Treatment outcome of ultrasound-guided hydrostatic reduction of intussusception and its associated factors among pediatric patients in a resource-limited setting

doi:10.21203/rs.3.rs-4893878/v1

Background: Ultrasound-guided hydrostatic reduction (USGHR) of intussusception was recently introduced and adopted as the initial management option for intussusception in children. Knowledge of the treatment outcome and associated factors will enhance the expansion of this technique to hospitals in Sub-Saharan Africa, where surgery largely remains the exclusive treatment strategy.

Methods: An institution-based cross-sectional study was conducted. We consecutively enrolled children with US-confirmed intussusception for whom USGHR of intussusception with normal saline was performed by a senior radiologist and/or final-year residents after ruling out contraindications. Firth’s logistic regression analysis was undertaken to determine odds ratios (ORs) and 95% confidence intervals (CIs) of factors predictive of successful outcomes.

Results: A total of 145 children with a mean age of 24 months were enrolled in the current study. The majority of patients 123 (84.8%) presented within 24 hours of symptom onset and colicky abdominal pain was the most common complaint 79 (54.5%). Ileocolic type and short-length intussusception were visualized more on ultrasound 135 (93.1) and 118 (81.4%), respectively. The overall reduction success rate was 93.1% [95% CI (89.0-97.2)]. Ten patients (13.5%) underwent surgery after a failed hydrostatic reduction with good postoperative outcomes. Reported duration of illness less than 24 hours Adjusted odds ratio (AOR) 6.77 (95% CI [1.25-30.42]) and length of intussusception less than 3.5 cm AOR 6.24 [95% CI (1.18-33.00)] were significantly associated with successful hydrostatic reduction outcomes.

Conclusion: We have found a high success rate of USGHR of intussusception in an implementation phase and a relatively low resource setup. Early presentation and short intussusception segments were favorably associated with successful outcomes.

Intussusception

Hydrostatic reduction

Ultrasound

Children

Ethiopia

Intussusception is the most common cause of acute intestinal obstruction in infants and young children [1, 2]. It occurs when a segment of the bowel invaginates into the distal bowel, causing venous congestion and bowel wall edema. Classic symptoms include abdominal colic, red jelly stool, and a palpable mass, which occurs in combination in only 10–20% of cases, while 20% of patients are asymptomatic at presentation [1–4]. In such cases, clinicians may need to rely on imaging techniques to promptly and accurately diagnose or rule out intussusception, thereby mitigating potential adverse outcomes [2, 3, 5]. Failure to timely diagnose and initiate appropriate treatment can result in intestinal ischemia, perforation, peritonitis, shock, and even death.

Ultrasound (US) is a reliable imaging modality for the diagnosis of intussusception, with a sensitivity of 98–100%, a specificity of 88%, and a negative predictive value of 100% [5, 6]. Characteristic US appearances, such as a target sign, doughnut sign, or concentric ring sign on a transverse section and a pseudo kidney or sandwich sign on a longitudinal section, are described as diagnostic findings [7, 8]. Abdominal US may also assist in the definition of a pathologic lead point and monitor the success of non-operative reduction [3, 6]. Moreover, US is widely available, easily performed, and does not produce radiation, making it the preferred imaging modality to screen suspected cases and monitor non-operative treatment [6–9].

There remains considerable variability regarding the treatment of intussusception in children. Currently, non-operative management is indicated in clinically stable children, whereas a surgical approach is chosen in patients with signs of perforation, shock, or peritonitis [8, 10–11]. Non-operative treatment includes reduction with pneumatic or hydrostatic media under fluoroscopic or US guidance [5]. Barium suspension or air with fluoroscopic guidance, or saline only or mixed with water-soluble contrast under US guidance has to be used. Regardless of the specific method used, non-operative reduction is an effective technique, being successfully employed in more than 80–90% of cases [11].

Ultrasound-guided hydrostatic reduction (USGHR) of intussusception has become a widely accepted tool for intussusception reduction. Literature references show a comparable or higher success rate and a better safety profile compared to fluoroscopically guided pneumatic reduction [5, 6, 9, 11]. Disadvantages include fluid leakage from the anus and risks of peritoneal contamination with fecal matter if perforations occur [7]. However, despite advances in non-invasive radiological techniques to treat intussusception, treatment of the condition remains exclusively surgical in many developing countries [3]. This is attributed to a variety of reasons, most notably a lack of resources and expertise [9]. In Ethiopia, USGHR was recently introduced through an international partnership in the main referral hospital of the country and subsequently adopted as the first treatment option for intussusception [7, 10].

While availability and technical expertise have historically posed significant barriers, emerging trends also highlight the challenges of limited local evidence and inconsistent practice standards [6, 12]. Therefore, the current study was conducted to determine the success rate of USGHR intussusception and factors associated with favorable or unfavorable outcomes in an implementation phase of the technique in a relatively resource-limited university-affiliated regional hospital in Ethiopia.

