Bacterial Enteritis and Childhood Intussusception
Abstract & Commentary
By Hal B. Jenson, MD, FAAP, Professor of Pediatrics, Tufts University School of Medicine, and Chief Academic Officer, Baystate Medical Center, Springfield, MA, is Associate Editor for Infectious Disease Alert.
Dr. Jenson reports no financial relationships relevant to this field of study., is Associate Editor for Infectious Disease Alert.
Synopsis: Bacterial enteritis in children significantly increased the risk for intussusception, with a relative risk of 40.6 (95% CI = 28.6-57.5; p < 0.0001).
Source: Nyland CM, Denson LA, Noel JM. Bacterial enteritis as a risk factor for childhood intussusception: A retrospective cohort study. J Pediatr. 2010;156:761-765.
A retrospective cohort study was conducted of all children age birth to five years enrolled at a Department of Defense treatment facility between January 1998 and December 2005, who were diagnosed with bacterial enteritis. Their medical records were reviewed for the ensuing six months for a diagnosis code (DRG code 560.0) or procedure code consistent with intussusception.
A total of 387,514 children were enrolled in a treatment facility, yielding a total of 293 cases of intussusception and an incidence of 15.1 cases/10,000 children/year. Of the 1,412 cases of bacterial enteritis, intussusception ensued in 37 cases (13 in females and 24 in males), representing 12.6% of all cases of intussusception. The overall relative risk for intussusception in the six months following bacterial enteritis was 40.6 (95% CI = 28.6-57.5; p < 0.0001). The relative risk was greater in children 1-5 years of age (56.2 [95% CI = 36.0-87.8]) compared to children < 1 year of age (16.0 [95% CI = 9.1-28.2]). The absolute risk for intussusception following enteritis was 2.3% for children < 1 year of age and 3.3% for children 1-5 years of age.
The relative risk of intussusception was increased for all four major causes of bacterial enteritis: Salmonella (16 cases; 28.7 [95% CI = 7.2-113.4]); Escherichia coli, including enteropathogenic, enterotoxigenic, enteroinvasive, and enterohemorrhagic (13 cases; 25.0 [95% CI = 5.62-111.6]); Shigella, including S. dysenteriae, S. flexneri, S. boydii, and S. sonnei (six cases; 23.6 [95% CI = 3.6-156.0]); and Campylobacter (two cases; 32.9 [95% CI = 3.48-310.7]). No cases of intussusception followed Yersinia enterocolitica enteritis, likely resulting from the low rate (1%) of Yersinia enteritis among this cohort.
The median interval between the episode of enteritis and development of intussusception was 58 days, with a range from 1 to 175 days. Using negative binomial regression for 30-day time periods while controlling for age, the relative risk for intussusception after bacterial enteritis was significantly increased for the first 30-day period (9.5 [95% CI = 2.5-35.8]; p < 0.0009). After the first 30 days, the risk decreased and did not reach significance, with the exception of the interval of 120-150 days.
Many studies have suggested an association between enteritis and intussusception, which is the prolapse of one part of the intestine into the lumen of an adjoining part, most frequently ileocolic. Lymphoid hyperplasia, or hypertrophy of Peyer's patches, is a common finding in intussusception that is felt to predispose to intussusception by serving as a mechanical lead point.
This retrospective study, using a large population cohort, showed a statistically significant increased risk of intussusception among children with bacterial enteritis within the previous six months. These results show the highest risk of intussusception in the first 30 days after enteritis, followed by a lower but continued risk through the subsequent six months. Physicians and parents should appreciate the increased risk, and should facilitate earlier recognition and prompt treatment of intussusception following bacterial enteritis. This study did not address the potential impact of antibiotic treatment on the risk for intussusception, which might be favorable.