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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 20-23

Childhood intussusception in Abeokuta, South-west Nigeria


1 Department of Surgery, Federal Medical Centre, Abeokuta, Nigeria
2 Department of Family Medicine, Federal Medical Centre, Abeokuta, Nigeria

Date of Submission14-May-2019
Date of Acceptance14-Apr-2020
Date of Web Publication14-May-2020

Correspondence Address:
Dr. Opeoluwa Adetola Adesanya
Department of Surgery, Pediatric Surgery Unit, Federal Medical Centre, Abeokuta
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_39_19

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  Abstract 


Background and Objective: While significant progress has been made in the management of childhood intussusception globally, many centers in the developing world still grapple with the challenges of late presentation and attendant high morbidity and mortality. This study aims to review the pattern of presentation and the treatment outcome of children treated for intussusception at a semiurban tertiary hospital in Abeokuta, South-west Nigeria.
Patients and Methods: A retrospective study of forty consecutive children aged 15 years old and below, who were managed for intussusception between April 2013 and March 2018 was done. The bio data, clinical presentation, operative findings, and outcome were obtained from the operating theater records and patient case notes. The data were analyzed using the SPSS software version 23.
Results: There were forty patients, of which 20 were male and 20 were female. Their age ranged from 4 months to 5 years, with a median age of 7 months. Thirty -five (87.5%) patients were aged less 1 year. The duration of symptoms ranged between 6 h and 9 days (median = 3 days). Majority (57.5%) of patients presented after 48 h of the onset of symptoms. The patients were treated by the operative manual reduction in 67.5%, whereas 32.5% had bowel resection and anastomosis. Seven children (17.5%) died while postoperative complications occurred in 27.5% of patients. Factors associated with poor outcome included late presentation, bowel resection, and severe sepsis.
Conclusion: The management of intussusception in Abeokuta is associated with high morbidity and mortality, which can be improved if affected children present earlier.

Keywords: Children, intussusception, presentation and outcome, risk factors


How to cite this article:
Adesanya OA, Aremo A, Adesanya OO. Childhood intussusception in Abeokuta, South-west Nigeria. J Clin Sci 2020;17:20-3

How to cite this URL:
Adesanya OA, Aremo A, Adesanya OO. Childhood intussusception in Abeokuta, South-west Nigeria. J Clin Sci [serial online] 2020 [cited 2020 Nov 25];17:20-3. Available from: https://www.jcsjournal.org/text.asp?2020/17/2/20/284278




  Introduction Top


Intussusception refers to the acquired invagination of one portion of the intestine into the adjacent bowel. It is one of the most frequent causes of bowel obstruction in infants and toddlers.[1] The etiology in children is often idiopathic unlike in older children and adults where an anatomic lead point such as a tumor or vascular lesion may be identified.[1] Several predisposing factors such as recent weaning from breastfeeding, upper respiratory tract infections, and recent anti-viral vaccination have been identified in previous studies.[1],[2],[3],[4],[5]

Intussusception is described by the proximal, inner segment of the intestine (intussusceptum) first and the outer distal, receiving portion of the intestine (intussusception) last.[1] Previous studies show that 80%–95% of intussusceptions are of the ileocolic type, with other varieties being rare.[1]

Childhood intussusception is associated with higher morbidity and mortality in the developing world compared with the reports from the developed high-income countries.[6] The factors responsible for these identified in previous studies include late presentation and lack of facilities for pediatric intensive care.[7],[8] Another trend observed in many high-income countries is a gradual shift to nonoperative image-guided treatment instead of operative treatment, which remains a major modality of treatment in the developing world.

This study aims to review the pattern of presentation, the treatment offered, and outcome of treatment in our center – a tertiary care center located at Abeokuta, South-west Nigeria, and compare with the findings in other centers.


  Patients and Methods Top


This was a 5-year retrospective study of forty consecutive children aged 15 years old and below, who were managed for intussusception between April 2013 and March 2018, at the study center. The study center, a 300 bed tertiary care hospital, is the only institution providing specialized pediatric surgery services for the residents of Abeokuta and environs. The bio data, clinical presentation, operative findings, investigations done, and treatment offered were collected from the pediatric surgical unit record book, the operating theater records, and case notes. The intraoperative findings, peri-operative complications, duration of hospitalization, and outcome of management were also noted. The data were analyzed using the SPSS software version 23 The Chi-square tests were used to analyze the categorical variables. P < 0.05 was considered statistically significant.


