An alternative non-operative method for childhood intussusception reduction: USG probe compression

An alternative non-operative method for childhood intussusception reduction: USG probe compression | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An alternative non-operative method for childhood intussusception reduction: USG probe compression Agah Koray Mansiroglu, Abdullah Duman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5622154/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Intussusception is the leading cause of bowel obstruction in children, with ultrasonography (USG) as the primary diagnostic tool. Non-operative management is the preferred treatment when surgery is unnecessary. This study aimed to evaluate ultrasound-guided external reduction using probe pressure as an alternative to manual reduction. Method: Twenty pediatric patients with intussusception and no surgical indication underwent USG-guided external reduction using linear probe compression. We assessed age, sex, admission month, time to admission, clinical and radiographic findings, USG results (pre-procedure, post-procedure, control), hospitalization duration, and recurrence. Results: The study included 20 patients (9 males, 11 females) with a mean age of 5.1 years (6–134 months). Seven patients had ileocolic intussusception (1–7 cm), and 13 had small bowel intussusception (1–3 cm). A single recurrence occurred in one patient within 24 hours. A total of 22 successful reductions were performed in 20 patients without complications. Conclusion: USG-guided external reduction with probe compression is a safe, effective, and non-invasive technique for reducing both small bowel and ileocolic intussusceptions. This method offers a promising alternative to existing non-operative approaches and may transform pediatric intussusception management. Pediatrics Intussusception Non-operative management Ultrasonography Figures Figure 1 Figure 2 Introduction Intussusception is the inward telescoping of a proximal bowel segment (intussusceptum) into an adjacent distal segment (intussuscipiens), resulting in bowel obstruction. Among children, this is a frequently observed etiology of intestinal obstruction[ 1 ]. A minimum of 72 hours is required to develop ischemic necrosis, characterized by tissue death secondary to compromised blood supply. Unidentified ischemic processes may lead to sepsis and eventual mortality from intestinal perforation. Despite a decrease in mortality rates to about 1.6% in developed regions, they still stand at 8–12% in Africa [ 1 – 3 ]. The phenomenon is accompanied by the formation of a focal point, known as a "lead point." While the etiology remains obscure in 95% of cases, the prevalence of pathological lead points (PLPs) is only 4%. Meckel's diverticulum is the most common PLP, followed by rectal polyps and duplications [ 1 ]. Malignant neoplasms represent an infrequent etiology of intussusception [ 1 , 4 ]. The most common clinical presentations involve the acute onset of colicky abdominal pain, emesis, a palpable abdominal mass on physical examination, and bloody stools. Fewer than 25% of patients diagnosed with intussusception exhibit all four clinical features [ 1 ]. Ultrasonography (USG) serves as the principal radiological imaging technique for the diagnosis of intussusception. When interpreted by a skilled radiologist, USG demonstrates near-perfect diagnostic accuracy and is the preferred initial imaging modality for identifying PLPs [ 1 ]. Non-operative management is the preferred initial treatment for children without signs of peritonitis. Non-operative techniques (pneumostatic/hydrostatic) achieve 90% success under imaging guidance. During the early 20th century, Monrad, succeeding Hirschsprung, developed a manual "desinvagination" method; this was later complemented by Grasso's application of transabdominal manual manipulation in the late 20th century. The medical literature cites these techniques as non-operative [ 1 , 5 ]. While these methods are suspected to exceed reported instances, scholarly documentation has demonstrably diminished [ 1 , 5 ]. Surgical intervention should be considered when a PLP is radiologically detected, enema reduction fails, clinical symptoms persist post-reduction, or perforation is present [ 1 , 4 ]. This study aimed to reduce intussusception externally using the pressure of the USG probe as an alternative to manual reduction in patients diagnosed with intussusception by USG without surgical indication. The results of the study are presented herewith. Methods Approval for this study was obtained from the Sivas Cumhuriyet University Ethics Committee dated June 22, 2023, and decision no. 2023-06/32. The study included pediatric patients (0–12 years) diagnosed with ileocolic or small bowel intussusception between August 2022 and July 2023. Exclusion criteria included evidence of peritonitis or perforation, symptom duration exceeding three days, and ultrasonographic findings suggestive of pathological lead points or intestinal vascular impairment. The evaluation included patient demographics (age and sex), admission date, time elapsed between symptom onset and admission, clinical presentation, radiographic and ultrasonographic findings (pre- and post-procedure and control), treatment regimen, time to initiation of oral feeding, length of hospitalization, and incidence of recurrence. The parents were fully apprised of the intervention and provided written consent before the commencement of the procedure. The procedure was undertaken using a supine positioning of the patient and with the appropriate measures to prevent aspiration while foregoing sedation. Parental presence was maintained throughout the procedure to alleviate patient anxiety. Ultrasound-guided hydrostatic reduction equipment was readied as a contingency procedure for patients presenting with ileocolic intussusception in the event of primary procedure failure. A linear probe was implemented for diagnostic and therapeutic purposes. Neither hydrostatic nor pneumostatic pressure was employed. With external linear probe pressure to the abdomen, the intussusceptum was compressed between the anterior and posterior layers of the peritoneum. A series of maneuvers, including distal-to-proximal milking and compressing, successfully reduced both ileocolic and small bowel intussusceptions. A comprehensive discussion of these reduction techniques is presented in the supplementary video. Notably, all procedures were completed without sedation, and their durations ranged from 3 to 50 minutes, with a mean duration of under 30 minutes. Results Participants ranged in age from 6 months to 134 months, with a mean age of 5.1 years. Patient admissions reached their highest point in November, with the study identifying nine new cases that month. Fourteen patients arrived at the emergency department at the initial appearance of symptoms, while six arrived the following day. Abdominal pain and vomiting were reported by thirteen of the twenty patients, with only two exhibiting bloody stools. Physical examination revealed no evidence of peritonitis in any patient. Three patients presented with a readily palpable abdominal mass. Rectal examination was conducted on 11 of 20 patients, with only one showing evidence of blood in the stool. Table 1 summarizes the study's findings, including subject demographics (number of male and female participants and respective age ranges) and clinical characteristics. Following admission, upright abdominal radiographs were conducted for 14 patients among the group of 20; evidence of obstruction was present in 5 cases. Moreover, 50% of patients' ultrasonographic findings indicated multiple reactive lymph nodes (5–11 mm along the short axis). Acute appendicitis and small bowel intussusception were concurrently diagnosed in two patients. Hepatic steatosis was incidentally identified in three patients, while a single patient showed a splenic cyst 1 cm in diameter. Nineteen USG diagnoses occurred in the emergency department, while the remaining diagnosis was made in the ward. Seven cases were categorized as ileocolic intussusceptions, and thirteen were classified as small bowel intussusceptions. A 1–7 centimeters size range was observed in ileocolic intussusceptions, whereas small bowel intussusceptions measured between 1 and 3 centimeters. In one patient, recurrence was observed on the second and third follow-up USG examinations (24-hour intervals), successfully managed in both incidences using probe compression. A single intravenous dose of methylprednisolone (1 mg/kg) was administered to the patient to prevent further recurrence. Twenty-four hours later, a subsequent ultrasound study demonstrated no recurrence of intussusception. Successful non-operative reduction of small bowel intussusception was achieved in two patients who also presented with acute appendicitis; these patients subsequently received medical therapy for the appendicitis. Following medical treatment, one patient experienced improvement, while the other had to undergo laparoscopic appendectomy. Twenty-two applications of this technique were recorded. The intussusceptions presented the following spatial distribution: nine in the right abdominal quadrants, nine in the left, two periumbilical, and two epigastric. Table 2 presents a detailed account of the ultrasonographic findings. Sedation was not employed during the external reduction procedure with the USG probe. Anchoring ileocolic intussusceptions to the right lateral abdominal wall aided in manipulating them. However, the reduction process was significantly more time-consuming (ranging from 10 to 50 minutes, with an average of under 30 minutes) than small bowel intussusceptions (3–30 