Perforation during attempted intussusception reduction in children —a comparison of perforation with barium and air

This paper compares the effects on patients of perforation with barium and with air during attempted intussusception reduction by reviewing the clinical, radiological, surgical and pathological findings and sequelae in seven children who received barium and seven who received air. In both groups perforation occurred in infants under 6 months of age (with one exception) with a long duration of symptoms. All patients with barium enema required resection of bowel whereas only four with air enema required resection. Anesthetic times were longer in those patients with barium perforation in whom the intussusception did not move and there was a large leak. The patients with perforation due to air had a shorter hospital stay with decreased morbidity compared to those with perforation due to barium. Perforation occurred through areas of transmural necrosis in a minority of patients in each group. Perforations through normal bowel and shear injury (with air enema) indicate that increased pressure during the examination is an important factor in some patients. Because perforation with air is so much easier to deal with surgically and the children do better clinically, there is a tendency for some to consider perforation with air an inconsequential situation. However, a potential rare complication with this technique is tension pneumoperitoneum. Keeping this in mind, we continue to use air as the contrast of choice because the procedure in our hands is a safe, quicker and easier technique and we have achieved a substantial improvement in reduction rates. Overall reported perforation rates with air enema compare favourably with those due to barium enema.     

Intussusception: evolution of current management

The records of 583 children who were treated for intussusception at the Children's Hospital of Buffalo in the period 1930-1985 were reviewed. Following a change in management in 1970 from operative treatment to hydrostatic reduction of the intussusception by barium enema, two main groups are defined. In earlier years 95% of patients underwent operative reduction whereas in the latter period 92% had barium reduction attempted. The remaining 8% in this group had clinical contraindications for hydrostatic enema attempt. Ten percent had pathological lead points. Recurrent intussusception occurred in 50 cases (8.5%), 66% following barium enema reduction and 33% after surgery. The mortality in the earlier group was 3.9% and 1.3% in the latter group. No deaths occurred in patients treated successfully with barium enema reduction, and there were no deaths in the children with simple uncomplicated intussusception requiring surgery.     

Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception

Background

The contemporary management of children with ileocolic intussusception often includes pneumatic reduction. While failure of the procedure or recurrence after reduction can result in the need for surgical treatment, more serious adverse sequelae can occur including perforation and, rarely, tension pneumoperitoneum. During the last year, four cases of perforation during attempted pneumatic reductions complicated by tense pneumoperitoneum have occurred in our center.

Objective

We have elected to report our patient experience, describe methods of management and review available literature on this uncommon but serious complication.

Materials and methods

Using ICD-9 diagnosis codes, we reviewed the records of children with intussusception during 2011. Demographic and therapeutic clinical data were collected and summarized.

Results

During the study period, 101 children with intussusception were treated at our institution, with 19% (19/101) of them requiring surgical intervention. Four children (4%) experienced a tense pneumoperitoneum during air enema reduction, prompting urgent needle decompression in the fluoroscopy suite. These children required bowel resection during subsequent laparotomy. No deaths occurred.

Conclusion

Pneumoperitoneum is a real and life-threatening complication of pneumatic enemas. It requires immediate intervention and definitive surgical management. Caution should be exercised by practitioners performing this procedure at institutions where pediatric radiology experience is limited and immediate pediatric surgical support is not available.     

Rectal prolapse of intussusception--a single institution's experience.

AIM: The objective was to study the clinical presentation and outcome of intussusceptions prolapsing rectally. METHODS: A retrospective analysis was done of 198 children who presented with intussusception at a single institution over a 5-year period. Of this group, the data of children with intussusception prolapsing rectally was studied. RESULTS: The incidence of prolapsing intussusception in this series was 8%. All 16 patients were infants with an average age of 5 months. The most common presenting features were rectal bleeding and abdominal mass. Only 56% of children had abdominal pain. 4/16 children had abdominal distension and 4 had dehydration. The duration of symptoms was less than 48 hours in 14/16 patients. Air enema reduction (AER) was attempted in 14/16 patients and was successful in 8 patients. The success rate of AER was 57%. One patient developed a perforation during AER. Manual reduction was done in six patients who failed AER and in two patients in whom AER was not attempted because of prolonged duration of symptoms (> 48 hrs). There were no recurrences in this series. CONCLUSION: The incidence of intussusceptions prolapsing rectally is high in this series. It can present in the absence of the cardinal symptoms of intussusception. A high index of clinical suspicion is necessary to make the diagnosis. AER is often successful and must be attempted in children who do not have contraindications for this procedure.     

