Pediatric Department, Pingtung Christian Hospital

屏東基督教醫院小兒科
Pediatric department, Pingtung Christian Hospital

兒專核心課程
腸套疊
兒專核心課程
關於腸套疊，您是否知道…
 好發的年齡？  處理治療方式？
 臨床特徵？  開刀的條件？
 男女比例？  復發的比例？
 如何診斷？  預後？
兒專核心課程
Four major causes of intestinal obstruction: (1) Herniation of a segment in the umbilical or
inguinal regions; (2) adhesion between loops of intestine; (3) intussusception; (4) volvulus
formation.
兒專核心課程
兒專核心課程
Intussusceptum vs Intussuscipiens
The part which prolapses into

the other is called the intussus
ceptum, and the part which rec
eives it is called the intussuscip
iens.
Due to peristaltic action of the

intestine.
兒專核心課程
腸套疊的臨床表徵
Early symptoms: nausea, vomiting, pulling legs to the ches
t area, intermittent crying due to abdominal (cramping) pa
in.
Later signs: rectal bleeding with red currant jelly stool (sto
ol mixed with blood and mucus), and lethargy.
兒專核心課程
Currant jelly stool ( 草莓醬便 )

兒專核心課程
腸套疊的臨床表徵
Most commonly at the terminal ileum, ie: ileocolic.
Physical examination: a sausage-shaped mass felt upon pal

pation of the abdomen.
Fever is not common. However, intussusception can cause
a loop of bowel to become necrotic. This leads to perforati
on and sepsis, which causes fever.
兒專核心課程
影像學檢查
The ultrasonography has the sensitivity of 97.9%
and specificity of 97.8% to diagnose intussusception.
The ultrasonography should be used as a first-line

examination for the assessment of possible pediatric
intussusception.
兒專核心課程
Plain abdomen X-ray:

1. Dilated loops of
small bowel
2. Little colon gas
兒專核心課程
腸套疊的診斷
Ultrasound
Target sign
Pseudokidney sign
兒專核心課程
腸套疊的診斷
Plain Abdomen X-ray
Ileus
air-fluid level
LGI series
Cup sign
Obstruction
兒專核心課程
Intussusception in an infant. The obstruction is evident in the proximal transverse

colon. Contrast material between the intussusceptum and the intussuscipiens is
responsible for the coil-spring appearance.
兒專核心課程
Contrast enema of a child with intussusception shows a sharp cutoff where the
contrast material meets the intussusceptum and the acute obstruction.
兒專核心課程
Lower GI contrast enema

Both diagnostic and therapeutic purposes.
The choice of therapeutic method varies among hospitals

and highly dependant on medical staff experience.
Surgeon standby ?
兒專核心課程
Intussusception, Ileoileocolic type

Similar clinical, images signs
Sonar: a typical complex appearance

due to frond-like loops ( 蕨類葉體 ) of
intussuscepted small bowel.
The hydrostatic reduction rate was

only 10% for ileoileocolic
intussusception, compared with >90%
for the ileocolic type.
兒專核心課程
Intraoperative photograph of a patient with an ileocolic intussusception.

The ileum (intussusceptum, blue arrow) is seen entering the ascending
colon (intussuscipen, green arrow)
兒專核心課程
腸套疊的復發 Recurrence
Recurrence rate around 10%.
Recurrence usually can be diagnosed earlier than previous
episodes and treated successfully by
hydrostatic reduction without complication.
Recurrence seldom occurs in surgical reduction.
Yang CM, et al. 2001, Recurrence of intussusception in childhood. Acta paediatrica Taiwanica
兒專核心課程
腸套疊的復發 Recurrence
Recurrence is possible after reduction, with a rate of 8-10%.
Failure of non-surgical reduction may require surgical

intervention.
兒專核心課程
Aims
1. To explore the epidemiological features of intussusception
in Taiwanese children based on a period of National
Health Insurance data (1998-2007)
2. To determine the rates of surgical intervention and

recurrence of intussusception and their risk factors.
兒專核心課程
Methods
 Children admitted to hospitals due to intussusception
(ICD9=560.0) between 1998 and 2007 were identified
from the NHI database.
 The incidence was calculated by age, sex, calendar year

and month of admission.
 The yearly incidences were calculated as the number of

cases divided by the population size of children < 15 years
of age during each calendar year.
兒專核心課程
Methods
 The rates and risk factors of recurrence and surgical
intervention were analyzed using a logistic regression
model. Recurrence was defined as readmitted to hospital.
 Weather statistics were obtained from the Central Weather