minutes, typically completed within 15 minutes). Figure 1 displays ultrasonographic images of ileocolic intussusception obtained under probe compression. Fourteen patients underwent upright abdominal radiography after the reduction procedure, revealing cecal and ascending colonic gas passage in eight instances. A comparative analysis of pre-and post-reduction radiographic images (Fig. 2) demonstrates colonic gas migration. Per the established guidelines, oral feeding was implemented 4–72 hours post-procedure. Of the twenty patients, ten (eight of whom presented with small bowel intussusception) received same-day treatment. Following a four-hour observation period, these patients were discharged upon exhibiting tolerance to oral intake and demonstrating the absence of clinical intussusception indicators. The remaining ten patients were admitted to the hospital for observation, with lengths of stay ranging from two to six days (mean: 1.95 days). The hospital stay was 3.33 days for patients presenting one-day post-symptom onset and 3 days for those with ileocolic intussusception. Notably, the procedures were uneventful, with no instances of aspiration, perforation, or other complications. Families were provided details regarding the signs and symptoms of recurrent intussusception before discharge. Follow-up appointments were attended by fifteen out of twenty patients. Subsequent monitoring of patients who did not apply to the hospital for control was conducted using the national health database. Given the absence of subsequent applications to other health centers, it was hypothesized that there would be no recurrence. An abdominal ultrasound was performed on patients during their subsequent visit. Two patients presented with reactive mesenteric lymphadenopathy, each exhibiting nodes less than one centimeter in diameter; a third patient displayed concurrent reactive mesenteric lymphadenopathy and terminal ileitis. A patient presented with signs suggestive of Morgagni hernia; this diagnosis was validated through subsequent plain radiography and CT scan imaging. Discussion Hunter's detailed description of intussusception came in the late 18th century. The historical evolution of non-operative treatment and transabdominal manipulation reveals that numerous pediatric surgeons initiated hydrostatic and pneumostatic reduction techniques during the 19th century, with reported enhancements in mortality rates compared to surgical intervention. Hirschsprung and his successors promoted combined transabdominal and hydrostatic reduction. Following the introduction of ultrasonography (USG) in the mid-20th century, Burke and Clarke (1977) utilized this technology to diagnose, screen, and assess reduction efficacy in intussusception [ 1 ]. Although Ravitch and McCune (1948) indicated a significant perforation risk associated with external manipulation, subsequent research by Katz and Kolm (1991) found that 36% of pediatric radiologists surveyed used transabdominal manipulation methods [ 6 ]. Conversely, a survey of pediatric radiologists in 2014 reported that this rate had fallen to 19% [ 7 ]. A 1994 series by Grasso et al. involving 35 patients demonstrated unsuccessful outcomes in 16 pneumostatic reduction procedures. In 10 of these 16 cases, transabdominal manipulation, which included milking, kneading, compressing, and shaking, was employed, achieving pneumostatic reduction in 7 cases [ 5 ]. The widespread adoption of ultrasonography (USG) in the early twenty-first century led to the development of sonographically guided hydrostatic reduction as a safer alternative [ 1 ]. This shift is attributable to two principal factors. Initially, fluoroscopic pneumostatic reduction has been shown to involve a high radiation dose, equivalent to approximately 400 abdominal radiographs for a one-year-old. Secondly, USG has become the more prevalent approach in clinical practice [ 8 ]. Today, prioritization is given to non-surgical techniques, with surgical intervention only considered if other methods prove inadequate. Given their similarity to our research and departure from established procedures, two recent publications deserve thorough scrutiny. Vazquez et al.'s 2012 study first analyzed ultrasound-guided manual external reduction.[ 9 ] Fifteen external manual reductions were performed on thirteen sedated patients (six male, seven female) under three years of age with ileocolic intussusception over thirty months, resulting in an 80% success rate. Consistent with our study, no fluid or air was introduced into the bowel during the procedure. In this method, USG guided the location of the intussuscipiens to be manually compressed from the outside and the direction of the pressure to be applied. In contrast to our study, they did not focus on small bowel intussusceptions, and sedation was utilized. Another relevant case study, published in 2022 by Zhong and Chang, details the ultrasonography-diagnosed 4cm small bowel intussusception in a two-year-old patient at a primary care facility [ 10 ]. Transabdominal manipulation was initially employed to reduce the intussusception; however, this proved ineffective. The operator thus adopted a visual method, manipulating the intussuscipiens under continuous ultrasound guidance to relieve the obstruction. Similar to our process, this procedure utilized ultrasound guidance and omitted sedation. Both publications offer new understandings of the non-operative approach to intussusception. Following a thorough examination of the historical context, a comparison of our results with existing literature was undertaken ( Table 3 ). The higher mean age observed in our cohort resulted from including small bowel intussusception cases, which predominantly affect older children (mean age of small bowel cases: 6.04 years). Although intussusception is more common in male infants, the male-to-female ratio tends to equalize with increasing age [ 10 – 12 ]. Analysis of 20 patients managed over one year indicated seven instances of ileocolic intussusception and thirteen cases of small bowel intussusception. A 2014 Society for Pediatric Radiology survey with 456 participants reported a mean annual intussusception reduction rate of 9.5 patients (range: 0–60) [ 7 ]. Considering the survey's predominance of ileocolic and, to a much lesser extent, colocolic intussusceptions, our center's identification of seven ileocolic cases within a year is consistent with established norms [ 7 ]. To improve the sample's representativeness, we included cases of small bowel intussusception, often underreported, in our analysis. The inclusion of small bowel intussusceptions was based on a multi-factorial decision process. The increased use of ultrasonography (USG) and computed tomography (CT) scans might have accounted for the recent rise in reported cases of small bowel intussusception and, thus, played a significant role [ 1 , 8 , 13 ]. Furthermore, a substantial contributing factor was the markedly faster reduction rate observed with probe compression compared to ileocolic intussusceptions. The decision considered several other factors: preventing potential complications through immediate intervention without waiting for spontaneous reduction, shortened hospital stays enabled by probe compression, the ineffectiveness of hydrostatic or pneumostatic methods for small bowel intussusceptions, and the immediate reduction in parental and clinical anxiety following demonstrable improvement. Substantial rates of false-negative and false-positive findings limit the diagnostic accuracy of plain radiography in intussusception [ 14 ]. Studies indicate that abdominal radiographs account for 29% of diagnoses [ 15 ]. Within our clinical practice, an upright abdominal radiograph serves as the initial imaging study for children with abdominal pain seen in the emergency department to aid in differential diagnosis; direct radiographs were obtained before and after reduction procedures to confirm the existence of obstruction or perforation to improve our diagnostic strategy. For reductions of > 20 minutes, we used serial radiographs 24 hours apart to check for perforation. No perforations were detected throughout this period. USG is a highly sensitive diagnostic modality for intussusception [ 11 , 16 , 17 ]. This modality offers several key advantages: bedside accessibility, freedom from ionizing radiation, differentiation between small bowel and ileocolic intussusception, usability in differential diagnosis, identification of PLPs (with approximately 70% detection rate), detection of ischemia within intussuscepted bowel segments, and guidance for reduction procedures [ 1 , 4 , 8 – 11 , 13 , 16 , 17 ]. Its significance in the management of intussusception is increasingly growing.