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Background: Intussusception is the common cause of bowel obstruction in infancy and childhood. Early diagnosis and effective management have reduced its morbidity and mortality in developed countries. Aim of the study: Aim of the study was to identify the perceived diagnosis of patients with intussusception obtained at lower health facilities in patients referred to KCMC, to describe duration of clinical symptoms and signs of patients with intussusception from onset to being attended at KCMC and to describe treatment outcome of patients with intussusception at KCMC. Patients and method: Thirty six consecutive cases with intussusception age one day to ten years seen at pediatric and surgical wards at KCMC over a period of one year were prospectively studied. Results: Of the 36 children, 22(61.1%) were males and fourteen (38.9%) were females giving a ration of 1.6 : 1. Of these, 31 (86.1%) were infants of age >12 months. The duration of symptoms was a median of 3 days with a range of 2 – 30 days. One patient of age 10 years presented with chronic SBO of 30 days due to jejunal polyps. Seventy seven percent were referrals from other hospitals. 22 (78.6%) of referred patients had perceived diagnosis at lower health facilities: dysentery 12 (54.5%), self medication at home before attending hospital 4 (18.2%), malaria 3 (13.6%), malaria & dysentery 2 (9.1%) and rectal prolapse 1 (4.5%). Decision to refer was prompted by either persistent symptoms and signs after initial antibiotics treatment or by setting of the abdominal distension. Classic triad of vomiting, abdominal pain and mucus blood diarrhea/red currant jelly was seen in only 17 (47.2%) out of 36 patients. Classic triad and palpable abdominal mass seen in 5 (29%) of the 17 patients. All patients (100%) were operatively. Sixty nine percent had ileo-colic intussusception, 30.6% colo-colic and 5.6% caeco-colic. Perforation was found in 5.6%, gangrenous intussusceptum in 41.7%, peritonitis 27.8%, gut malrotation 5.6%, inverted appendix 2.8% and PLP in 16.7%. PLP were mesenteric adenitis 3(8.3%), Caecal tumor (Histology of both – Burkitt’s lymphoma) 2(8.3%) and jejunal polyps 1(2.8%). 13 (36.1%) were managed by manual reduction and bowels were viable, 4 (30.8%) attended KCMC ≤ 24 hrs and 9 (69.2%) attended > 24 hrs from onset of symptoms. 22 (61.1%) were managed by resection and primary anastomosis, 3 (13.6%) out of twenty-two patients attended KCMC ≤ 24 hrs from onset of symptoms and 19 (86.4%) reported with duration of symptoms > 24 hrs. Failure of manual reduction at hepatic flexure level due to gangrenous intussusceptum occurred in fifteen out of 22 patients, right hemicolectomy and end-end ileo-transverse primary anastomosis done. Failure reduction at caecal level occurred in four out of 22 patients, resection and end-end ileo-caecal primary anastomosis done. One patient presented with transanal intussusceptum prolapse with gangrene of ascending, transverse and descending colon and small multiple perforations, resection done and end-end ileo-sigmoid primary anastomosis. Two patients got resection of small intestine, one due to polyps and the other due to gangrenous distal ileum. Colostomy done to one patient due to multiple perforation of colon noted on inspection before attempted manual reduction, perforation repaired and double barrel colostomy made. Operative management complications were: pneumonia 1 (2.8%), septic shock 4(11.1%), intra operative arrest 2 (5.6%), iatrogenic bowel fistula and peritonitis 1 (2.8%) and post operative intestinal obstruction due to adhesion 3 (8.3%). Majority of patients 26 (72.2%) were discharged. Ten patients died post operatively, mortality was 27.8%. The duration of hospital stay ranged from 1 – 18 days with mean of 6.8 ±3.5. Conclusions: The mortality rate was high because majority of cases presented late for medical attention with advanced stage of the illness(gangrenous bowel, peritonitis and perforated bowel). Recommendation: Awareness campaign of childhood bowel obstruction caused by intussusception should be done by training, informing and sensitizing of the health staff in the primary health facilities and the population in general. Decentralization and strengthening of health services delivery to enable district hospitals deal with pediatric surgical emergencies and provide pediatric critical care. |
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