Bureau of Taiwan to compare the average number of
hospitalized cases in each month.
兒專核心課程
Results
A total of 8217 hospitalizations due to intussusception
among 7541 children.
Overall recurrence rate: 597/7541 = 7.9%
Overall operation rate: 1878/7541 = 24.9%
800 100
90
Cum ula tive pe rce nta ge (% )

80
600
79.4% 70
Ca s e num be r
Ca s e numbe r
60
Cumula tive %
400 50
56.5%
40
30
200
20
24.8% 10
0 0
0- 3- 6- 9- 12- 15- 18- 21- 24- 27- 30- 33- 36- 39- 42- 45- 48- 51- 54- 57- 60- 72- 84- 96- 108- 120- 132- 144- 156- 168-
180
Months of a ge
Figure. Case numbers and cumulative percentage of intussusception in

Taiwanese children less than 15 years of age between 1998 and 2007.
Table. Incidence rate of intussusception by age groups in Taiwanese children
less than 15 years of age, 1998 to 2007
Yearly incidence rate Cumulative incidence rate
Year 0-1 1-2 2-3 0-3 0-5 0 - 15
1998 75.9 72.7 41.2 62.5 37.3 14.2
1999 64.2 85.8 50.6 65.8 38.5 15.1
2000 66.8 88.1 83.3 79.0 45.7 18.6
2001 79.5 69.4 44.8 64.3 38.3 15.0
2002 84.4 102.9 65.5 83.3 50.1 18.1
2003 81.5 95.3 63.8 79.9 44.8 16.5
2004 85.0 114.1 69.5 89.0 49.4 17.7
2005 86.5 112.7 99.5 99.8 56.6 19.1
2006 74.8 106.4 61.9 80.7 46.3 15.5
2007 78.8 109.6 90.4 92.9 54.2 18.9
Total average* 77.0 93.5 65.0 78.3 45.5 16.8
Incidence rate = the number of cases per 100,000 person-years in the same age group.
* Mean of all children in the specified age category.
30
Female Male Total
25
per 100,000 persons
20
15
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Calendar Year
Figure. Incidence of intussusception by two genders in Taiwanese children

below 15 years of age during the calendar year of 1998 to 2007. Incidence
was defined as the number of cases per 100,000 children.
120 3.0
Ma le -to-F e m a le incide nce ra te ra tio

Incide nce ra te (ca s e num be rs p e r
100 2.5
100,000 pe rs on-ye a rs )
80 2.0
60 1.5
Female incidence rate
Male incidence rate
40 1.0
Total incidence rate
M/F incidence rate ratio
20 0.5
0 0.0
0~1 1~2 2~3 3~4 4~5 5~6 6~7 7~8 8~9 9 ~ 12 12 ~ 15
Age s (Ye a r)
Figure. Incidence rates (case number per 100,000 person-years) of

intussusception of two sexes and the male-to-female incidence rate ratio
in Taiwanese children less than 15 years of age between 1998 and 2007.
Recurrence Operation
Age (year) Case No. Subtotal % Case No. Subtotal %
0~1 200 1869 10.7 641 1869 34.3
1~2 192 2382 8.1 518 2382 21.8
2~3 122 1736 7.0 363 1736 20.9
3~ 83 1554 5.3 356 1554 22.9
Total 597 7541 7.9 1878 7541 24.9
Hospitalization Operation No. Total No. %
Once* 1814 6944 26.1
Multiple times* 270 1273 21.2
2 times 223 1066 20.9
3 times 37 159 23.3
> 3 times 10 48 20.8
Total 2084 8217 25.4
*Pearson Chi-square test, p value < 0.001
Table. Logistic regression model for risk factors associated with
recurrence of intussusception
No. (%) Odds Ratio(95%CI)
Age (years), 0 – 1 200 (10.7) 1
1-2 192 (8.1) 0.65 (0.53 – 0.80)
2-3 122 (7.0) 0.55 (0.44 – 0.70)
3- 83 (5.3) 0.42 (0.32 – 0.55)
Sex, Female 221 (7.8) 1
Male 376 (8.0) 1.08 (0.90 – 1.28)
Seasons, Cooler (Nov.-Apr.) 278 (7.9) 1
Warmer (May–Oct.) 319 (7.9) 1.00 (0.84 – 1.18)
Operation, No 533 (9.4) 1
Yes 64 (3.4) 0.31 (0.24 – 0.41)
Total 597 (7.9)
Table. Logistic regression model for risk factors associated with
operation of intussusception
No. (%) Odds Ratio(95%CI)
Age (years), 0 – 1 641 (34.3) 1
1-2 518 (21.7) 0.51 (0.45 – 0.59)
2-3 363 (20.9) 0.48 (0.41 – 0.56)
3- 356 (22.9) 0.53 (0.46 – 0.62)
Sex, Female 675 (23.9) 1
Male 1203 (25.5) 1.12 (1.01 – 1.26)
Seasons, Cooler (Nov.-Apr.) 897 (25.4) 1
Warmer (May–Oct.) 981 (24.4) 0.94 (0.85 – 1.05)
Recurrence, No 1814 (26.1) 1
Yes 64 (10.7) 0.31 (0.24 – 0.41)
Total 1878 (24.9)
900 30
25
Mean temperature℃( )
Case numbers
600 20
Admissions 15
Temperature(℃ )
300 10
0 0
1 2 3 4 5 6 7 8 9 10 11 12
Month
Figure. The monthly mean temperature and the case numbers of