[ 7 ] The high spontaneous reduction rates (81.8–100%) reported in small bowel intussusceptions frequently lead to a preference for conservative management [ 1 , 8 , 11 , 13 ]. Conversely, spontaneous reduction of ileocolic intussusceptions is less likely, owing to the potential full rotation of the Peyer plates of the terminal ileum within the intussuscipiens [ 1 ]. Intussusceptions of the small bowel are distinguished by a less constricted intussusception, allowing for reduction via non-invasive probe compression [ 8 ]. The existing literature, however, is deficient in formal studies concerning probe compression as a treatment modality for small bowel intussusceptions. Several factors must be considered when determining the appropriate application of conservative treatments, which are more commonly used due to the high spontaneous reduction rate. The most significant factors include the length of intussusception, which must be more than 2.5 centimeters, and the presence of PLP, including lymph nodes. In such cases, a spontaneous reduction might not occur [ 13 ]. It is further essential to recognize the risk of ischemia in the small bowel and ileocolic intussusception [ 4 , 10 ]. Successfully reducing the intussusception with probe compression also eased the anxiety of clinicians and families by lessening the risk of ischemia. Importantly, external reductions in this study were conducted without sedation. Data from the 2014 survey indicated that 93% of pediatric radiologists did not employ sedation for these procedures [ 7 ]. Based on our observations, small bowel intussusceptions usually needed less time for reduction. By contrast, a lengthened reduction time was observed in the ileocolic cases. Despite limited research on the duration of other common non-surgical methods, our findings indicate that increased symptom duration, lymph nodes in the intussuscipiens, and ileocolic location were associated with more prolonged procedures and hospital stays. In our previous experience, patients exhibiting small bowel intussusception were subject to a minimum of 24 hours of monitoring. Nonetheless, our method facilitated day-case management for half of the patients (80% presenting with small bowel intussusception), resulting in a mean hospital stay of 1.95 days. Several contributing factors resulted in shorter hospital stays: early presentation, immediate intervention (avoiding observation), negligible post-procedure bowel edema, and thus the intestinal lumen not narrowing, a brief procedure (less than 20 minutes), compliance with the radiologist's guidelines, and the lack of persistent symptoms. Literature suggests that pediatric patients who have undergone uncomplicated hydrostatic or pneumostatic reduction, demonstrate adequate health status, tolerate oral nutrition, and experience an uncomplicated procedure are candidates for discharge directly from the pediatric emergency department [ 1 ]. Studies have shown that 26–63.8% of patients are released following an average observation time of 7–12 hours, with an average hospital stay lasting from 33.7 to 38 hours [ 12 , 18 ]. Conversely, individuals subjected to surgical procedures might necessitate inpatient care for up to twelve days [ 2 ]. This study's low incidence of complications resulted from careful use of probe compression. Post-discharge monitoring was performed using ultrasonography. Among the 15 patients who returned for evaluation, none exhibited PLPs. The limitations of our study arise from its single-center design. The data collected would be more reliable if a multicenter, longitudinal research design were utilized; one year proved insufficient for evaluating specific parameters. An experienced radiologist is critical for accurate diagnosis, performing the procedure, and guiding the reduction of intussusception. Conclusions Despite ongoing skepticism surrounding transabdominal manipulation, these methods continue to be a part of the treatment approach for intussusception. However, the number of pediatric radiologists utilizing these methods has demonstrably and consistently fallen. In the 1990s, Grasso identified a lack of scientific foundation as the origin of the bias against transabdominal manipulation; concurrently, Vazquez aimed to rectify this prejudice by standardizing the procedure of manual external reduction under ultrasonographic guidance. Driven by our positive probe compression results in small bowel intussusceptions, this study investigated its subsequent application to ileocolic intussusceptions, which also demonstrated favorable outcomes. Our study's primary criterion was performing USG-guided probe compression on all pediatric intussusception cases not requiring surgical intervention; those cases were usually treated with hydrostatic or pneumostatic reduction. We implemented this approach following a thorough review of relevant literature and documented instances of transabdominal manipulation. The USG probe use enabled successful navigation beyond the ileocecal valve in cases of small bowel intussusception, thereby expediting discharges and minimizing hospital length of stay compared to previous protocols. Moreover, a marked decrease in the rate of USG-guided hydrostatic reduction procedures was noted at our institution following the implementation of the USG probe compression technique. We conclude from these observations that the minimally invasive USG probe compression technique constitutes a suitable first-line approach for pediatric intussusception cases where surgery is not indicated. Declarations Ethics approval: The study adhered to the ethical principles outlined in the Declaration of Helsinki. Ethical approval for this study was granted by the Sivas Cumhuriyet University Ethics Committee (protocol # 2023-06/32). Consent to participate: Parental informed consent was secured for all participating patients. Consent for publication: Written informed consent was obtained from participants' parents for the publication of medical case details and accompanying images. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Funding: No funds, grants, or other support was received. Author Contribution: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AKM and AD. The first draft of the manuscript was written by AKM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data Availability: The datasets and materials used and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Columbani PM, Scholz S (2012) Intussusception. In: Coran AG, Adzick NS, Krummel TM et al (eds) Pediatric Surgery. Elsevier Saunders Philadelphia Ekenze SO, Mgbor SO, Okwesili OR (2010) Routine surgical intervention for childhood intussusception in a developing country. Ann Afr Med 9:27–30. https://doi.org/10.4103/1596-3519.62621 Blanch AJM, Perel SB, Acworth JP (2007) Paediatric intussusception: Epidemiology and outcome. Emerg Med Australas 19:45–50. https://doi.org/10.1111/j.1742-6723.2007.00923.x Maki AC, Fallat ME (2014) Intussusception. In: Holcomb GW, Murphy JD, Ostlie DJ, (eds) Ashcraft's Pediatric Surgery. 6 edn.Elsevier Philadephia Grasso SN, Katz ME, Presberg HJ et al (1994) Transabdominal manually assisted reduction of pediatric intussusception: reappraisal of this historical technique. Radiology 191:777–779. https://doi.org/10.1148/radiology.191.3.8184063 Katz ME, Kolm P (1992) Intussusception reduction 1991: an international survey of pediatric radiologists. Pediatr Radiol 22:318–322. https://doi.org/10.1007/BF02016243 Stein-Wexler R, O'Connor R, Daldrup-Link H et al (2015) Current methods for reducing intussusception: survey results. Pediatr Radiol 45:667–674. https://doi.org/10.1007/s00247-014-3214-7 Zhang M, Zhou X, Hu Q et al (2021) Accurately distinguishing pediatric ileocolic intussusception from small-bowel intussusception using ultrasonography. J Pediatr Surg 56:721–726. https://doi.org/10.1016/j.jpedsurg.2020.06.014 Vazquez JL, Ortiz M, Doniz MC et al (2012) External manual reduction of paediatric idiopathic ileocolic intussusception with US assistance: a new, standardised, effective and safe manoeuvre. Pediatr Radiol 42:1197–1204. https://doi.org/10.1007/s00247-012-2424-0 Zhong Q, Zhang Y, You X (2022) Ultrasound-guided manual reduction of small-intestine intussusception: A case report. Asian J Surg 45:2105–2106. https://doi.org/10.1016/j.asjsur.2022.04.119 Khasawneh R, El-Heis M, Al-Omari M et al (2021) The radiological characteristics of childhood intussusception including unusual features and rare pathological lead points. Heliyon 7:e07231. https://doi.org/10.1016/j.heliyon.2021.e07231 Fidanci I, Guleryuz OD, Tokgoz A (2021) Evaluation of spontaneous reduction among the invagination cases admitted to the paediatric emergency department; retrospective study. Int J Clin Pract 75. ARTN e14322 https://doi.org/10.1111/ijcp.14322 Subramaniam S, Chen AE, Khwaja A et al (2022) Point-of-Care Ultrasound For Differentiating Ileocolic From Small Bowel-Small Bowel Intussusception. J Emerg Med 62:72–82. https://doi.org/10.1016/j.jemermed.2021.07.002 Henderson AA, Anupindi SA, Servaes S et al (2013) Comparison of 2-view abdominal radiographs with ultrasound in children with suspected intussusception. Pediatr Emerg Care 29:145–150. https://doi.org/10.1097/PEC.0b013e3182808af7 Hernandez JA, Swischuk LE, Angel CA (2004) Validity of plain films in intussusception. Emerg Radiol 10:323–326. https://doi.org/10.1007/s10140-004-0354-3 Edwards EA, Pigg N, Courtier J et al (2017) Intussusception: past, present and future. Pediatr Radiol 47:1101–1108. https://doi.org/10.1007/s00247-017-3878-x Yan JY, Shen QL, Peng CH et al (2022) Colocolic Intussusception in Children: A Case Series and Review of the Literature. Front Surg 9. https://doi.org/10.3389/fsurg.2022.873624 . ARTN 873624 Whitehouse JS, Gourlay DM, Winthrop AL et al (2010) Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg 45:1182–1186. https://doi.org/10.1016/j.jpedsurg.2010.02.085 Tables Table 1. Demographic data and clinical findings of the patients CASE Age (Months) Gender Month of the Year Abdominal Pain Vomiting Bloody Stool Abdominal Mass Blood in Rectal Exam Findings in PA Direct Radiographs Duration to Admission Comorbidity Direct X-Ray OBS. GTC 1 46 M AUGUST + + - + + + + < 24H - 2 20 F AUGUST + + - - + - + < 48H - 3 6 F OCTOBER - + (bilious) + + + + + + < 48H - 4 85 F NOVEMBER + - - - - - < 24H - 5 61 F NOVEMBER + + - - + + + < 24H ACUTE APPENDICITIS 6 108 M NOVEMBER + - - - - - < 24H MORGAGNI HERNIA 7 58 M NOVEMBER + + - - + - + < 24H - 8 93 F NOVEMBER - + - - + - - < 24H - 9 86 F NOVEMBER + + - - - + - - < 24H AGE 10 62 M NOVEMBER + + + - - + - - < 48H AGE 11 82 M NOVEMBER + + - - - + + - < 24H - 12 134 M NOVEMBER + + - - - + - - < 24H AGE 13 17 F DECEMBER - + - - - + - + < 24H - 14 94 F JANUARY + + - - - < 48H AGE, ACUTE APPENDICITIS 15 74 F FEBRUARY + + - - - - < 24H - 16 68 F MARCH + - - - - - < 24H - 17 37 F APRIL + + - - - < 24H AGE 18 79 M MAY + + - - + - - < 48H SPLENIC CYST 19 16 M JUNE + + (bilious) - + + + + < 24H - 20 12 M JULY - + - - - + - + < 48H - M: Male, F: Female, OBS: Obstruction, GTC: Gas transit to the colon, AGE: Acute Gastroenteritis Table 2. Ultrasonographic findings and follow-up results of the patients USG FINDINGS CASE Abdominal site Length Ileocolic Small bowel Mesenteric LAP Antibiotic Use Recurrence Discharge day FOLLOW-UP USG FINDINGS 1 Right lower 3 cm + + (10 mm) + - 3. day - 2 Paraumbilical 1 cm + + (5 mm) - - 2. day - 3 Right lower 7 cm + - + - 4. day Mesenteric LAP 4 Right lower 1.5 cm + +(7 mm) - - Daily - 5 Left middle 3 cm + - + - 6. day - 6 Left lower 2 cm + - - - Daily Morgagni Hernia? 