Intussusception: influence of age on reducibility

Our experience of hydrostatic reduction of intussusception by barium enema over the last 7 years is reviewed. There were 115 attempted hydrostatic reductions out of a total of 129 patients diagnosed as having intussusception on barium enema or at surgery. Age at presentation varied from one month to nine years, 81% of patients presenting before one year of age. Of 115 attempted reductions, 63 were successful giving an overall success rate of 55%. Looking at the different age groups, it was found that hydrostatic reduction was much less successful in infants aged 3 months and younger; success rate 20% compared to a 60% success rate in the remainder. Conscious of recent reports in the literature of bowel perforation during attempted hydrostatic reduction in young infants, we suggest that there should be a reappraisal of the role of hydrostatic reduction in the three months and younger age group.     

Enema reduction of intussusception with a small dose of iopamidol may have advantages over barium

Barium enema (B-enema) has been the standard method for hydrostatic reduction of intussusception, although recently air enema has been used due to the lower risk when perforation occurs. Recently, we have administered a small dose of iopamidol during enema reduction (I-enema) in children with intussusception. From November 1989 to December 1993, we treated 50 children with intussusception at Kiyama Hospital. Barium was used in the first half of the period, and iopamidol in the second half. Reduction was successful in 22 of 24 patients with barium (92%) and 23 of 26 with iopamidol (88%); 25 children had the ileocolic type and 25 the ileoileocolic (-cecal) type of intussusception. Operations were carried out in 3 patients from each group. I-enema avoids some of the drawbacks of barium and air enemas. It is a new method of enema reduction, as a contrast medium is injected first. It is possible to obtain a good image of the advanced portion with a small dose of contrast medium, which is important for treatment. For institutions performing B-enemas, I-enemas can be performed easily with the same equipment and technique. It causes less contamination upon leakage than a B-enema, and also has less influence on the intestinal membrane with very few risks if perforation occurs. Better images are obtained than with air. A large dose of contrast medium is not needed, thereby reducing medical expenses to a minimum. Iopamidol can be used safely for enema reduction of intussusception with an expected high success rate.     

Intussusception: effectiveness of gas enema

In tertiary paediatric centres, gas enema reduction of intussusception appears to be more effective and perhaps safer than barium enema reduction. Despite the higher success rate of reduction when gas is used, there remain some patients in whom the technique fails but who at operation have an intussusception that theoretically should have been reducible with the gas enema: easy to reduce manually, no necrosis of the bowel, and no pathological lesion at the leadpoint. After a gas enema failed, manual reduction of an intussusception was achieved in 41 of 49 patients and was difficult in less than one-half. It is suggested that a significant proportion might have been reducible had the technique of gas reduction been modified, either by repeating the enema some hours after the first attempt or by using higher insufflation pressures. In practice, clinical features were not useful in predicting in which patients gas enema would be unsuccessful or whether operative reduction would be successful without resection.     

Intussusception

Intussusception is the most common cause of intestinal obstruction in infancy and early childhood. It occurs when one segment of bowel (the intussusceptum) invaginates into an adjacent distal segment of bowel (the intussuscepien). The classical presentation is with intermittent abdominal pain, vomiting and redcurrant jelly-like stool. Diagnosis can be accurately confirmed with an ultrasound scan. Initial management is with fluid resuscitation and antibiotics. Following adequate resuscitation, treatment is usually with a non-operative air enema reduction under fluoroscopic guidance. If this fails to completely reduce the intussusception, the air enema may be repeated in patients that are clinically stable. The main risks associated with an air enema are bowel perforation, failed reduction and recurrence. Surgical intervention is indicated in patients presenting with perforation, those that are clinically unstable or where multiple air enemas have failed to reduce the intussusception. Surgery can be performed open or laparoscopic and involves attempted manual reduction of the intussusception and may require bowel resection and anastomosis.     

Air enema for intussusception: Is predicting the outcome important?

Air enema is the treatment of choice for childhood intussusceptions. Although peritonitis is the established contraindication, studies have attempted to identify factors that affect the outcome of air enema. In our series we studied the impact of such factors on the clinical scenario to determine if it was important to predict the outcome of air enema. We retrospectively reviewed the records of 179 children who underwent air enema for intussusception at our institution over a 5-year period. Abdominal colic was present in 144 children, vomiting in 139 and rectal bleeding in 108 children. The duration of symptoms was less than 24 h in 131 children. An abdominal mass was present in 121 children, rectal prolapse of intussusception in 14, dehydration in 31 and small bowel obstruction in 27 children. The success rate of air enema was calculated. All clinical features were analyzed for impact on outcome using univariate and multivariate analysis. The extent of this impact on the clinical scenario was examined. Air enema was successful in 157 cases (89%). One child developed a perforation during the procedure (0.6%). The recurrence rate was 8%. Using χ² test, success of air enema was reduced in the presence of rectal bleeding, rectal prolapse of intussusception, dehydration, and small bowel obstruction. This reduction was statistically significant (P < 0.05). Using logistic regression analysis, the success of air enema was significantly reduced (P < 0.05) only in the presence of prolapsing rectal intussusception (57%) and small bowel obstruction (52%). Small bowel obstruction and prolapsing rectal intussusceptions merely reduce the success of air enema and do not increase the complications. Since the success of air enema is very high, it must be attempted in all children with the exception of peritonitis. Predicting the outcome is not crucial because of the high success rate and low complication rate.     

