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ORIGINAL ARTICLE

Sonographic findings predictive of the need for surgical

management in pediatric patients with small

bowel intussusceptions

Yao Zhang   & Yu-Zuo Bai   & Shi-Xing Li   & Shou-Jun Liu   &

Wei-Dong Ren   & Li-Qiang Zheng

Received: 20 September 2010 /Accepted: 17 January 2011 /Published online: 28 January 2011# Springer-Verlag 2011

Abstract

 Purpose   This study aims to evaluate ultrasound findingsthat are predictive of the need for surgical management in

 pediatric patients with small bowel intussusceptions (SBIs).

 Methods   A retrospective review of pediatric patients with

SBIs treated from 2004 to 2009 was conducted. Patients

were divided into surgical and non-surgical groups.

Demographic data, ultrasound findings, treatments, and

outcomes were collected and analyzed.

 Results   There were 56 cases of SBIs in 31 males and 25

females ranging in age from 4 months to 9 years; 39 patients

were managed conservatively and 17 patients underwent 

surgery. The mean length and diameter of the intussusception

in the surgical group were 6.53 and 2.78 cm, respectively, and3.21 and 1.81 cm, respectively in the non-surgical group

(both,   P <0.001). Multivariate logistic regression analysis

indicated that diameter, length, and thickness of the outer rim

were independent predictors of surgery. Receiver operating

characteristic curve analysis indicated an intussusception

diameter  ≥2.1 cm, length  ≥4.2 cm, and thickness of the outer 

rim  ≥0.40 cm were optimal cutoff values for predicting the

need for surgery.

Conclusions   A diameter   ≥2.1 cm, length   ≥4.2 cm,

and thickness of the outer rim   ≥0.40 cm predict the needfor surgical management in pediatric patients with SBIs.

Keywords   Intussusception . Small bowel intussusception .

Ultrasound . Intestinal diseases . Infants

Introduction

Acute intussusception is the most common condition

causing an acute abdomen in infants, and typical clinical

manifestations include paroxysmal crying, abdominal pain,

abdominal mass, and bloody stool [1]. Intussusceptions are

usually located in the ileocolic region and ileocecal

 junction, and these two types comprise approximately

80% of the intussusceptions in pediatric patients [2]. Small

 bowel intussusceptions (SBIs) are relatively rare and

accounts for <10% of the intussusceptions in pediatric

 patients [2]. Clinical manifestations of SBIs are not typical,

 patients may present with non-specific signs and symptoms,

an abdominal mass and bloody stool occur infrequently,

and diagnosis may be delayed resulting in intestinal

necrosis and a potential life-threatening situation [1 – 3].

Ultrasound is highly accurate for the diagnosis of ileocolic

intussusceptions with a reported sensitivity of 98 – 

100%, and

the ultrasound detection rate for SBIs is approximately 76%

[4]. Diagnosis of an intussusception is made by the

appearance of characteristic findings on ultrasound [5,   6].

Because some SBIs reduce spontaneously, it is controversial

whether or not surgical treatment is necessary for all cases in

 pediatric patients [7,   8]. Doi et al. [8] reported that 

spontaneous reduction happens in most cases of SBI in

children, and only clinical observation, rather than surgical

intervention, is needed and has termed these transient 

Y. Zhang : S.-X. Li : S.-J. Liu : W.-D. Ren

Department of Ultrasound, Shengjing Hospital,

China Medical University,Shenyang 110004, China 

Y.-Z. Bai (*)

Department of Pediatric Surgery,

Shengjing Hospital of China Medical University,

 No. 36 Sanhao St, Heping District Shenyang 110004, China 

e-mail: baiyz@sj-hospital.org

L.-Q. Zheng

Department of Library,

Shengjing Hospital of China Medical University,

Shenyang 110004, China 

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DOI 10.1007/s00423-011-0742-6

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intussusceptions, benign SBIs. Sönmez et al. [9] consider that 

SBIs secondary to Henoch – Schonlein purpura can be reduced

spontaneously, and conservative treatment is feasible. How-

ever, Ko et al. [2] report that persistent SBIs are often

associated with intestinal ischemia, necrosis, and perforation,

and surgical intervention is warranted once diagnosed. Koh et 

al. [3] consider that though spontaneous reduction can be

achieved in most cases of SBIs, surgical treatment isinevitable in some patients with intestinal ischemia or a 

 pathological lead point.