An institution-based cross-sectional study was conducted from February to August 2023 at Tibebe Ghion Specialized Hospital (TGSH), Bahir Dar, Ethiopia. US confirmed intussusception cases were prospectively enrolled in the study. Intussusception reduction was performed by a senior radiologist and/or three final-year residents under supervision. Careful records were kept to ensure no case with intussusception was missed and to reduce bias. Data on age, gender, clinical symptoms such as abdominal pain, vomiting or bloody stools, duration of symptoms, and recurrence of intussusception were collected.

Ultrasound was performed with a linear array 16-MHz transducer, Siemens Acuson NX3 (Siemens Healthineers, Erlangen, Germany) to confirm the diagnosis of intussusception. Imaging findings such as the presence of an inner fatty core in the intussusception, lesion diameter, wall thickness, the ratio of fatty core thickness to outer wall thickness, and the presence of lymph nodes in the lesion were used to differentiate between ileocolic and small-bowel intussusceptions [13]. Cases of small bowel intussusception were excluded from the study. The length of intussusception was estimated and a 3.5 cm criterion was used to categorize as short or long segment intussusception.

During the study period, there were a total of 145 patients and all were included in the study, as none exhibited contraindications such as:

a. peritonitis, perforation, hemodynamic instability,

b. complex intraperitoneal fluid,

c. absence of bowel wall color flow on Doppler US, or

d. Symptoms lasting over 4 days.

The procedure was explained in detail to the parents and a written consent was obtained. A different size Foley catheter (10 to 18 French) based on age was inserted into the rectum and the balloon inflated with distilled water to hold the catheter in place. The rectum was sealed by taping the buttocks together to prevent fluid leakage. US was used to locate the intussusception and provide guidance during the procedure. The Foley catheter was connected to warm normal saline and placed approximately 120 cm above the patient. The entire colon was filled by gravity and the head of the intussusceptum was shifted towards the ileocecal valve.

The progression of the saline column into the colon was monitored by US through real-time monitoring of intussusception reduction. Successful reduction was defined as the disappearance of the intussusceptum and reflux of saline into the ileum. A maximum of three attempts were made, with each reduction lasting approximately 3-5 minutes with an interval of 15 minutes, provided patients' vital signs remained stable and no clinical and sonographic evidence of viscus perforation was present. After the procedure was completed, a repeat US scan was performed to rule out a residual lesion and to check for free peritoneal fluid. All patients who successfully underwent USGHR were followed for 24 hours to assess for recurrence and procedure-related complications. No sedation was used. The procedure was done following the SPR -ACR practice guidelines for hydrostatic reduction of intussusception (https://www.acr.org/-/media/ACR/Files/Practice-Parameters/FluourConEnema-Ped.pdf).

Data Collection

Data entry and cleansing were performed by two authors (C.T and T.H) using Epi-Data version 3.1 software. Data collection was carried out by radiology residents in their final year of training. The completeness and consistency of the collected data were checked daily by the two authors as part of the data collection. When incompleteness or ambiguity is identified in the record, the completed information formats are compared with the source data.

Statistical analysis

Statistical analysis was performed with SPSS, version 26.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to generate and summarize frequencies. Fisher's exact test and two-tailed Student's t-test were used as appropriate to test the significance of the association between the factors considered and the dependent variable. Multivariable analyses via Firth’s logistic regression was performed to identify factors associated with the treatment outcome of USGHR of intussusception. Multicollinearity between independent variables was checked using the variance inflation factor (VIF), and the observations in the data set were independent of each other. A P-value less than or equal to 0.05 was considered to declare a statistical significance.

A total of 145 pediatric patients with a confirmed diagnosis of intussusception met the inclusion criteria and were included in the study. The age of study participants ranged from 1 month to 14 years (mean age 24 months) and 96 (66.2%) of the participants were male (Table 1). Age distribution was made as per the NICHD, Eunice Kennedy Shriver National Institute of Child Health and Human Development [32]. Accordingly, 32.4% were infants (28 days to 12 months), 22.1% were toddlers (13 months to 2 years) and 45.5% were in early to late childhood age (2-14 years). 16 (11%) patients were outside of the typical 6-month-36-month age range, with 2 infants under 6 months of age. A separate analysis of these patients revealed no significant differences, hence it is excluded from further discussion.

Residents performed 20% of the 1st reduction attempts while the remaining initial attempts and all repeated (2nd and 3rd) attempts were done by a senior radiologist. The overall reduction success rate was 93.1% [95% CI (89.0-97.2)] and most occurred on the first attempt; 85%, 49%, and 9% for the 1^st, 2^nd, and 3^rd attempts respectively. There was no statistically significant association between age groups and the success of USGHR of intussusception (P-value=0.77).