Duodenal perforation in childhood dermatomyositis

Perforation of the duodenum is an uncommon, but serious complication which may occur in children with dermatomyositis. In this disease vasculitis may involve the bowel to a variable extent and result in radiologic manifestations of intestinal injury ranging from benign pneumatosis intestinalis to signs of bowel perforation. We report two children with dermatomyositis in whom perforation of the second portion of the duodenum occurred. This serious complication should be considered in any child with dermatomyositis when extraluminal gas is suspected on abdominal radiographs.     

Gas reduction of intussusception

Efforts to improve the non-surgical management of childhood intussusception centre around (a) reassessment of selection criteria used to ensure as many children as possible have the advantage of hydrostatic reduction, and (b) improvements and modifications of enema technique to ensure successful and safe reductions without increased morbidity. Reports that pneumatic reduction was highly successful in treating childhood intussusception prompted the authors to evaluate this technique over an 18 month period using our previously reported technique of oxygen at 2 litres/minute and a pressure of 80 mm Hg. Pneumatic reduction was attempted in 114 of 129 consecutive cases of intussusception, and was successful in 85 (75%). Fifteen patients (8.6%) were considered unacceptable risks for gas reduction using our current selection criteria and had primary surgery. The overall success rate considering all cases of intussusception managed at our institution over this period was 66% (85/129). As with any form of hydrostatic reduction, pneumatic reduction of intussusception requires careful selection of patients, meticulous technique, and awareness of complications and their appropriate management. Because of its simplicity and improved success rate, pneumatic reduction has replaced traditional barium reduction at our institution. It may be that with further evaluation of selection criteria, higher pressures, and prolonged attempts that results will improve further.     

Intussusception reduced by barium enema. Outcome and short-term follow-up

A retrospective study was performed of 88 consecutive cases of intussusception that occurred during a 3-year period. Forty-eight patients experienced hydrostatic reduction of intussusception with barium enema and 40 patients required surgical correction of intussusception when barium enema reduction was unsuccessful. Patients with fever or duration of symptoms greater than 24 hours, or ileo-ileocolic type of intussusception had a significantly greater rate of unsuccessful hydrostatic reduction (p less than 0.001). Of 48 cases of intussusception hydrostatically reduced by barium enema, 47 patients received repeat physical examination after reduction, 45 having normal findings. Oral feeding was tolerated in these 47 patients within 12 hours after reduction. All 41 hospitalized patients were discharged within 24 hours of reduction without developing complication; of seven non-hospitalized patients, six reported no complications during the initial 24 hour post-reduction period. The single complication that occurred was recurrence of intussusception (ileo-ileocolic type) in a patient 6 hours after initial reduction; this was the only case in which neither post-reduction physical examination nor trial of feeding had been performed. Children with intussusception hydrostatically reduced by barium enema are at low risk for complication during the subsequent 24 hour post-reduction period. When the pre-reduction course has been relatively uncomplicated, the post-reduction physical examination does not reveal abnormalities, and the patient is able to tolerate oral feeding, close outpatient monitoring appears to be safe.     

Intussusception in infants and children: feasibility of ambulatory management

To evaluate the ambulatory management of ileo-colic intussusception in infants and children, a retrospective study over 3 years of 113 children treated for ileo-colic intussusception in a paediatric emergency department was undertaken with the aim of shortening the length of stay. A total of 113 children aged 10 days to 9 years (median 12 months) were treated for intussusception between January 1993 and December 1996. None had septic shock or peritoneal aeric effusion. Barium enema reduction was attempted in all patients. Successful reduction rate was 81%. Fifty patients (44.2%) were completely ambulatory managed and 42 were hospital-supervised after successful enema reduction. Twenty-one children underwent laparotomy after failure of enema. With the ambulatory device, costs were reduced ($1000/case) compared with conventional in-patient treatment. Conclusion Outpatient treatment of acute ileo-colic intussusception is secure and reduces costs. It depends on the willingness of the medical team but requires simultaneous adaptation of hospital funding to promote this trend. Received: 28 October 1998 / Accepted in revised form: 8 February 1999     