Therefore, it is clinically very important to determine

whether an SBI is likely to reduce spontaneously in order to

avoid complications and perform surgery in a timely

manner, as well as avoid surgery when not necessary. In

the present study, we carried out a retrospective analysis of 

 pediatric patients with SBIs who required surgery and in

whom the intussusception resolved spontaneously in order 

to identify ultrasound characteristics predictive of the need

for surgical management.

Materials and methods

This retrospective study was conducted in the Pediatric

Department of Shengjing Hospital of the China Medical

University. This study was approved by the institutional

review board of the hospital, and the requirement of informed

consent was waived because of its retrospective nature.

The records of pediatric patients (from birth to 14 years of 

age) with single SBIs diagnosed by ultrasound who were

admitted between January 2004 and December 2009 were

reviewed. Patients were divided into a group that received

surgery (surgical group) and a group that did not receive

surgery (non-surgical group). In the non-surgical group,

spontaneous reduction was proven by ultrasound, and surgical

intervention was not required. Data extracted from the

medical records and evaluated included patient demographic

characteristics, clinical symptoms and signs, ultrasound

imaging features, operative findings, and treatment outcomes.

Collected ultrasound image data included the location of 

the intussusception (left upper quadrant, left lower quad-

rant, right upper quadrant, and right lower quadrant of the

abdomen), length, diameter, thickness of the sheath, the

 presence of enlarged lymph nodes (defined as  ≥1.0×0.5 cm),

the presence of intestinal expansion (diameter  ≥3.0 cm), the

 presence of a visible pathological lead point, and the

 presence of free fluid in the abdomen. Two physicians,each with more than 5-year experience in reading

 pediatric ultrasounds, performed the ultrasounds and

confirmed the diagnoses, i.e., both physicians read each

ultrasound, and agreement between the physicians was

arrived at before a final diagnosis was made. The

diagnosis of SBI was based on the presence of a   “target 

sign”   on cross section and   “sleeve sign”   on vertical

section in ultrasound images (Figs.   1  and   2). Ultrasound

machines used were either a GE V730 (General Electric

Healthcare, USA) or PHILIPS iu22US (Philips Medical

Systems, Holland), and probes used were a 2 – 5-MHz

convex array probe and a 6 – 

12-MHz linear array probe.

Statistical analyses

Categorical data were presented by number and percentage

and tested by chi-square test or Fisher 's exact test.

Continuous data were presented with mean and standard

deviation or median and interquartile range and tested by  t 

test or Wilcoxon rank sum test. Diameter, length, and

thickness of the outer rim were separately tested in a 

logistic regression model adjusted for age, gender, and the

 presence of free fluid and enlarged lymph nodes, with

results expressed as a parameter estimate (log odds) and

95% confidence interval (CI) for surgery as the outcome. A

receiver operating characteristic (ROC) was used to

determine an optimal value for deciding whether a SBI

 patient required surgery. Data were analyzed using SPSS

15.0 (SPSS Inc., Chicago, IL, USA). A value of   P <0.05

was considered to indicate statistical significance.

F ig . 1 a   A 2 2 - mo n t h- o l d

female. Ultrasound shows the

“target sign”, and the diameter 

of the abdominal mass was

2.8 cm. Ileal intussusception

was confirmed at surgery.  b  A

2-year-old male with transient 

small bowel intussusception.

Ultrasounds show the   “target 

sign”, and the diameter of the

abdominal mass was 2.0 cm.

The mass had disappeared at 

reexamination

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Results

Between January 2004 and December 2009, there were 56

cases of single SBIs diagnosed by abdominal ultrasound

findings of a  “target sign” and   “sleeve sign”. There were 31

males and 25 females ranging in age from 4 months to9 years. There were 39 patients who were managed

conservatively and did not receive surgery (non-surgical

group), and 17 patients who underwent surgery (surgical

group). Patient data by group are presented in Table  1.