The most common symptom was colicky abdominal pain, occurring in 79 (54.5%) patients, followed by bloody diarrhea and vomiting in 35 (24.1%) and 28 (19.3%) patients, respectively. Only 3 (2.1%) of the patients had abdominal distension. No statistically significant association was found between the clinical presentation of the patients and the success rate of non-operative reduction (p-value=0.77).

Most patients presented within 24 hours of symptom onset (84.8%). The success rate of hydrostatic reduction of intussusception was significantly higher in patients who presented within 24 hours of symptom onset than those with delayed presentation (p-value=0.008).

The intussusception was a short segment 118 (81.4%), periumbilical in location 101 (69.1%), and ileocolic in type 135 (93.1%) in the majority of patients. Non-operative reduction was more successful in patients with a short segment of intussusception than a long segment intussusception (p-value=0.020). Lead points were identified in 19 (13.1%) of patients and their presence was associated with a significantly lower chance of successful reduction (p-value=0.004).

Follow-up US was performed on successfully treated patients and no recurrence was observed. All 10 patients with failed reduction after three attempts were treated surgically. Intraoperative, five of the cases had mesenteric lymphadenopathies as a lead point, and a long segment (> 3.5 cm) of intussusception was identified in the other five cases. Histologic analysis showed a reactive lymphoid hyperplasia in all cases. Spontaneous reduction was noted in one patient after induction of general anesthesia whereas manual reduction was performed in four patients. Bowel resection and anastomosis were performed in the remaining five patients due to irreducible or gangrenous changes. No complications occurred in either group during or after reduction. US findings before and after reduction are summarized in Figure 1 and 2.

In a multivariable analysis, the odds of success of nonoperative reduction were 6 times higher in patients presenting within 24 hours of symptom onset than in those with delayed presentation AOR 6.17 [95% CI (1.25-30.42)]. Patients with short-segment intussusception also had significantly higher odds of successful nonoperative reduction than patients with long-segment intussusception AOR 6.24 [95% CI (1.18-33.00)] (Table 2).

Patients with intussusception in whom a lead point was identified (which in our study were exclusively enlarged mesenteric lymph nodes) were less likely to achieve successful non-operative reduction of intussusception, although this did not reach statistical significance when other variables were accounted for (p-value=0.12).

USGHR of intussusception is a non-invasive treatment with high success rates, ease of use, and no radiation exposure [1-3]. The mean age of 24 months and a male-to-female ratio of about 2 to 1 in the current study are consistent with what was observed in previous studies [5, 14, 15]. We found that abdominal pain is the most common symptom and the site is frequently ileocolic in children consistent with previous literature [7, 16, 17]. Ileocolic intussusception was observed in up to 78.7% of all cases in a prospective study [16]. Other forms of intussusception, such as ileoileal and colocolic intussusception may also occur in children, but they are much less common than ileocolic intussusception [16, 18].

A pathological lead point was absent in most cases. Mesenteric lymphadenopathies were the identified lead points in patients with secondary causes. However, a separate study from Ethiopia reported that Meckel's diverticulum and inflamed appendix were the main lead points [18]. It is well known that enlarged lymph nodes impede the exit of the intussusceptum thereby decreasing the success of reduction.

The highest success rate was found in patients who presented within 24 hours of symptom onset, consistent with previous studies that reported a lower success rate of non-operative reduction with longer symptom duration [19, 20]. However, some authors have reported comparable success rates between patients presenting before and after 24 or 48 hours of symptom onset [21, 22]. Depending on the patient's condition, a cautious and gentle attempt can be made under close supervision if the patient is stable and a 4-day mark is not passed [5]. No increased-risk complications were seen with this approach and emergency surgery with its associated complications can be reduced. We found no significant difference in the success rate of nonsurgical reduction based on the sex or age category of the study participants. Similar observations have also been reported previously [23]. Therefore, patient age may not be considered a contraindication to hydrostatic reduction.

The overall success rate of USGHR in our study was 93.1%, in line with previously stated findings from both developed and developing countries. A success rate comparable to that of experienced centers has previously been reported from Ethiopia [7]. Authors from other less experienced centers have also found a success rate as high as 95.5% [45, 46]. A review conducted in 2004 found that the success rate of hydrostatic reduction ranged from 12.5% to 95.5% [11]. The large difference can be attributed to many factors, including whether the intussusception was the first episode or a recurrent case, the prevalence of pathologic lead points, and differences in how success rates were calculated. Overall, US is helpful in hydrostatic reduction of intussusception. This is even truer in resource-limited settings like ours, where fluoroscopy is not routinely available [6]. In addition, USGHR performs well even in the hands of less experienced but appropriately trained radiologists [9]. The results should encourage more medical centers to consider implementing USGHR of intussusception.