Spontaneous reduction of intussusception: clinical spectrum, management and outcome

Background. To analyze the spectrum of clinical features, management and outcome of children with documented spontaneous reduction of intussusception (SROI).¶Materials and methods. Review of records of 50 children (33 boys, ¶17 girls; age range 11 days–15 years; mean age 4 years) with documented SROI, in whom intussusception was initially diagnosed by sonography (US) in 44, air enema in 2, and computed tomography in 4, in the 6-year period 1992–1998.¶Results. Symptoms suggestive of intussusception were present in 21 (3 of whom had Henoch-Schönlein purpura and 4 had previous ileocolic intussusception reduced by air enema). Intussusception was an incidental finding in the other 29, in 28 of whom the finding was in the small bowel. Intussusception was limited to the small bowel in 43 and was ileocolic in 7. SROI was usually documented on US. Laparotomy performed in only 4 showed no evidence of intussusception or pathologic lead point. Outcome in all patients was favorable.¶Conclusions. SROI may present in symptomatic or asymptomatic children and occurs more commonly than previously reported. These intussusceptions are usually short-segment, small-bowel intussusceptions with no recognizable lead point. In asymptomatic patients, conservative observation is warranted. Intervention should be dictated by the clinical findings in symptomatic patients.     

The impact of imaging in the management of intussusception owing to pathologic lead points in children

OBJECTIVE: To review the imaging appearances, management and outcome of a large number of children with intussusception owing to pathologic lead points (PLP) in an attempt to define the role of various imaging modalities in this clinical setting. MATERIALS AND METHODS: Review of the records and imaging studies of 43 children with intussusception due to PLP diagnosed between 1986 and 1999. RESULTS: The commonest PLP found were Meckel diverticulum, polyps, Henoch-Schonlein purpura and cystic fibrosis. PLP were depicted on sonography in 23 (66%) of 35 patients, on computed tomography in 5 (71%) of 7, on air enema in 3 (11%) of 28, and on barium enema in 6 (40%) of 15. Air enema successfully reduced 60% of the intussusceptions. Nine children had recurrent intussusceptions. CONCLUSION: Sonography depicted two-thirds of PLP and provided a specific diagnosis in nearly one-third of our series. Our review does not provide sufficient data on how to continue the investigation of those patients in whom sonography does not depict a PLP but in whom there is a high index of suspicion for its presence. It remains a diagnostic challenge as to how to search for PLP in these patients, and other imaging modalities have to be requested according to each particular case.     

Adding a custom made pressure release valve during air enema for intussusception: A new technique

Background:

Non-surgical reduction remains the first line treatment of choice for intussusception. The major complication of air enema reduction is bowel perforation. The authors developed a custom made pressure release valve to be added to portable insufflation devices, delivering air at pressures accepted as safe for effective reduction of intussusception in children under fluoroscopic guidance. The aim of this study was to develop a custom made pressure release valve that is suitable for the insufflation devices used for air enema reduction of intussusception and to put this valve into regular clinical practice.

Materials and Methods:

An adjustable, custom made pressure release valve was assembled by the authors using readily available components. The valve was coupled to a simple air enema insufflation device. The device was used for the trial of reduction of intussusception in a prospective study that included 132 patients.

Results:

The success rate for air enema reduction with the new device was 88.2%. The mean pressure required to achieve complete reduction was 100 mmHg. The insufflation pressure never exceeded the preset value (120 mmHg). Of the successful cases, 58.3% were reduced from the first attempt while 36.1% required a second insufflation. Only 5.55% required a third insufflation to complete the reduction. In cases with unsuccessful pneumatic reduction attempt (18.1%), surgical treatment was required. Surgery ranged from simple reduction to resection with a primary end to end anastomosis. No complications from air enema were recorded.