7 Right & left upper, epigastric 1.5 cm, 3 cm, 1 cm +,+,+ + (11 mm) + + (Twice) 6. day - 8 Right lower 1 cm + - - - Daily Missed follow-up 9 Left upper 2 cm + - - - Daily - 10 Right lower 2 cm + + (9 mm) + - 5. day - 11 Paraumbilical 2 cm + - - - Daily - 12 Left upper 2 cm + - - - Daily - 13 Left lower 1.5 cm + - - - Daily Mesenteric LAP, Terminal ileitis 14 Epigastric 1 cm + + (6 mm) + - 4. day Missed follow-up 15 Left lower 2 cm + - - - Daily Missed follow-up 16 Right lower 1 cm + + (6 mm) - - Daily Missed follow-up 17 Left upper 2 cm + + (7 mm) - - Daily - 18 Left lower 1.5 cm + - + - 2. day Mesenteric LAP-Splenic cyst 19 Right upper and lower 7 cm + + (7 mm) + - 5. day - 20 Right lower 2 cm + + + 3. day Missed follow-up Table 3. A comparative analysis of our results with existing literature Aligning with previous studies Early hospital admission rates in developed and developing countries (1,2,3) Vomiting followed by abdominal pain as the most common reason for presentation (1,11,12) The rate of patients diagnosed with intussusception without abdominal pain (1) The rate of mesenteric lymphadenopathy detected in surgery (2) Small bowel intussusceptions most frequently detected in the left abdominal quadrants (1,13) Ileo-colic intussusceptions being detected in the right abdominal quadrants (1,13) The average number of hydrostatic/pneumostatic reductions performed by a pediatric radiologist in a year (7) Recurrence rates after applying non-operative methods (1,4,11) Recurrence rates after laparoscopic reduction (4) Perforation risk following intussusception reduction through transabdominal manipulation (5,9) Perforation risk in hydrostatic/pneumostatic intussusception reduction (1) Length of hospital stay after successful hydrostatic reduction (18) Inconsistent with previous studies The male-to-female ratio being close among patients diagnosed with intussusception (1) Most frequently observed in November (1) Higher average age (5.1 years) (1,4) Lower prevalence of bile-stained vomiting, bloody stools, and palpable abdominal masses (1) Higher frequency of small bowel intussusceptions (1) Higher recurrence rates compared to surgery (4) Lower risk of complications and shorter hospital stay compared to surgery (2) Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5622154","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":454886520,"identity":"63986e12-1eaf-4da6-8bff-5318276299d5","order_by":0,"name":"Agah Koray Mansiroglu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYHACNhBhwMbefPDBBxCXnRgtB4Ba+HiOJRvOAHGZidUiJ5FjJswD4hPSwt+/+Nnjj233jNkk0tKYbX5tk+djZmD88DEHtxaJG8/MDQ62FZux8Tw+9ji377ZhGzMDs+TMbXisuXHATOJgW4ING3taunFuz21GoBY2Zl48WuRvHP8G0cKQYyZt2XPbnqAWg/M9YFvM2DiAWhh+3E4kqMXwBk+ZxJlzCcZsoEDubbid3MbM2IzXL3Lnj2+TqChLMJzfDozKH39u24IYHz7i875EAhKHsQ1MNuBRDwT8B5B5f/ArHgWjYBSMgpEJAPS6U163nx8wAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-8175-7747","institution":"Sivas State Hospital","correspondingAuthor":true,"prefix":"","firstName":"Agah","middleName":"Koray","lastName":"Mansiroglu","suffix":""},{"id":454886521,"identity":"8d80f07e-7c9d-4c22-a68e-4a2e5014ce49","order_by":1,"name":"Abdullah Duman","email":"","orcid":"https://orcid.org/0000-0002-5631-9155","institution":"Sivas State Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Duman","suffix":""}],"badges":[],"createdAt":"2024-12-11 08:02:52","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5622154/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5622154/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82700645,"identity":"4d81c2e4-eef2-4ed1-89a0-b6e051de3847","added_by":"auto","created_at":"2025-05-14 09:29:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":618469,"visible":true,"origin":"","legend":"\u003cp\u003eProgressive USG views of the intussusceptum reduction process without intraluminal pressure in the same patient\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5622154/v1/20bc42660a1534bcc6ab6dc7.png"},{"id":82701235,"identity":"7102643d-1193-4aea-89d4-06f10516aaca","added_by":"auto","created_at":"2025-05-14 09:37:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":115475,"visible":true,"origin":"","legend":"\u003cp\u003eThe pre-procedural (a) and post-procedural (b) PA abdominal X-rays of a patient\u003c/p\u003e\n\u003cp\u003eshowing passage of the gas from the small intestine to the colon\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5622154/v1/5c5082c8f43109aa69174642.png"},{"id":82701239,"identity":"cf533696-7af5-4049-9592-4e713064360d","added_by":"auto","created_at":"2025-05-14 09:38:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1658253,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5622154/v1/8a59582c-d26a-429d-843a-dc39445e5e5c.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAn alternative non-operative method for childhood intussusception reduction: USG probe compression\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntussusception is the inward telescoping of a proximal bowel segment (intussusceptum) into an adjacent distal segment (intussuscipiens), resulting in bowel obstruction. Among children, this is a frequently observed etiology of intestinal obstruction[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A minimum of 72 hours is required to develop ischemic necrosis, characterized by tissue death secondary to compromised blood supply. Unidentified ischemic processes may lead to sepsis and eventual mortality from intestinal perforation. Despite a decrease in mortality rates to about 1.6% in developed regions, they still stand at 8\u0026ndash;12% in Africa [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe phenomenon is accompanied by the formation of a focal point, known as a \"lead point.\" While the etiology remains obscure in 95% of cases, the prevalence of pathological lead points (PLPs) is only 4%. Meckel's diverticulum is the most common PLP, followed by rectal polyps and duplications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Malignant neoplasms represent an infrequent etiology of intussusception [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most common clinical presentations involve the acute onset of colicky abdominal pain, emesis, a palpable abdominal mass on physical examination, and bloody stools. Fewer than 25% of patients diagnosed with intussusception exhibit all four clinical features [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Ultrasonography (USG) serves as the principal radiological imaging technique for the diagnosis of intussusception. When interpreted by a skilled radiologist, USG demonstrates near-perfect diagnostic accuracy and is the preferred initial imaging modality for identifying PLPs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNon-operative management is the preferred initial treatment for children without signs of peritonitis. Non-operative techniques (pneumostatic/hydrostatic) achieve 90% success under imaging guidance.\u003c/p\u003e \u003cp\u003eDuring the early 20th century, Monrad, succeeding Hirschsprung, developed a manual \"desinvagination\" method; this was later complemented by Grasso's application of transabdominal manual manipulation in the late 20th century. The medical literature cites these techniques as non-operative [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While these methods are suspected to exceed reported instances, scholarly documentation has demonstrably diminished [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Surgical intervention should be considered when a PLP is radiologically detected, enema reduction fails, clinical symptoms persist post-reduction, or perforation is present [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to reduce intussusception externally using the pressure of the USG probe as an alternative to manual reduction in patients diagnosed with intussusception by USG without surgical indication. The results of the study are presented herewith.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e Approval for this study was obtained from the Sivas Cumhuriyet University Ethics Committee dated June 22, 2023, and decision no. 2023-06/32. The study included pediatric patients (0\u0026ndash;12 years) diagnosed with ileocolic or small bowel intussusception between August 2022 and July 2023. Exclusion criteria included evidence of peritonitis or perforation, symptom duration exceeding three days, and ultrasonographic findings suggestive of pathological lead points or intestinal vascular impairment.\u003c/p\u003e \u003cp\u003eThe evaluation included patient demographics (age and sex), admission date, time elapsed between symptom onset and admission, clinical presentation, radiographic and ultrasonographic findings (pre- and post-procedure and control), treatment regimen, time to initiation of oral feeding, length of hospitalization, and incidence of recurrence.