In the surgical group, 14 patients had various degrees of 

intestinal obstruction, and symptoms included vomiting,

abdominal distention, and the absence of flatus and

defecation. Bloody stool was present in one case, and plain

abdominal radiograph showed a stepped liquid – gas inter-

face. There were six secondary SBIs (four associated with

intestinal polyps and two ileocolic intussusceptions sec-

ondary to an inverted Meckel's diverticulum), five postop-

erative SBIs, and four were primary SBIs without an

identifiable cause. In two cases, preoperative ultrasound

showed an SBI, and repeated ultrasound scanning was

carried out every 2 – 3 h in which a SBI was observed every

time; however, no SBI was found during exploratory

laparotomy. Intraoperative manual reduction of the SBI

was performed in the 15 cases in which an SBI was found

during surgery. In addition, polypectomy was performed infour cases, and Meckel's diverticulum resection was

 performed in two cases. Intestinal necrosis occurred in

one case, and resection and anastomosis were performed.

Ultrasound-guided hydrostatic reduction using a saline

enema was attempted in five cases and failed in four cases.

In one case, recurrence occurred after successful reduction,

and surgical treatment was carried out after the intussus-

ception developed four times in 2 days. Surgery and

 postoperative recovery were without complications in all

cases, and patients were discharged in good condition.

In the non-surgical group, the main clinical manifesta-

tion was diarrhea in 21 cases, paroxysmal crying andabdominal pain in 11, and vomiting in 15. In five cases,

there were no clinical symptoms, and the SBIs were found

F ig . 2 a   A 2 2 - mo n t h- o l d

female. Ultrasounds show the

“sleeve sign”, and the length of 

the mass was 5.5 cm. Ileal

intussusception was confirmed

at surgery.  b  A 3-year-old male

with transient small bowel

intussusception. Ultrasounds

show the   “sleeve sign”  on ver-

tical section, and the length of the mass was 2.1 cm. The mass

had disappeared at reexamina-

tion

 Non-surgery group (n=39) Surgery group (n=17)   P  value

Female (n, %)a  19 (18.7) 6 (35.3) 0.3528

Age (months) b 24 [21 – 48] 22 [9 – 48] 0.2861

Abdominal pain 21 17

Vomiting 15 15

 No flatus or defecation 2 14

Bloody stool 0 1

 No clinical symptoms 5 0Secondary small bowel

intussusception

0 6

Diameter (cm) b 1.81±0.28 2.78±0.41 <0.0001*

Length (cm) b 3.21±0.86 6.53±2.60 <0.0001*

Thickness of outer rim (mm) b 0.35±0.05 0.55±0.10 <0.0001*

Location (LU/LL/RU/RL)a  24:6:8:1 2:6:5:4 <0.0001*

Free fluid present (n, %) 2 (5.1) 13 (76.5) <0.0001*

Enlarged lymph nodes present (n, %)a  15 (42.2) 7 (41.2) 0.8483

Bowel dilatation present (n, %)a  2 (5.1) 11 (64.7) <0.0001*

Table 1   Patient demographic

and sonographic data 

 LU   left upper,  LL  left lower,  RU 

right upper,  RL  right lower 

* P <0.05, statistical significancea 

Chi-square test or Fisher 's exact 

test  b

Median [interquartile range],

Wilcoxon rank sums test, or  

mean±standard deviation,  t   test 

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incidentally (two underwent ultrasound reexamination after 

abdominal tumor resection, one underwent ultrasound

reexamination after appendectomy, and two underwent 

routine abdominal ultrasound examination after a car 

accident). No abdominal distention, abdominal mass,

 bloody stool, or signs of acute intestinal obstruction were

noted in any of the patients in this group. Spontaneous

reduction of the SBI was proven by ultrasound in all 39 patients. In 6 cases, spontaneous reduction was observed

during scanning, in 31 cases, reduction occurred 30 – 60 min

after ultrasound scanning, and in 2 cases, reduction

occurred 2 – 3 h after scanning. Abdominal ultrasound,

 performed 12 – 24 h after the apparent reduction in all

 patients, revealed no signs of SBI. In 11 patients, carbon

 powder was administered orally, and discharge through the

anus 8 – 24 h later was noted, indicating that the SBI had

resolved.

Ultrasound findings of both groups are presented in

Table 1. No pathologic lead point was found in any patient 

in either group. The mean length and diameter of theintussusception in the surgical group were 6.53 and

2.78 cm, respectively, and both were statistically greater 

than the corresponding measurements in the non-surgical

group (3.21 and 1.81 cm, respectively; both,  P <0.001).