Conclusions:

The authors recommend adding pressure release valves to ensure safety by avoiding pressure overshoot during the procedure.Key words: Air enema, intussusception, pneumatic, pressure release, reduction, safety, valve     

某市级医院儿童急性肠套叠流行病学特征及分析

目的通过分析珠海市10年间儿童急性肠套叠病例,探讨儿童急性肠套叠的流行病学特点及一般规律,为预防、诊断和治疗提供理论依据。方法对2004——2013年本院收治的儿童肠套叠病例进行回顾性研究,并结合珠海地区的气候、卫生条件等对患儿的临床资料、治疗方法、治疗效果、复发特点进行分析。结果 10年间本院共收治儿童肠套叠患儿1 045例,其中男性706例,女性339例,男:女=2.08:1。生后12~4个月为发病高峰年龄。全部病例均予空气灌肠治疗,获成功829例,需手术治疗216例,空气灌肠成功率79.33%。复发133例。术中发现继发性肠套叠23例。年龄2岁以上的15例。结论珠海地区儿童肠套叠好发于秋冬季,2岁以内儿童高发。多为原发性,2岁以上患儿需警惕继发性的可能。6个月内是肠套叠空气灌肠复位成功后复发的高发期。彩超是重要的诊断手段,空气灌肠是较有效的治疗方法,也是复发性肠套叠首选的治疗手段。     

Childhood intussusception in Ile-Ife, Nigeria.

A retrospective review of 41 intussusceptions encountered in 39 children seen over an 8-year period in Ile-Ife, Nigeria is presented. Most cases (61.5%) occurred in infancy. This contrasts with previous reports from Nigeria where intussusception has been presented as being commoner in older children. Vomiting, abdominal pain, excessive crying and passage of bloodstained stools were the main presenting symptoms. An abdominal mass was palpable in only 28.2% of patients. Generally, patients presented late in hospital with only two (5.1%) arriving within 24 hours of the onset of illness. Hydrostatic reduction with barium enema was attempted in these two patients, and it successfully reduced the intussusception in one and caused partial reduction in the other. Nineteen patients (46.3%) required bowel resection. There were nine deaths, giving a mortality rate of 23.1%. The relatively high bowel resection and mortality rates were attributed to the delay in seeking medical treatment.     

Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile?

Pneumatic reduction of idiopathic intussusception is successful in about 80% of cases, while 60% of the failures are reduced at surgery without resection. To determine whether delayed, repeated attempts at enema reduction of failures would reduce the need for operation in selected cases, over a 2-year period (1994-1996 inclusive), 17 infants with idiopathic intussusception underwent delayed repeat enemas 2-19 h following the first failed attempt at reduction. Clinical parameters and radiologic findings were evaluated with respect to outcome. Ten intussusceptions were successfully reduced after the second attempt in 9 and after the fourth attempt in 1. Seven children underwent a laparotomy, 5 because of failure of progressive reduction at air enema (AE). Two were taken to surgery early in the series, 1 because of perforation during a second attempt and 1 while awaiting a third reduction attempt. The 10 successful reductions all showed progressive movement of the intussusceptum on each AE; the 2 who perforated failed to show progressive reduction on their second AE. Because of these cases, the remaining 5 were referred to surgery because of failure of progressive reduction of the intussusceptum on the second attempt. At laparotomy, of the 7 unsuccessful reductions, 4 required resection and 3 had difficult manual reduction. The presence of vomiting, a mass, and/or bloody stools were not predictors of outcome. Failures had higher body temperatures (38.1 +/- 0.3 vs 37.4 +/- 0.1 degrees C, P = 0.07), heart rates (153.7 +/- 8 vs 136.9 +/- 2.1 min, P = 0.03), and longer duration of symptoms (36.8 +/- 4 vs 21.3 +/- 3.6 h; P = 0.01) than successes. Delayed repeat AEs may be safe and effective in selected cases of idiopathic intussusception, but should be considered only if significant movement of the intussusceptum is noted at each attempt. The ideal time for repeat AE reduction prior to surgery is not established, but 2-4 h appears appropriate. Pyrexia, tachycardia, and duration of symptoms greater than 36 h are relative contraindications to this course of management.     

高频彩超及全控式水压复位器诊治幼儿肠套叠

目的总结彩超下水灌肠诊治急性肠套叠的经验。方法采用高频超声定位并诊断肠套叠,用彩色多谱勒显像（CDFI）确定套叠部血流动力学改变,判断是否适宜灌肠复位,并用自制全控式水压复位器于高频彩超监测下灌肠复位。同期设立临床诊断70例肠套叠患儿为对照组,经低频（3．5MHz）B超诊断、监测并分次注水灌肠复位。结果72例拟诊幼儿肠套叠病例中明确诊断68例,判断不宜灌肠3例（经手术证实为难复性肠套叠,肠缺血严重。65例以全控式水压复位器于高频彩超监测下灌肠复位全部成功。对照组70例临床诊断幼儿肠套叠病例在低频B超监测下分次注水灌肠复位治疗56例,44例成功。结论全控式水压复位器结合高频彩超治疗幼儿肠套叠较之低频B超分次注水复位法,指征更明确,治疗更安全快速,效果更好,便于基层医院推广。