Acute Intestinal Invagination of the Child at the Teaching Hospital of Bouaké: Ultrasound Diagnosis and Clinical-Echo-Surgical Correlation

Background: Acute intestinal invagination or intussusception is the most common abdominal surgical emergency in infants, but it can occur at any age. Performing an ultrasound scan at the slightest clinical suspicion contributes to early diagnosis and therapeutic management. Objective: To show the relevance of ultrasound in the therapeutic management of the child’s intussusception through a correlation between the ultrasound diagnosis and the clinical and/or per operative diagnosis. Patients and Methods: It was a retrospective study of 24 cases from July 2017 to September 2020 (30 months) in the Medical Imaging and Paediatric Surgery departments of Teaching Hospital of Bouaké. We included only patients from 0 to 15 years old who had digestive symptoms, an abdominal ultrasound scan. These patients were eligible for surgery. Data analysis was performed with Epi info 7 software. Results: Median age was 17.2 months [02 120]. Male gender predominated (83.3%). Clinico-biological data were dominated by abdominal pain (79.2%), vomiting (75%) and rectorragies (33.3%), with Ombredanne’s triad in 33.3% and hyperleukocytosis (70.8%). Ultrasonography showed invaginated coves (95.8%) sitting in the right angl iliac fossa, peri-umbilical and right flank in 73.9%. Cockade image coupled with the sandwich image accounted for 95.6%. Superficial adenopathies (45.8%) and peri-lesional fluid effusion (20.8%) were associated with it. An occlusive syndrome complicating intusHow to cite this paper: Kouakou, B.D.M., Issa, K., Kouassi, K.P.B., Bénié, A.C., Bravo, T.A.B., Tanoh, K.E., Kouadio, A.F., Yao, B.L., Akobe, A.J.-R., Sanogo, S.C., Soro, M. and N’Dri, K. (2021) Acute Intestinal Invagination of the Child at the Teaching Hospital of Bouaké: Ultrasound Diagnosis and Clinical-Echo-Surgical Correlation. Open Journal of Medical Imaging, 11, 18-28. https://doi.org/10.4236/ojmi.2021.111003 Received: December 3, 2020 Accepted: March 5, 2021 Published: March 8, 2021 Copyright © 2021 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/


Introduction
Acute intestinal invagination (A.I.I.) or intussuception is the penetration of an intestinal segment and its meso into the downstream intestine. It is the most common abdominal emergency in infants and young children, but can occur at any age. Intussuception is idiopathic in more than 95% of cases [1]. Its clinical manifestation is variable but classically includes paroxysmal abdominal pain, vomiting and bloody stools. Intestinal invagination results in intestinal occlusion and ischaemia with the risk of intestinal perforation and peritonitis [2] [3] [4]. Precarious financial situation of patients, but also the delay in diagnosis and treatment, puts their vital prognosis at risk. In our developing countries, A.I.I is characterized by a still very high morbidity and mortality [5]. This pathology therefore requires an abdominal ultrasound for its diagnosis. Ultrasound is the reference diagnostic examination. It allows us to determine anatomical type of the blood sausage, to identify digestive distress, to detect a primitive lesion and therefore to guide the therapeutic treatment [6]. Very few studies have been carried out on the contribution of ultrasound in management of this pathology. The objective of this study was to show relevance of ultrasound in the therapeutic management of a child's intussusception by correlating ultrasound diagnosis with the clinical and/or per operative diagnosis.

Patients and Methods
We carried out a retrospective study based on an exhaustive sampling. The study covered 24 files. This study was carried out in the Medical Imaging and Paedia-

 Epidemiological aspects
Average age of the patients was 17.2 months with extremes of 2 and 120 months. Infants predominated in 83.3% of the cases in our study (N = 20). These patients were not in school in 95.83% (N = 23) and their Expanded Programme on Immunization (E.P.I) and excluding EPI vaccination status was up to date in 83.3% and 16.7% respectively. Male gender represented 83.3% of the respondents, i.e. a sex ratio of 5.  Clinical and biological aspects Functional signs were dominated by classic symptomatic triad of Ombredanne (33.3%), consisting of paroxysmal abdominal pain (79.2%), bilious vomiting (75%) and rectorragies (33.3%).
Dehydration and fever were the most common general signs in our study, reflecting poor general condition of patients in 58.3% (N = 14) and 37.5% (N = 9) of cases respectively.

 Medical imaging aspects
All patients had an abdominal ultrasound. However, no opaque enema was performed. Only 37.5% of patients had an x-ray of abdomen without preparation (ASP).
Cockade image coupled with sandwich image (Figure 1) was the most represented with 95.6% (N = 22). However, an indeterminate image was noted in 4.3% (N = 1). In cross-section, diameter of cockade image varied between 20 mm and 50 mm. Invagination sausage in cross-section measured between 30 and 50 mm in 81.8% of cases i.e. 18 cases (Table 1) These ultrasound signs were associated with superficial adenopathies (45%) which were mostly located in mesentery (67%).
All patients surveyed had integrity of solid intra-abdominal organs (liver, spleen, kidneys, pancreas). They had an alithiasic gallbladder with a thin wall.      (Table 2).
There is a significant diagnostic concordance between the clinic, ultrasound and surgery (Table 3).