\u003c/p\u003e \u003cp\u003e The parents were fully apprised of the intervention and provided written consent before the commencement of the procedure. The procedure was undertaken using a supine positioning of the patient and with the appropriate measures to prevent aspiration while foregoing sedation. Parental presence was maintained throughout the procedure to alleviate patient anxiety. Ultrasound-guided hydrostatic reduction equipment was readied as a contingency procedure for patients presenting with ileocolic intussusception in the event of primary procedure failure.\u003c/p\u003e \u003cp\u003eA linear probe was implemented for diagnostic and therapeutic purposes. Neither hydrostatic nor pneumostatic pressure was employed. With external linear probe pressure to the abdomen, the intussusceptum was compressed between the anterior and posterior layers of the peritoneum. A series of maneuvers, including distal-to-proximal milking and compressing, successfully reduced both ileocolic and small bowel intussusceptions. A comprehensive discussion of these reduction techniques is presented in the supplementary video. Notably, all procedures were completed without sedation, and their durations ranged from 3 to 50 minutes, with a mean duration of under 30 minutes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants ranged in age from 6 months to 134 months, with a mean age of 5.1 years. Patient admissions reached their highest point in November, with the study identifying nine new cases that month. Fourteen patients arrived at the emergency department at the initial appearance of symptoms, while six arrived the following day. Abdominal pain and vomiting were reported by thirteen of the twenty patients, with only two exhibiting bloody stools. Physical examination revealed no evidence of peritonitis in any patient. Three patients presented with a readily palpable abdominal mass. Rectal examination was conducted on 11 of 20 patients, with only one showing evidence of blood in the stool. \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e summarizes the study's findings, including subject demographics (number of male and female participants and respective age ranges) and clinical characteristics.\u003c/p\u003e \u003cp\u003eFollowing admission, upright abdominal radiographs were conducted for 14 patients among the group of 20; evidence of obstruction was present in 5 cases. Moreover, 50% of patients' ultrasonographic findings indicated multiple reactive lymph nodes (5\u0026ndash;11 mm along the short axis). Acute appendicitis and small bowel intussusception were concurrently diagnosed in two patients. Hepatic steatosis was incidentally identified in three patients, while a single patient showed a splenic cyst 1 cm in diameter.\u003c/p\u003e \u003cp\u003eNineteen USG diagnoses occurred in the emergency department, while the remaining diagnosis was made in the ward. Seven cases were categorized as ileocolic intussusceptions, and thirteen were classified as small bowel intussusceptions. A 1\u0026ndash;7 centimeters size range was observed in ileocolic intussusceptions, whereas small bowel intussusceptions measured between 1 and 3 centimeters. In one patient, recurrence was observed on the second and third follow-up USG examinations (24-hour intervals), successfully managed in both incidences using probe compression. A single intravenous dose of methylprednisolone (1 mg/kg) was administered to the patient to prevent further recurrence. Twenty-four hours later, a subsequent ultrasound study demonstrated no recurrence of intussusception.\u003c/p\u003e \u003cp\u003eSuccessful non-operative reduction of small bowel intussusception was achieved in two patients who also presented with acute appendicitis; these patients subsequently received medical therapy for the appendicitis. Following medical treatment, one patient experienced improvement, while the other had to undergo laparoscopic appendectomy.\u003c/p\u003e \u003cp\u003eTwenty-two applications of this technique were recorded. The intussusceptions presented the following spatial distribution: nine in the right abdominal quadrants, nine in the left, two periumbilical, and two epigastric. \u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e presents a detailed account of the ultrasonographic findings.\u003c/p\u003e \u003cp\u003eSedation was not employed during the external reduction procedure with the USG probe. Anchoring ileocolic intussusceptions to the right lateral abdominal wall aided in manipulating them. However, the reduction process was significantly more time-consuming (ranging from 10 to 50 minutes, with an average of under 30 minutes) than small bowel intussusceptions (3\u0026ndash;30 minutes, typically completed within 15 minutes). Figure\u0026nbsp;1 displays ultrasonographic images of ileocolic intussusception obtained under probe compression.\u003c/p\u003e \u003cp\u003eFourteen patients underwent upright abdominal radiography after the reduction procedure, revealing cecal and ascending colonic gas passage in eight instances. A comparative analysis of pre-and post-reduction radiographic images \u003cb\u003e(Fig.\u0026nbsp;2)\u003c/b\u003e demonstrates colonic gas migration. Per the established guidelines, oral feeding was implemented 4\u0026ndash;72 hours post-procedure.\u003c/p\u003e \u003cp\u003eOf the twenty patients, ten (eight of whom presented with small bowel intussusception) received same-day treatment. Following a four-hour observation period, these patients were discharged upon exhibiting tolerance to oral intake and demonstrating the absence of clinical intussusception indicators. The remaining ten patients were admitted to the hospital for observation, with lengths of stay ranging from two to six days (mean: 1.95 days). The hospital stay was 3.33 days for patients presenting one-day post-symptom onset and 3 days for those with ileocolic intussusception. Notably, the procedures were uneventful, with no instances of aspiration, perforation, or other complications.\u003c/p\u003e \u003cp\u003eFamilies were provided details regarding the signs and symptoms of recurrent intussusception before discharge. Follow-up appointments were attended by fifteen out of twenty patients. Subsequent monitoring of patients who did not apply to the hospital for control was conducted using the national health database. Given the absence of subsequent applications to other health centers, it was hypothesized that there would be no recurrence.\u003c/p\u003e \u003cp\u003eAn abdominal ultrasound was performed on patients during their subsequent visit. Two patients presented with reactive mesenteric lymphadenopathy, each exhibiting nodes less than one centimeter in diameter; a third patient displayed concurrent reactive mesenteric lymphadenopathy and terminal ileitis. A patient presented with signs suggestive of Morgagni hernia; this diagnosis was validated through subsequent plain radiography and CT scan imaging.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHunter's detailed description of intussusception came in the late 18th century. The historical evolution of non-operative treatment and transabdominal manipulation reveals that numerous pediatric surgeons initiated hydrostatic and pneumostatic reduction techniques during the 19th century, with reported enhancements in mortality rates compared to surgical intervention. Hirschsprung and his successors promoted combined transabdominal and hydrostatic reduction.\u003c/p\u003e \u003cp\u003eFollowing the introduction of ultrasonography (USG) in the mid-20th century, Burke and Clarke (1977) utilized this technology to diagnose, screen, and assess reduction efficacy in intussusception [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although Ravitch and McCune (1948) indicated a significant perforation risk associated with external manipulation, subsequent research by Katz and Kolm (1991) found that 36% of pediatric radiologists surveyed used transabdominal manipulation methods [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Conversely, a survey of pediatric radiologists in 2014 reported that this rate had fallen to 19% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA 1994 series by Grasso et al. involving 35 patients demonstrated unsuccessful outcomes in 16 pneumostatic reduction procedures. In 10 of these 16 cases, transabdominal manipulation, which included milking, kneading, compressing, and shaking, was employed, achieving pneumostatic reduction in 7 cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe widespread adoption of ultrasonography (USG) in the early twenty-first century led to the development of sonographically guided hydrostatic reduction as a safer alternative [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This shift is attributable to two principal factors. Initially, fluoroscopic pneumostatic reduction has been shown to involve a high radiation dose, equivalent to approximately 400 abdominal radiographs for a one-year-old. Secondly, USG has become the more prevalent approach in clinical practice [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eToday, prioritization is given to non-surgical techniques, with surgical intervention only considered if other methods prove inadequate. Given their similarity to our research and departure from established procedures, two recent publications deserve thorough scrutiny. Vazquez et al.'s 2012 study first analyzed ultrasound-guided manual external reduction.