Management of intussusception in children

Review question

How is intussusception best managed in children?

Background

Intussusception is a medical emergency that occurs in children when a part of the bowel 'telescopes' (folds) into another part of the bowel. This causes pain, vomiting, and obstruction, preventing passage. If left untreated, the bowel can perforate, resulting in passage of its contents into the abdominal cavity, causing further complications. In rare cases, these events can cause death. Prompt diagnosis and management reduces associated risks and the need for surgery.

Once intussusception is diagnosed, most doctors agree on the use of enema as initial treatment. This procedure involves introducing a substance (air or liquid) into the bowel, via the rectum, with a particular pressure that reduces the 'telescoped' bowel into its normal position.

Debate persists on specifics regarding what type of substance should be used for the enema, how the substance is visualised during the process, whether extra medications should be given to enhance treatment, and how one should deal with treatment failure, as well as the best approach to surgical management of intussusception in children.

Study characteristics

Evidence is current to September 2016. We identified six randomised studies, with a total of 822 participants, that explored the management of intussusception in children and assessed different types of interventions. We also identified three ongoing trials.

Main results

The main outcome was the number of children with a successfully reduced intussusception. Furthermore, outcomes included the number of children returning with a recurrent intussusception and evaluation of harms (adverse events) resulting from the interventions.

Evidence from two studies suggests that using air for the enema to reduce intussusception is superior to using liquid for the enema. Evidence from two studies also suggests that giving the child with intussusception a steroid medication, such as dexamethasone, may reduce the recurrence of intussusception, irrespective of whether liquid or air is used for the enema.

We identified only sparse information on intraoperative and postoperative complications and on other adverse events.

Quality of the evidence

Of the six trials identified, we considered all to be potentially biased owing to lack of detail in reporting of how each study was undertaken. We found lack of consistency in how outcomes were defined and measured. All included studies were subject to serious concerns of imprecision based on few events, wide confidence intervals,or high risk of bias, Overall, we concluded that the quality of evidence provided by these studies was low, and that the real effects may differ significantly from those noted in these studies.

Further research is needed to help doctors better understand the most effective way to manage intussusception in children.

Authors' conclusions: 

This review identified a small number of trials that assessed a variety of interventions. All included trials provided evidence of low quality and were subject to serious concerns about imprecision, high risk of bias, or both. Air enema may be superior to liquid enema for successfully reducing intussusception in children; however, this finding is based on a few studies including small numbers of participants. Dexamethasone as an adjuvant may be more effective in reducing intussusception recurrence rates following air enema or liquid enema, but these results are also based on a few studies of small numbers of participants. This review highlights several points that need to be addressed in future studies, including reducing the risk of bias and including relevant outcomes. Specifically, surgical trials are lacking, and future research is needed to address this evidence gap.

Read the full abstract...
Background: 

Intussusception is a common abdominal emergency in children with significant morbidity. Prompt diagnosis and management reduces associated risks and the need for surgical intervention. Despite widespread agreement on the use of contrast enema as opposed to surgery for initial management in most cases, debate persists on the appropriate contrast medium, imaging modality, pharmacological adjuvant, and protocol for delayed repeat enema, and on the best approach for surgical management for intussusception in children.

Objectives: 

To assess the safety and effectiveness of non-surgical and surgical approaches in the management of intussusception in children.

Search strategy: 

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library; Ovid MEDLINE (1950 to September 2016); Ovid Embase (1974 to September 2016); Science Citation Index Expanded (via Web of Science) (1900 to September 2016); and BIOSIS Previews (1969 to September 2016).

We examined the reference lists of all eligible trials to identify additional studies. To locate unpublished studies, we contacted content experts, searched the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (September 2016), and explored proceedings from meetings of the British Association of Paedatric Surgeons (BAPS), the American Soceity of Pediatric Surgery, and the World Congress of Pediatric Surgery.

Selection criteria: 

We included all randomised controlled trials comparing contrast media, imaging modalities, pharmacological adjuvants, protocols for delayed repeat enema, and/or surgical approaches for the management of intussusception in children. We applied no language, publication date, or publication status restrictions.

Data collection and analysis: 

Two review authors independently conducted study selection and data extraction and assessed risk of bias using a standardised form. We resolved disagreements by consensus with a third review author when necessary. We reported dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We analysed data on an intention-to-treat basis and evaluated the overall quality of evidence supporting the outcomes by using GRADE criteria.

Main results: 

We included six randomised controlled trials (RCTs) with a total of 822 participants. Two trials compared liquid enema reduction plus glucagon versus liquid enema alone. One trial compared liquid enema plus dexamethasone versus liquid enema alone. Another trial compared air enema plus dexamethasone versus air enema alone, and two trials compared use of liquid enema versus air enema.

We identified three ongoing trials.

We judged all included trials to be at risk of bias owing to omissions in reported methods. We judged five of six trials as having high risk of bias in at least one domain. Therefore, the quality of the evidence (GRADE) for outcomes was low. Interventions and data presentation varied greatly across trials; therefore meta-analysis was not possible for most review outcomes.

Enema plus glucagon versus enema alone

It is uncertain whether use of glucagon improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 218 participants; RR 1.09, 95% CI 0.94 to 1.26; low quality of evidence). No trials in this comparison reported on the number of children with bowel perforation(s) nor on the number of children with recurrent intussusception.

Enema plus dexamethasone versus enema alone

Use of the adjunct, dexamethasone, may be beneficial in reducing intussusception recurrence with liquid or air enema (two trials, 299 participants; RR 0.14, 95% CI 0.03 to 0.60; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 13 (95% CI 8 to 37). It is uncertain whether use of the adjunct, dexamethasone, improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 356 participants; RR 1.01, 95% CI 0.92 to 1.10; low quality of evidence).

Air enema versus liquid enema

Air enema may be more successful than liquid enema for reducing intussusception (two trials, 199 participants; RR 1.28, 95% CI 1.10 to 1.49; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 6 (95% CI 4 to 19). No trials in this comparison reported on the number of children with bowel perforation(s) or on the number of children with recurrent intussusception nor any intraoperative complications, such as bowel perforation, or other adverse effects. Only one trial reported postoperative complications, but owing to the method of reporting used, a quantitative analysis was not possible. We identified no studies that exclusively evaluated surgical interventions for management of intussusception.

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