Results of the multivariate logistic regression analysis

are presented in Table  2, and indicate that diameter, length,

and thickness of the outer rim were all independent 

 predictors of the necessity of surgery with estimate values

(95% CIs) of 6.2 (1.5 – 11.0), 2.4 (0.7 – 4.1), and 24.2 (4.6 – 

43.8), respectively. Age, gender, and the presence of free

fluid, enlarged lymph nodes, and bowel dilatation had no

independent correlation with whether or not a patient 

required surgical treatment.

ROC curve analysis was performed to determine the best 

critical values for diameter, length, and thickness of the

outer rim for evaluating whether or not an SBI patient 

requires surgical management, and results are presented in

Fig.   3   and Table   3. The diameter was 2.1 cm (area under 

the ROC curve [AUC] 0.973, 95% CI 0.939 – 1.000), the

length was 4.2 cm (AUC 0.964, 95% CI 0.920 – 1.000), and

the thickness of the outer rim was 0.40 cm (AUC 0.968,

95% CI 0.929 – 1.000). The sensitivity, specificity, positive

 predictive value, and negative predictive value of the values

are shown in Table   3. If the length of the intussusception

is   ≥4.2 cm, the sensitivity and specificity for the need of 

surgical management are 94.1% and 84.6%, respectively.

Discussion

In the present study, we retrospectively analyzed the

clinical manifestations and ultrasound imaging features of 

all cases of SBIs managed surgically and conservatively.

Our results showed that diameter, length, and thickness of 

the outer rim of the intussusception were all independent 

 predictors of the need for surgery. ROC analysis indicated

that when the length of intussusception is   ≥4.2 cm, the

sensitivity and specificity of the need of surgical manage-

ment are 94.1% and 84.6%, respectively.

Diagnosis of most SBIs relies on ultrasound scanning,

and types of intussusceptions can be readily distinguished

[5,   6,   10]. In addition, with the development and wide

Fig. 3  Diagnostic accuracy of diameter, length, and thickness of the

outer rim on a continuous scale in the prediction of surgery using a 

receiver operating characteristic curve. Diameter: AUC1   (95% CI),

0.973 (0.939 – 1.000),   P <0.001. Length: AUC2   (95% CI), 0.964

(0.920 – 1.000),   P <0.001. Thickness of the outer rim: AUC3   (95%

CI), 0.968 (0.929 – 1.000),   P <0.001.   AUC   area under the curve,  CI 

confidence interval

Table 2   Parameter estimates of logistic regressions and 95% CIs for 

surgery as a function of diameter, length, and thickness of the outer rim, adjusted by age, gender, free fluid present, enlarged lymph nodes

 present, and bowel dilatation present 

Ultrasound feature Estimates 95% CI   P  value

Diameter 6.2 (1.5 – 11.0) 0.0099*

Length 2.4 (0.7 – 4.1) 0.0058*

Thickness of the outer rim 24.2 (4.6 – 43.8) 0.0153*

CI   confidence interval

* P <0.05, statistical significance

Table 3   Specific ultrasound features as predictors of the necessity of 

surgery

Ultrasound

feature (cm)

Sensitivity Specificity Positive

 predictive value

 Negative

 predictive value

Diameter  ≥2.1 100 82.1 70.8 100

Length  ≥4.2 94.1 84.6 72.7 97.1

Thickness  ≥0.4 88.2 84.6 71.4 94.3

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application of ultrasound technology, the presence of 

temporary or transient small bowel intussusceptions has

 become clinically apparent [1,   4,   5,   8,  11]. Doi et al.   [8]

have suggested the term benign small bowel intussuscep-

tion to describe those that are found incidentally and/or 

resolve spontaneously. Reports have suggested that 50%

or more of SBIs will resolve spontaneously [1, 8, 12], thus

identifying those that will resolve with conservativemanagement, and those that require surgical management 

is of clinical importance. Delay of surgery can result in

intestinal necrosis, and surgical management of an SBI

that is likely to resolve spontaneously exposes the patient 

to the risks of surgery [2]. While the findings of this study

indicated that a large percentage of SBIs resolved

spontaneously, we are confident of the results as the

diagnosis of SBI was confirmed by two experienced

 physicians in each case.