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Fifteen external manual reductions were performed on thirteen sedated patients (six male, seven female) under three years of age with ileocolic intussusception over thirty months, resulting in an 80% success rate. Consistent with our study, no fluid or air was introduced into the bowel during the procedure. In this method, USG guided the location of the intussuscipiens to be manually compressed from the outside and the direction of the pressure to be applied. In contrast to our study, they did not focus on small bowel intussusceptions, and sedation was utilized.\u003c/p\u003e \u003cp\u003eAnother relevant case study, published in 2022 by Zhong and Chang, details the ultrasonography-diagnosed 4cm small bowel intussusception in a two-year-old patient at a primary care facility [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Transabdominal manipulation was initially employed to reduce the intussusception; however, this proved ineffective. The operator thus adopted a visual method, manipulating the intussuscipiens under continuous ultrasound guidance to relieve the obstruction. Similar to our process, this procedure utilized ultrasound guidance and omitted sedation. Both publications offer new understandings of the non-operative approach to intussusception.\u003c/p\u003e \u003cp\u003eFollowing a thorough examination of the historical context, a comparison of our results with existing literature was undertaken (\u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e). The higher mean age observed in our cohort resulted from including small bowel intussusception cases, which predominantly affect older children (mean age of small bowel cases: 6.04 years). Although intussusception is more common in male infants, the male-to-female ratio tends to equalize with increasing age [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnalysis of 20 patients managed over one year indicated seven instances of ileocolic intussusception and thirteen cases of small bowel intussusception. A 2014 Society for Pediatric Radiology survey with 456 participants reported a mean annual intussusception reduction rate of 9.5 patients (range: 0\u0026ndash;60) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Considering the survey's predominance of\u003c/p\u003e \u003cp\u003eileocolic and, to a much lesser extent, colocolic intussusceptions, our center's identification of seven ileocolic cases within a year is consistent with established norms [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo improve the sample's representativeness, we included cases of small bowel intussusception, often underreported, in our analysis. The inclusion of small bowel intussusceptions was based on a multi-factorial decision process. The increased use of ultrasonography (USG) and computed tomography (CT) scans might have accounted for the recent rise in reported cases of small bowel intussusception and, thus, played a significant role [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Furthermore, a substantial contributing factor was the markedly faster reduction rate observed with probe compression compared to ileocolic intussusceptions. The decision considered several other factors: preventing potential complications through immediate intervention without waiting for spontaneous reduction, shortened hospital stays enabled by probe compression, the ineffectiveness of hydrostatic or pneumostatic methods for small bowel intussusceptions, and the immediate reduction in parental and clinical anxiety following demonstrable improvement.\u003c/p\u003e \u003cp\u003eSubstantial rates of false-negative and false-positive findings limit the diagnostic accuracy of plain radiography in intussusception [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Studies indicate that abdominal radiographs account for 29% of diagnoses [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithin our clinical practice, an upright abdominal radiograph serves as the initial imaging study for children with abdominal pain seen in the emergency department to aid in differential diagnosis; direct radiographs were obtained before and after reduction procedures to confirm the existence of obstruction or perforation to improve our diagnostic strategy. For reductions of \u0026gt;\u0026thinsp;20 minutes, we used serial radiographs 24 hours apart to check for perforation. No perforations were detected throughout this period.\u003c/p\u003e \u003cp\u003eUSG is a highly sensitive diagnostic modality for intussusception [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This modality offers several key advantages: bedside accessibility, freedom from ionizing radiation, differentiation between small bowel and ileocolic intussusception, usability in differential diagnosis, identification of PLPs (with approximately 70% detection rate), detection of ischemia within intussuscepted bowel segments, and guidance for reduction procedures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Its significance in the management of intussusception is increasingly growing.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe high spontaneous reduction rates (81.8\u0026ndash;100%) reported in small bowel intussusceptions frequently lead to a preference for conservative management [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Conversely, spontaneous reduction of ileocolic intussusceptions is less likely, owing to the potential full rotation of the Peyer plates of the terminal ileum within the intussuscipiens [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Intussusceptions of the small bowel are distinguished by a less constricted intussusception, allowing for reduction via non-invasive probe compression [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The existing literature, however, is deficient in formal studies concerning probe compression as a treatment modality for small bowel intussusceptions.\u003c/p\u003e \u003cp\u003eSeveral factors must be considered when determining the appropriate application of conservative treatments, which are more commonly used due to the high spontaneous reduction rate. The most significant factors include the length of intussusception, which must be more than 2.5 centimeters, and the presence of PLP, including lymph nodes. In such cases, a spontaneous reduction might not occur [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It is further essential to recognize the risk of ischemia in the small bowel and ileocolic intussusception [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Successfully reducing the intussusception with probe compression also eased the anxiety of clinicians and families by lessening the risk of ischemia.\u003c/p\u003e \u003cp\u003eImportantly, external reductions in this study were conducted without sedation. Data from the 2014 survey indicated that 93% of pediatric radiologists did not employ sedation for these procedures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on our observations, small bowel intussusceptions usually needed less time for reduction. By contrast, a lengthened reduction time was observed in the ileocolic cases. Despite limited research on the duration of other common non-surgical methods, our findings indicate that increased symptom duration, lymph nodes in the intussuscipiens, and ileocolic location were associated with more prolonged procedures and hospital stays.\u003c/p\u003e \u003cp\u003eIn our previous experience, patients exhibiting small bowel intussusception were subject to a minimum of 24 hours of monitoring. Nonetheless, our method facilitated day-case management for half of the patients (80% presenting with small bowel intussusception), resulting in a mean hospital stay of 1.95 days. Several contributing factors resulted in shorter hospital stays: early presentation, immediate intervention (avoiding observation), negligible post-procedure bowel edema, and thus the intestinal lumen not narrowing, a brief procedure (less than 20 minutes), compliance with the radiologist's guidelines, and the lack of persistent symptoms.\u003c/p\u003e \u003cp\u003eLiterature suggests that pediatric patients who have undergone uncomplicated hydrostatic or pneumostatic reduction, demonstrate adequate health status, tolerate oral nutrition, and experience an uncomplicated procedure are candidates for discharge directly from the pediatric emergency department [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Studies have shown that 26\u0026ndash;63.8% of patients are released following an average observation time of 7\u0026ndash;12 hours, with an average hospital stay lasting from 33.7 to 38 hours [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Conversely, individuals subjected to surgical procedures might necessitate inpatient care for up to twelve days [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study's low incidence of complications resulted from careful use of probe compression. Post-discharge monitoring was performed using ultrasonography. Among the 15 patients who returned for evaluation, none exhibited PLPs.\u003c/p\u003e \u003cp\u003eThe limitations of our study arise from its single-center design. The data collected would be more reliable if a multicenter, longitudinal research design were utilized; one year proved insufficient for evaluating specific parameters. An experienced radiologist is critical for accurate diagnosis, performing the procedure, and guiding the reduction of intussusception.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite ongoing skepticism surrounding transabdominal manipulation, these methods continue to be a part of the treatment approach for intussusception. However, the number of pediatric radiologists utilizing these methods has demonstrably and consistently fallen. In the 1990s, Grasso identified a lack of scientific foundation as the origin of the bias against transabdominal manipulation; concurrently, Vazquez aimed to rectify this prejudice by standardizing the procedure of manual external reduction under ultrasonographic guidance. Driven by our positive probe compression results in small bowel intussusceptions, this study investigated its subsequent application to ileocolic intussusceptions, which also demonstrated favorable outcomes.