The success rate of USGHR of intussusception in our study was higher compared to some regional reports. A recent single-center study conducted in Nigeria found a 65% success rate [24]. A lack of expertise was cited as the main reason for the low success rate by the authors [24]. Another study from Ghana also reports a relatively low success rate of 75% [15]. Delayed presentation related to poor referral and transportation can contribute to lower success rates and increased complications [25]. Of note, signs of late presentation such as vomiting and abdominal distension were reported more in the later study [24]. Patients with US findings of recurrence rates after successful pneumatic or hydrostatic intussusception reduction are between 7.1% and 12.5% [4]. No recurrent cases were recorded in this study, although we followed the patients for 24 hours after successful reduction and performed a rescan to avoid missing recurrent cases or complications.

This study has found comparatively robust evidence that USGHR of intussusception is an attractive option for intussusception management in low-resource settings as it has high success rates, ease of application, and a better safety profile. We have not excluded secondary cases of intussusception while calculating the success rate of the procedure, which has enabled a fair assessment. However, This study has some limitations. There was a difference in the level of expertise of the physicians performing the procedure. We also didn’t follow the patients long-term after hydrostatic reduction or surgery.

In sum, USGHR should be recognized as a relatively easy, safe, and effective first-line treatment modality for children with intussusception in resource-limited settings. Our results should encourage more medical centers to consider implementing USGHR of intussusception because of the additional significant resource implications. Patient groups with early presentation and short intussusception segments may achieve higher reduction success rates.

Ethical approval

The study was approved by the Ethics Review Committee, College of Medicine and Health Sciences, Bahir Dar University. An informed written consent was obtained from the parents/legal guardians of the enrolled children.

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Table 1. Distribution of Socio-demographic characteristics and factors associated with hydrostatic reduction in pediatric patients at TGSH, Bahir Dar, Ethiopia, 2023 (n=145).

Variables	Category	Frequency	%, percentage	ꭓ2	P
Sex	Male	96	66.2	NA	0.016*
Sex	Female	49	33.8
Age	Infancy	61	42.1	0.81	0.77
	Toddler	32	22.1
	Childhood	52	35.9
Clinical presentation	Abdominal pain	79	54.5	6.76	0.77
	Abdominal distension	3	2.1
	Vomiting	28	19.3
	Diarrhea	35	24.1
Duration of illness	Less than 24 hours	123	84.8	NA	0.008*
Duration of illness	More than 24 hours	22	15.2
Length of intussusception	>3.5 cm	27	18.6	NA	0.02*
Length of intussusception	<3.5cm	118	81.4
Location	Periumbilical	101	69.7	NA	0.17
Location	RUQ or RLQ	44	30.3
Lead point	Identified	19	13.1	NA	0.004*
Lead point	Not identified	126	86.9
Type of intussusception	Ileocolic	135	93.1	1.49	0.52
	Ileoileocolic	7	4.8
	Colocolic	3	2.1
Hydrostatic reduction outcome	Successful	135	93.1	NA
Hydrostatic reduction outcome	Failed	10	6.9

^{RUQ: right upper quadrant, LUQ: left upper quadrant, *p-value <0.05, NA: Fisher exact test/Not Applicable}

Table 2. Multivariable logistic regression analysis showing predictors of successful hydrostatic reduction of intussusception under ultrasound guidance in pediatric patients seen at TGSH, Bahir Dar, 2023.

Variables	Categories	COR 95% CI	P	AOR 95% CI	P
Age category	<12 months	__	__	__	__
Age category	≥ 12 months	1.25 (0.36-4.37)	0.728	1.06 (0.26-4.27)	0.93
Length of intussusception	>3.5cm	__	__	__	__
Length of intussusception	<3.5cm	5.04 (1.42-17.88)	0.012	6.24 (1.18-33.00)	0.031*
Duration of illness	More than 24hrs	__	__	__	__
Duration of illness	Less than 24hrs	6.77 (1.88-24.45)	0.004	6.17 (1.25-30.42)	0.025*
Location	Periumbilical	__	__	__	__
Location	RUQ OR RLQ	0.41 (0.12-1041)	0.157	0.38 (0.94-1.55)	0.18
Lead point	Identified	__	__	__	__
Lead point	Not identified	8.38 (2.28-30.77)	0.001	2.07(0.42-10.10)	0.12

^{*Statistically significant at P value <0.05; RUQ: right upper quadrant; RLQ: right lower quadrant; CI: confidence interval; COR: crude odds ratio; AOR: Adjusted odds ratio}

No competing interests reported.

Treatment outcome of ultrasound-guided hydrostatic reduction of intussusception and its associated factors among pediatric patients in a resource-limited setting

Status:

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Abstract

Figures

Introduction

Methods and Procedure

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Status:

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