Kim [4] reviewed the ultrasound findings of 34 SBIs

diagnosed in 32 infants and children and found that 

transient SBIs typically exhibited a small size (meandiameter 1.5 cm) without wall swelling, a short segment 

(mean length 1.8 cm), preserved wall motion, and the

absence of a lead point. Mateen et al. [11] reviewed the

records of 108 consecutive patients (adults and children)

with intestinal intussusceptions, of which 41 were diag-

nosed as transient SBIs. They found that SBIs without an

identifiable pathological lead point, normal wall thickness,

normal non-dilated proximal bowel, normal vascularity on

color Doppler ultrasound, and a length of <3.5 cm reduced

spontaneously and were not of clinical significance. On the

other hand, Munden et al. [1], in a study of 35 cases of 

SBIs in adults and children, found that a length >3.5 cm

was a strong indicator for the need of surgical intervention.

Possible reasons for the difference between the results of 

Munden et al. and those of the current study are ethnic

differences in the subjects of the two studies, differences in

the ultrasound equipment used, and differences in the

statistical methods used.

The presence of a pathological lead point is suggestive

of the need for surgical intervention. Koh et al. [3] reported

the characteristics of six patients with SBIs who required

surgical intervention, and five exhibited a pathological lead

 point on ultrasound. Ko et al. [2] reported the presence of 

 pathological lead points in 8 of 19 surgically proven cases

of SBIs in pediatric patients. Navarro et al. [13] found that 

surgery was required in 32 of 43 children with intussus-

ceptions with pathological lead points. Interestingly, a 

 pathological lead point was not identified in any of the

 patients, surgical or non-surgical, in our study.

In the surgical group, ultrasound-guided hydrostatic

reduction using a saline enema was attempted in five cases,

and failed in four cases. In one case, recurrence occurred

after successful reduction, and surgical treatment was

carried out. Mirilas et al. [14] studied the sonographic

features that correlated with hydrostatic reducibility of 

intestinal intussusceptions in infants and children. They

found that when the head of the intussusception appeared as

a target-like mass, the hydrostatic reduction rate was 100%.

When the head appeared as a donut-like mass, hydrostatic

reproducibility depended on the thickness of the hypo-

echoic external ring of the donut, with larger thicknessescorrelating with failure of hydrostatic reduction and the

need for surgery. In addition, when a small amount of fluid

was present within the head of the intussusception,

hydrostatic reduction was unsuccessful in all cases.

Though ultrasound imaging features are useful for 

determining the necessity of surgical intervention, the

need for surgical intervention also depends on clinical

signs and symptoms that may suggest intestinal obstruc-

tion or ischemia. Our results suggest that if the patient 

has no signs of mechanical ileus, the length of intussus-

ception is short (<4.2 cm), the diameter of intussuscep-

tion is small (<2.1 cm), and there is no swelling of theintestinal wall, it should be considered a transient SBI,

and close observation and repeat ultrasounds are war-

ranted. Conversely, if the length of intussusception is

≥4.2 cm, the diameter of intussusception is   ≥2.1 cm, the

thickness of the outer rim is  ≥0.4 cm, there is swelling of 

the bowel wall, and there is evidence of mechanical ileus

(e.g., vomiting, abdominal distension), surgical manage-

ment should be considered.

There are some limitations to the current study that should

 be considered. This was a retrospective study with a relatively

small number of cases performed at one center. A larger 

number of cases are necessary to confirm the findings. Enema 

reduction was not attempted primarily in all of the 17 cases

that were managed surgically; although 5 cases once

underwent ultrasound-guided hydrostatic reduction using a 

saline enema, all failed. Thus, evaluation of a relationship

 between the reducibility of intussusception with non-surgical

methods vs. spontaneous reduction or the need for laparotomy

was not possible. Lastly, unavoidable error in ultrasound

measurements may potentially affect the results.

Conclusion

In summary, our data indicate that an intussusception

diameter   ≥2.1 cm, length   ≥4.2 cm, and thickness of the

outer rim   ≥0.40 cm predict the need for surgical manage-

ment in pediatric patients with SBIs. These values may be

of assistance to clinicians when determining if surgery is

required in pediatric patients with SBIs. Values below those

determined from these data should be interpreted with

caution in patients with signs and symptoms of mechanical

ileus or intestinal ischemia.

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Acknowledgments   This work was financially supported by Shengjing

Outstanding Scientific Foundation (grant no. m850) from The Shengjing

Hospital of China Medical University.

Conflicts of interest   None.

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