  Results Top


Forty children were treated for intussusception over a 5-year period. There were twenty males and twenty females, with a male-to-female ratio of 1:1. The ages ranged from 4 months to 5 years, with a mean age of 0.8 ± 0.15 years. The median age was 7 months. The peak incidence was between 7 and 9 months, during which 25 (62.5%) of the patients were recorded, whereas only 5 (12.5%) of the children were older than 1 year old [Figure 1]. 20 (50%) of the patients were weaning and 3 (7.5%) were recently treated for respiratory tract infection. None of the children had recent anti-viral immunization. Peaks in monthly frequency were observed in May, September, and December [Figure 2].
Figure 1: Age distribution of patients

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Figure 2: Monthly incidence of intussusception

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The duration of symptoms at presentation ranged from 1 to 9 days, with a mean duration of 3.6 ± 2.5 days and median of 3 days. The classical triad of abdominal pain, bloody mucoid stools, and a palpable abdominal mass was seen in 14 (35%) of the cases. In 8 (20%) patients, there was gross abdominal distension and guarding. Seven (17.5%) patients presented with prolapsing masses from the anus [Table 1].
Table 1: Clinical presentation

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Intravenous fluid resuscitation, correction of electrolyte derangements, antibiotic therapy, and early surgical exploration were the main thrusts of our management. Abdominal ultrasonography was performed in 34 (85%) of the patients and was accurate in 30 patients. Admission -operation interval ranged from 12 to 72 h, with a median of 24 h. 36 (90%) of patients were operated within 24 h of admission. Infrastructural delays, financial difficulties, and prolonged resuscitation need in moribund patients were responsible for delayed intervention in 4 (10%) children. Hydrostatic reduction was not attempted in this series due to logistic challenges within our hospital during the period of study.

Surgical exploration was the mainstay of treatment in all the patients. Ileocolic intussusception was seen in 38 (95%) of all cases, the colo-colic variety was recorded in 1 (2.5%) case, while the ileo-ileal type was seen in 1 (2.5%). In 27 (67.5%) patients, manual reduction was done successfully, the remaining 13 (32.5%) underwent bowel resection and end-to-end anastomosis. Lead points were not seen in any of the children at surgery.

The duration of hospitalization ranged from 2 to 23 days, with a mean hospitalization period of 7.9 ± 4.2 days. Severe sepsis was the most common complication, occurring in 7 (17.5%) of all operated cases. Superficial surgical site infection occurred in 2 (5%), fecal fistulae occurred in 1 (2.5%), peritoneal abscess in 1 (2.5%), whereas burst abdomen was seen in 2 (5.0%) of our cases. Late complications seen in our patients were postoperative adhesive bowel obstruction in 1 (2.5%) child. Follow-up period was 3 months–2 years, with no case of recurrence observed.

Overall, 33 (82.5%) survived, whereas 7 (17.5%) died in the peri-operative period from overwhelming sepsis in 12 (6.9%). Mortality was more likely in children who had bowel resection (χ2 = 4.855, P = 0.002) than those who had manual reduction.


  Discussion Top


Intussusception is the most common surgical emergency in children under 1 year from our records at the study center, with one case seen on the average every month. Like the observations in Lagos by Bode[5] and Talabi et al.[9] in Ife, there was a higher incidence during the months where there was a change over from rainy to dry season (December) and dry to rainy season (May). These periods are usually associated with respiratory tract infections in Abeokuta [Figure 2]. The peak age of onset in our series is in keeping with the findings in reports from other settings; however, most other studies recorded a male preponderance unlike our findings.[5],[7],[8]

Late presentation is a common feature in our patients, with 77.5% presenting after 24 h of symptoms. This is mainly because most parents initially take their wards to local dispensaries or prayer houses before presentation at primary care centers and other referral centers when the conditions persist. In some cases also, they are misdiagnosed by primary care practitioners and treated for dysentery for days before eventual referral to our center, sometimes with children moribund. The delayed presentation has also been documented as a poor prognostic factor by other centers.[5],[6],[7],[8],[9],[10] Abdominal ultrasound was the imaging modality of the diagnosis in most of our patients; however, the accuracy was less than reported in many other studies.[11],[12],[13] It is expected that as more specialist radiologists are available to perform the evaluation during call hours at the center, the accuracy will improve.