Limits
The aim of this study was to show relevance of ultrasound in therapeutic man-

 Epidemiological aspects
Average age of patients was 17.2 months. Infants were the most represented among patients in 85% of cases. These results are consistent with those of Rakotoarisoa [8] who found a predominance of infants in her study but with a younger average age of 8.1 months.
Male sex observed in this study is consistent with data in literature [8] [9] [10] [11]. According to Weihmiller, male sex is a factor favouring acute intestinal invagination and accounts for 60% of cases [12].

 Clinical aspects
Diagnosis time exceeded 48 hours in 79.2% of cases. Carcassonne [13] and Rakotoarisoa [8] reported average durations of 35.5 hours and 44.1 hours respectively, with extremes of 6 hours to 5 days in their studies. This delay in diagnosis is said to result from unfavourable socio-cultural and economic conditions of our populations who first try traditional medication for digestive disorders before considering a medical consultation. Also, absence of social security in our health centers is a hindrance to early diagnosis of patients. There is also a lack of awareness of this pathology among both para-medical and non-specialised medical staff. The time required to diagnose an A.I.I. is highly dependent on the skills of practitioner and available equipment [14].
Beyond a positive diagnosis, the clinical examination aims to assess severity of Open Journal of Medical Imaging In our study, this triad dominated the functional signs with 33.3%. This rate is higher than that of Vandertuin, who noted presence of this triad in 24% of patients (7 out of 29) in Geneva and only in 1 case out of 37 in Lausanne [15]. For Bines, only 20% of invaginations have such a presentation [16], because in current practice it is difficult to observe these three signs at same time.
Invagination sausage was palpable in 6 patients, i.e. 25%. This rate is close to that of Rakotoarisoa [8] who found an abdominal mass 7 times out of 22, i.e. in 31.8% of cases. These data are comparable to those in literature, which found invagination sausage's head in 25% to 50% of ileocolic invaginations [16].

 Medical imaging aspects
Invaginated loops were observed in almost all cases, 95.8% (N = 23). Cockade image was represented in 95.6% of cases. According to Vandertuin [15], this image, which corresponds in cross-section to the layers of intestinal walls inside each other, is easily identifiable. Abdominal ultrasound by an experienced radiologist is currently examination of choice to confirm diagnosis of an intestinal invagination. Sensitivity and specificity of this examination is close to 100% [17].
Right location of invagination sausage was the most represented (73.9%), consisting of right iliac fossa and right flank involvement in 26.1% each and peri-umbilical involvement (21.7%). This result is close to the data in literature, particularly in Franchi's study [18], in which the vast majority of intestinal invaginations occurred in right subhepatic region and on right flank. This right location of A.I.I. is inherent to high frequency of ileocolic topography [1]. However, all areas of abdomen must be explored, as the head of invagination sausage may sit as far as the rectum.
In 73.7% of cases, invagination sausages measured more than 30 mm in cross-section diameter. According to literature, this indicates an ileocolic or colocolic invagination [18]. Our result is therefore consistent with those of De Lamber and Franchi, who found that an ileocolic or colocolic invagination coil in cross-section measures between 30 and 50 mm in diameter and is located under the abdominal wall [18] [19].
 Therapeutic aspects From a therapeutic point of view, many recent publications confirm interest of barium enema in reducing A.I.I. of infants [19] [20]. According to Becmeur [21], before deciding on a non-operative treatment, it is necessary to ensure its safety and assess its chances of success. None of our patients have been able to benefit from this so-called medical reduction treatment for clinical and technical reasons. In our practice, surgery unfortunately still remains the only logical therapeutic weapon. Twenty-two patients or 91.7% were treated surgically in our Open Journal of Medical Imaging showing digestive suffering. We detected 5 cases, i.e. 20.8% in our study. The greater the quantity of liquid, the greater the degree of suffering [22]. According to Baud, combination of two severity criteria leads to surgical treatment [5].
As for the site of lesion, it was an ileocolic A.I.I. in majority of patients (77.8%).
Our ultrasound results and data from literature are close to this result [1] [15].
Invagination's cause of these coves was not found in 81.8% (N = 18), which is evidence of idiopathic etiology well described in literature related to intusception [1]. Ileal tumour (N = 3) and dolichocolon (N = 1) were only etiologies observed in our study.

 Diagnostic concordance
We assessed the diagnostic concordance on 22 files in this study. There was indeed a significant concordance between clinical, ultrasound and per operative diagnosis (p = 0.002 < 0.05). Clinical-echo diagnostic concordance (PPV) was calculated at 47.6%, thus reflecting a high diagnostic discordance (Table 2). This discrepancy could be explained by difficulty in obtaining symptomatic triad in clinical picture and also in palpating invagination sausage.
Relevance of ultrasound results was therefore assessed after laparotomy. This enabled us to calculate positive predictive value (PPV) of ultrasound results which was very high: 95.4%. This result is in agreement with that of other authors who agree on primordial importance of ultrasound in diagnosis of A.I.I. in children. Kouamé [23] found a positive predictive value of 100%.

Conclusion
In spite of the poverty of technical platform, ultrasound in sub-Saharan Africa remains essential in the care of children with A.I.I. In this study, it allowed us to make a positive diagnosis with a very high positive predictive value (95.4%). We evaluated clinical-echo-surgical diagnostic concordance which was significant (p = 0.002). In order to reduce morbi-mortality linked to A.I.I, it is necessary to raise awareness and increase knowledge of practitioners, and to promote multidisciplinary consultation meetings involving radiologists and paediatric surgeons. A study on desinvagination by water enema under ultrasound surveillance could be envisaged to reduce the occurrence of complications, thus contributing to early diagnosis and treatment.