\u003c/p\u003e \u003cp\u003e Our study's primary criterion was performing USG-guided probe compression on all pediatric intussusception cases not requiring surgical intervention; those cases were usually treated with hydrostatic or pneumostatic reduction. We implemented this approach following a thorough review of relevant literature and documented instances of transabdominal manipulation. The USG probe use enabled successful navigation beyond the ileocecal valve in cases of small bowel intussusception, thereby expediting discharges and minimizing hospital length of stay compared to previous protocols. Moreover, a marked decrease in the rate of USG-guided hydrostatic reduction procedures was noted at our institution following the implementation of the USG probe compression technique. We conclude from these observations that the minimally invasive USG probe compression technique constitutes a suitable first-line approach for pediatric intussusception cases where surgery is not indicated.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval:\u003c/strong\u003e \u003cp\u003e The study adhered to the ethical principles outlined in the Declaration of Helsinki. Ethical approval for this study was granted by the Sivas Cumhuriyet University Ethics Committee (protocol # 2023-06/32).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate:\u003c/strong\u003e \u003cp\u003e Parental informed consent was secured for all participating patients.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eWritten informed consent was obtained from participants' parents for the publication of medical case details and accompanying images.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo funds, grants, or other support was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution:\u003c/h2\u003e \u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AKM and AD. The first draft of the manuscript was written by AKM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability:\u003c/h2\u003e \u003cp\u003eThe datasets and materials used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eColumbani PM, Scholz S (2012) Intussusception. In: Coran AG, Adzick NS, Krummel TM et al (eds) Pediatric Surgery. Elsevier Saunders Philadelphia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkenze SO, Mgbor SO, Okwesili OR (2010) Routine surgical intervention for childhood intussusception in a developing country. Ann Afr Med 9:27\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/1596-3519.62621\u003c/span\u003e\u003cspan address=\"10.4103/1596-3519.62621\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlanch AJM, Perel SB, Acworth JP (2007) Paediatric intussusception: Epidemiology and outcome. Emerg Med Australas 19:45\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1742-6723.2007.00923.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1742-6723.2007.00923.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaki AC, Fallat ME (2014) Intussusception. In: Holcomb GW, Murphy JD, Ostlie DJ, (eds) Ashcraft's Pediatric Surgery. 6 edn.Elsevier Philadephia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrasso SN, Katz ME, Presberg HJ et al (1994) Transabdominal manually assisted reduction of pediatric intussusception: reappraisal of this historical technique. Radiology 191:777\u0026ndash;779. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1148/radiology.191.3.8184063\u003c/span\u003e\u003cspan address=\"10.1148/radiology.191.3.8184063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatz ME, Kolm P (1992) Intussusception reduction 1991: an international survey of pediatric radiologists. Pediatr Radiol 22:318\u0026ndash;322. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/BF02016243\u003c/span\u003e\u003cspan address=\"10.1007/BF02016243\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStein-Wexler R, O'Connor R, Daldrup-Link H et al (2015) Current methods for reducing intussusception: survey results. Pediatr Radiol 45:667\u0026ndash;674. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00247-014-3214-7\u003c/span\u003e\u003cspan address=\"10.1007/s00247-014-3214-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang M, Zhou X, Hu Q et al (2021) Accurately distinguishing pediatric ileocolic intussusception from small-bowel intussusception using ultrasonography. J Pediatr Surg 56:721\u0026ndash;726. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpedsurg.2020.06.014\u003c/span\u003e\u003cspan address=\"10.1016/j.jpedsurg.2020.06.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVazquez JL, Ortiz M, Doniz MC et al (2012) External manual reduction of paediatric idiopathic ileocolic intussusception with US assistance: a new, standardised, effective and safe manoeuvre. Pediatr Radiol 42:1197\u0026ndash;1204. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00247-012-2424-0\u003c/span\u003e\u003cspan address=\"10.1007/s00247-012-2424-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhong Q, Zhang Y, You X (2022) Ultrasound-guided manual reduction of small-intestine intussusception: A case report. Asian J Surg 45:2105\u0026ndash;2106. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.asjsur.2022.04.119\u003c/span\u003e\u003cspan address=\"10.1016/j.asjsur.2022.04.119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhasawneh R, El-Heis M, Al-Omari M et al (2021) The radiological characteristics of childhood intussusception including unusual features and rare pathological lead points. Heliyon 7:e07231. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.heliyon.2021.e07231\u003c/span\u003e\u003cspan address=\"10.1016/j.heliyon.2021.e07231\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFidanci I, Guleryuz OD, Tokgoz A (2021) Evaluation of spontaneous reduction among the invagination cases admitted to the paediatric emergency department; retrospective study. Int J Clin Pract 75. ARTN e14322 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ijcp.14322\u003c/span\u003e\u003cspan address=\"10.1111/ijcp.14322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubramaniam S, Chen AE, Khwaja A et al (2022) Point-of-Care Ultrasound For Differentiating Ileocolic From Small Bowel-Small Bowel Intussusception. J Emerg Med 62:72\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jemermed.2021.07.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jemermed.2021.07.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenderson AA, Anupindi SA, Servaes S et al (2013) Comparison of 2-view abdominal radiographs with ultrasound in children with suspected intussusception. Pediatr Emerg Care 29:145\u0026ndash;150. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/PEC.0b013e3182808af7\u003c/span\u003e\u003cspan address=\"10.1097/PEC.0b013e3182808af7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHernandez JA, Swischuk LE, Angel CA (2004) Validity of plain films in intussusception. Emerg Radiol 10:323\u0026ndash;326. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10140-004-0354-3\u003c/span\u003e\u003cspan address=\"10.1007/s10140-004-0354-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdwards EA, Pigg N, Courtier J et al (2017) Intussusception: past, present and future. Pediatr Radiol 47:1101\u0026ndash;1108. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00247-017-3878-x\u003c/span\u003e\u003cspan address=\"10.1007/s00247-017-3878-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan JY, Shen QL, Peng CH et al (2022) Colocolic Intussusception in Children: A Case Series and Review of the Literature. Front Surg 9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fsurg.2022.873624\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2022.873624\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. ARTN 873624\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitehouse JS, Gourlay DM, Winthrop AL et al (2010) Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg 45:1182\u0026ndash;1186. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpedsurg.2010.02.085\u003c/span\u003e\u003cspan address=\"10.1016/j.jpedsurg.2010.02.085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographic data and clinical findings of the patients\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"908\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eCASE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e(Months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMonth of the Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eAbdominal Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eBloody Stool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eAbdominal Mass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eBlood in Rectal Exam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eFindings in PA Direct Radiographs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eDuration to Admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eComorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eDirect X-Ray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003eOBS.