 Male) patients, who were diagnosed with invagination with complaints of abdominal pain, refractory emesis, crying attacks, bloody stool and abdominal distension that treated with USGHR with a mean age of 34 (Range 6 – 98) months, showed a worse clinical prognosis due to missed secondary conditions. Missed secondary pathologies included appendicitis (3 cases), lymphoma (1 case), Meckel diverticulitis (1 case), appendiceal intussusception (3 cases), acute gastroenteritis (3 cases) and Henoch-Schonlein Purpura (1 case). The patient with Henoch-Schonlein purpura diagnosis was treated with USGHR in combination with corticosteroids and all the other cases required open surgery. Follow-up of the patient with Henoch-Schonlein purpura is ongoing whereas all the other cases were treated successfully.

Conclusion: Although most intussusception cases are successfully treated with non-surgical USGHR treatments in our pediatric surgery clinic, missing the conditions that are seen with invagination causes an increase in surgical intervention rates, morbidity rates and medical costs. The main challenge for pediatric surgeons in invagination cases caused by pathological leading point conditions is the possibility of missing the actual underlying disease which caused the invagination following a successful USGHR after target-sign is detected. Although ultrasound and computed tomography studies might be helpful in preliminary diagnosis, it must be kept in mind that an actual diagnosis can only be done with surgery in some cases.

Keywords

• Misdiagnosis,Intussusception,Ultrasound guided hydrostatic reduction

Pediatrik hastalarda hidrostatik redüksiyon ile başarılı intususepsiyon tedavisi: Her şey tamam mı?

Öz

Amaç: İntussusepsiyon, proksimal bağırsak segmentinin distal bağırsak segmentinin içine teleskopik olarak girmesi olarak tanımlanır, kesin tedavisi cerrahidir. Bağırsaklarda nekroz veya perforasyon yoksa Ultrason eşliğinde Hidrostatik redüksiyon (USGHR) ile başarılı bir şekilde tedavi edilebilir. Bununla birlikte, intussusepsiyon ile görülebilen ikincil anomalilerin yanlış tanı alması veya atlanması morbiditede kaçınılmaz bir artışa yol açar. Bu çalışmada, bir çocuk cerrahisi kliniğinde tanı ve tedavi açısından yanlış tanıya bağlı komplikasyonlar gelişen intussusepsiyon hastalarının retrospektif olarak gözden geçirilmesini sunmak istedik.

Yöntemler: Mayıs 2014 ve Eylül 2017 arasında Yüzüncü Yıl Üniversitesi Çocuk Cerrahi Kliniği’nde intussusepsiyon tanısı alan ve USGHR ile tedavi edilen 12 hasta ıskalanmış tanılar ve ek patolojiler açısından retrospektif olarak değerlendirildi. Bu olgu serisindeki hastaların yaşı, cinsiyeti, semptomları, uygulanan tanı ve tedavi yöntemleri, komplikasyonlar ve hastanede kalış süreleri değerlendirildi. 

Bulgular: Ağrı, kusma, ağlama atakları, dışkıda kan ve abdominal distansiyon şikayetleri ile başvuran ve USGHR ile tedavi edilen ve ortalama yaşları 34 (Aralık 6 - 98) ay olan 12 (5 kadın - 7 erkek) hasta, atlanmış sekonder durumlar nedeniyle daha kötü bir klinik prognoz gösterdi. apandisit (3 olgu), lenfoma (1 olgu), Meckel divertikülit (1 olgu), apendikal intussusepsiyon (3 olgu), akut gastroenterit (3 olgu) ve Henoch-Schonlein Purpura (1 olgu) atlanmış sekonder patolojilerdi. Henoch-Schonlein purpura tanısı olan hasta USGHR ve kortikosteroidler ile birlikte tedavi edildi ancak diğer tüm olgular açık cerrahi gerektirdi. Henoch-Schonlein purpurası olan hastanın takibi devam ederken, diğer tüm olgular başarıyla tedavi edildi.

Sonuç:  Çocuk cerrahisi kliniğimizdeki invajinasyon hastalarının çoğu USGHR ile cerrahi yapılmadan başarılı bir şekilde tedavi edilmesine rağmen, sekonder patolojiler gözden kaçırıldığında cerrahi girişim endikasyonu, artan morbidite ve medikal maliyetler kaçınılmazdır. Lead point'in mevcut olduğu invajinasyon vakalarında, bu hastalar için en önemli dezavantaj, ultrasonografide target sign görüntüsünün saptanmasını takiben yapılan başarılı bir USGHR ye rağmen altta yatan patolojinin ıskalanmasıdır. Ultrasonografi ve bilgisayarlı tomografi çalışmaları ön tanı için yararlı olsa da, gerçek bir teşhisin sadece bazı durumlarda cerrahi ile yapılabileceği akılda tutulmalıdır.

Anahtar Kelimeler

• Yanlış teşhis,İntususepsiyon,Ultrason eşliğinde Hidrostatik redüksiyon

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