intussusception hospitalizations in Taiwanese children less than 15 years
of age between 1998 and 2007 were shown together.
兒專核心課程
Conclusions
Peak incidence rate: 3-36 months old
Male predominance with a dynamic male-to-female incidence

rate ratio from
1.3 (<1 year) to 2.5 (8-9 year)
Overall recurrence rate is 8% and operation rate is 25%.
Both are more frequently in age < 1 year.
More cases occur in warmer seasons (May ~ October)
than cooler seasons in Taiwan.
兒專核心課程
Treatment Protocol - Hydrostatic Reduction

Prepare warm N/S 1000-1500 mL
Set IV line
 IV Dormicum for sedation
 IV Buscopan to relax intestinal muscle
兒專核心課程
Treatment Protocol - Hydrostatic Reduction

Use the largest Foley tube inserted into rectum,
connected with N/S line and sealed well.
Let N/S go into rectum, under sonar guidance.

The target lesion will withdraw gradually under
the hydrostatic pressure.
兒專核心課程
Education after Treatment

Before reduction, tell family Operation may be needed
if N/S reduction fails.
After reduction, NPO for some hours.
If patient feels hungry, try feeding with water first,

then solid food.
兒專核心課程
Education after Treatment

Remember to educate the family that Recurrence is
possible (rate 8%)
Failure of reduction
True recurrence
兒專核心課程
Rotavirus vaccine
Intussusception was reported to be associated with v
accines that contain “live, oral, rhesus-based rotaviru
s” Vaccines: documented risks (2007). Retrieved on 2007-11-15.
兒專核心課程
Rotavirus vaccine
In 2006, two new rotavirus vaccination, RotaTeq (Merck)
& Rotarix (GlaxoSmithKline), were introduced after exten
sive testing and clinical trials.
More than 60,000 doses of the vaccine were given to chil
dren before the vaccine was approved by the FDA. The nu
mber of cases of intusussception in children receiving the
vaccine was no higher than would be naturally expected.
兒專核心課程
課後討論及評值
1. 腸套疊的好發年齡及男女比例 ?
2. 腸套疊的臨床特徵 ?
3. 如何診斷腸套疊 ?
4. 腸套疊的治療方式、開刀條件及復發的比例 ?

Pediatric Department, Pingtung Christian Hospital

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屏東基督教醫院 小兒科

Pediatric department, Pingtung Christian Hospital

The part which prolapses into

Due to peristaltic action of the

Currant jelly stool ( 草莓醬便 )

Physical examination: a sausage-shaped mass felt upon pal

The ultrasonography should be used as a first-line

Plain abdomen X-ray:

Intussusception in an infant. The obstruction is evident in the proximal transverse

Lower GI contrast enema

The choice of therapeutic method varies among hospitals

Intussusception, Ileoileocolic type

Sonar: a typical complex appearance

The hydrostatic reduction rate was

Intraoperative photograph of a patient with an ileocolic intussusception.

Failure of non-surgical reduction may require surgical

2. To determine the rates of surgical intervention and

 The incidence was calculated by age, sex, calendar year

 The yearly incidences were calculated as the number of

 Weather statistics were obtained from the Central Weather

Cum ula tive pe rce nta ge (% )

Figure. Case numbers and cumulative percentage of intussusception in

Figure. Incidence of intussusception by two genders in Taiwanese children

Ma le -to-F e m a le incide nce ra te ra tio

Figure. Incidence rates (case number per 100,000 person-years) of

Figure. The monthly mean temperature and the case numbers of

Male predominance with a dynamic male-to-female incidence

Treatment Protocol - Hydrostatic Reduction

Treatment Protocol - Hydrostatic Reduction

Let N/S go into rectum, under sonar guidance.

Education after Treatment

If patient feels hungry, try feeding with water first,

Education after Treatment

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屏東基督教醫院小兒科