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003eGTC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAUGUST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAUGUST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 48H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eOCTOBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+ (bilious)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 48H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eACUTE APPENDICITIS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eMORGAGNI HERNIA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 48H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNOVEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eDECEMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eJANUARY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 48H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eAGE, ACUTE APPENDICITIS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFEBRUARY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMARCH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAPRIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMAY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 48H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eSPLENIC CYST\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eJUNE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+ (bilious)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 24H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eJULY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt; 48H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eM: Male, F: Female, OBS: Obstruction, GTC: Gas transit to the colon, AGE: Acute Gastroenteritis\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eUltrasonographic findings and follow-up results of the patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"849\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 367px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUSG FINDINGS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003eCASE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eAbdominal site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eLength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eIleocolic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eSmall bowel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eMesenteric LAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eAntibiotic Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDischarge day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFOLLOW-UP USG FINDINGS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (10 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eParaumbilical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (5 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e7 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMesenteric LAP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1.5 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+(7 mm)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 cm\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e6. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMorgagni Hernia?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight \u0026amp; left upper, epigastric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1.5 cm, 3 cm, 1 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+,+,+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (11 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e+ (Twice)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e6. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMissed follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft upper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (9 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eParaumbilical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft upper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1.5 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMesenteric LAP, Terminal ileitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eEpigastric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (6 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMissed follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMissed follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (6 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMissed follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft upper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (7 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLeft lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1.5 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMesenteric LAP-Splenic cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight upper and lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e7 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+ (7 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5. day\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRight lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3. day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMissed follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. A comparative analysis of our results with existing literature Aligning with previous studies\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eEarly hospital admission rates in developed and developing countries (1,2,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eVomiting followed by abdominal pain as the most common reason for presentation (1,11,12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eThe rate of patients diagnosed with intussusception without abdominal pain (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eThe rate of mesenteric lymphadenopathy detected in surgery (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eSmall bowel intussusceptions most frequently detected in the left abdominal quadrants (1,13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eIleo-colic intussusceptions being detected in the right abdominal quadrants (1,13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eThe average number of hydrostatic/pneumostatic reductions performed by a pediatric radiologist in a year (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eRecurrence rates after applying non-operative methods (1,4,11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eRecurrence rates after laparoscopic reduction (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003ePerforation risk following intussusception reduction through transabdominal manipulation (5,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003ePerforation risk in hydrostatic/pneumostatic intussusception reduction (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eLength of hospital stay after successful hydrostatic reduction (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eInconsistent with previous studies\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eThe male-to-female ratio being close among patients diagnosed with intussusception (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eMost frequently observed in November (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eHigher average age (5.1 years) (1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eLower prevalence of bile-stained vomiting, bloody stools, and palpable abdominal masses (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eHigher frequency of small bowel intussusceptions (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eHigher recurrence rates compared to surgery (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eLower risk of complications and shorter hospital stay compared to surgery (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Intussusception, Non-operative management, Ultrasonography","lastPublishedDoi":"10.21203/rs.3.rs-5622154/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5622154/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eIntussusception is the leading cause of bowel obstruction in children, with ultrasonography (USG) as the primary diagnostic tool. Non-operative management is the preferred treatment when surgery is unnecessary. This study aimed to evaluate ultrasound-guided external reduction using probe pressure as an alternative to manual reduction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eTwenty pediatric patients with intussusception and no surgical indication underwent USG-guided external reduction using linear probe compression. We assessed age, sex, admission month, time to admission, clinical and radiographic findings, USG results (pre-procedure, post-procedure, control), hospitalization duration, and recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe study included 20 patients (9 males, 11 females) with a mean age of 5.1 years (6–134 months). Seven patients had ileocolic intussusception (1–7 cm), and 13 had small bowel intussusception (1–3 cm). A single recurrence occurred in one patient within 24 hours. A total of 22 successful reductions were performed in 20 patients without complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eUSG-guided external reduction with probe compression is a safe, effective, and non-invasive technique for reducing both small bowel and ileocolic intussusceptions. This method offers a promising alternative to existing non-operative approaches and may transform pediatric intussusception management.\u003c/p\u003e","manuscriptTitle":"An alternative non-operative method for childhood intussusception reduction: USG probe compression","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-14 09:29:53","doi":"10.21203/rs.3.rs-5622154/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0135b254-b3c8-4947-b9f6-dadf9702131d","owner":[],"postedDate":"May 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48360227,"name":"Pediatrics"}],"tags":[],"updatedAt":"2025-09-25T11:40:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-14 09:29:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5622154","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5622154","identity":"rs-5622154","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}