Surgery was the major modality of the treatment in this series of patients. This is attributable largely to late presentation in majority of the patients, which made them unsuitable for hydrostatic reduction. This is unlike reports from other centers located in the urban areas and in the developed world where nonoperative reduction has been used in a significant percentage of patients.[6],[14],[15] The findings at the surgery were largely in keeping with reports from other settings – most cases were amenable to manual reduction, but a large percentage required bowel resection and anastomosis, with ileocolic anastomosis being the most common anastomosis performed. The outcome of the treatment in this series was comparable to the reports from other centers in the tropics.[6],[7],[9] Higher mortality was recorded in late presenters many of whom had irreducible and sometimes gangrenous bowel.


  Conclusion Top


This study reveals that the treatment of intussusception is associated with high morbidity and mortality in our setting. There is an urgent need to increase public awareness about this disorder to facilitate the early diagnosis and referral to specialist centers for prompt and appropriate treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ignacio RC Jr., Fallat ME. In: Holcomb GW IIIrd, Murphy JP, Editors. In Intussusception. Ashcraft's Pediatric Surgery. 5th ed. Philadelphia: Saunders/Elsevier; 2010.  Back to cited text no. 1
    
2.
Joana L, Simon NH. Intussusception. Surgery (Oxford) 2013;31:626-30.  Back to cited text no. 2
    
3.
Gunawan PY. Pediatric ileocolic intussusception caused by introducing solid food before 6 months old: A Case Report. Pediatr Ther 2018;8:343.  Back to cited text no. 3
    
4.
Bines JE, Ivanoff B. Acute intussusception in infants and children. Incidence, clinical presentation and management: A global perspective. A report prepared for the steering committee on diarrhoeal diseases, vaccines and vaccine development. In: Vaccines and Biologicals. India: World Health Organization; 2002.  Back to cited text no. 4
    
5.
Bode CO. Presentation and management outcome of childhood intussusception in Lagos: A prospective study. Afr J Paediatr Surg 2008;5:24-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Jiang J, Jiang B, Parashar U, Nguyen T, Bines J, Patel MM. Childhood intussusception: A literature review. PLoS One 2013;8:e68482.  Back to cited text no. 6
    
7.
Ekenze SO, Mgbor SO, Okwesili OR. Routine surgical intervention for childhood intussusception in a developing country. Ann Afr Med 2010;9:27-30.  Back to cited text no. 7
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8.
Nuhu A, Madziga AG. Childhood intussusception in north eastern Nigeria: A review of its surgical management. Port Harcourt Med J 2008;3:27-31.  Back to cited text no. 8
    
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Talabi AO, Sowande OA, Etonyeaku CA, Adejuyigbe O. Childhood intussusception in Ile-ife: What has changed? Afr J Paediatr Surg 2013;10:239-42.  Back to cited text no. 9
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Ekenze SO, Mgbor SO. Childhood intussusception: The implications of delayed presentation. Afr J Paediatr Surg 2011;8:15-8.  Back to cited text no. 10
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Usang UE, Inah GB, Inyang AW, Ekabua AT. Intussusception in children: Comparison between ultrasound diagnosis and operation findings in a tropical developing country. Afr J Paediatr Surg 2013;10:87-90.  Back to cited text no. 11
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Hryhorczuk AL, Strouse PJ. Validation of US as afirst-line diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radiol 2009;39:1075-9.  Back to cited text no. 12
    
13.
Bartocci M, Fabrizi G, Valente I, Manzoni C, Speca S, Bonomo L. Intussusception in childhood: Role of sonography on diagnosis and treatment. J Ultrasound 2015;18:205-11.  Back to cited text no. 13
    
14.
Ogundoyin O, Lawal T, Olulana D, Atalabi O. Experience with Sonogram-guided hydrostatic reduction of Intussusception in Children in South-West Nigeria. J West Afr Coll Surg 2013;3:76-88.  Back to cited text no. 14
    
15.
Talabi AO, Famurewa OC, Bamigbola KT, Sowande OA, Afolabi BI, Adejuyigbe O. Sonographic guided hydrostatic saline enema reduction of childhood intussusception: A prospective study. BMC Emerg Med 2018;18:46.  Back to cited text no. 15
    


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