Documentation of spontaneous reduction of childhood intussusception by ultrasound

Spontaneous reduction of a presumed ileo-colonic intussusception was demonstrated by ultrasound examination followed by a barium enema. No premedication or anesthetic had been given to the child. This case illustrates the possible natural history of intussusception rarely confirmed by imaging studies. Intussusception is the most common abdominal emergency of early childhood [1]. Diagnosis and therapy is usually performed with a contrast enema. If unsuccessful, surgical reduction is indicated. We wish to report a case of spontaneous reduction of a presumed ileocolonic intussusception. This was initially diagnosed by ultrasound examination, but had spontaneously reduced by the time a barium enema was performed.     

Reliability of the abdominal plain film diagnosis in pediatric patients with suspected intussusception

In order to reassess the diagnostic reliability of the abdominal plain film examination in suspected intussusception, the findings in 100 consecutive cases of this disorder were analysed. Then, these were compared with the same number of cases in which the diagnosis had been rejected by means of barium enema. It was found that a positive plain film diagnosis of intussusception was possible in 89 patients. In 11 cases inconclusive plain film findings called for supplementary barium enemas to establish the diagnosis. In the reference group intussusception was excluded on the basis of plain film findings alone in 74% of cases. In the remaining 26% of patients a barium enema proved necessary to reject the diagnosis of suspected intussusception.     

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.     

The role of abdominal x-rays in the diagnosis and management of intussusception.

The management of intussusception requires early diagnosis and reduction with either barium enema or surgical intervention. Supine and erect abdominal radiographs are often obtained prior to ordering a barium enema. In many pediatric centers, the critical, initial interpretation of these radiographs is made by nonradiologists and, in most instances, by pediatric emergency physicians. We determined the sensitivity and specificity of abdominal radiographs in diagnosing intussusception when interpreted by these physicians. Six full-time pediatric emergency physicians evaluated 126 radiographs from 42 patients with intussusception, 42 in whom the disease was clinically suspected but ruled out, and 42 in whom the final radiology report was "normal." These were presented to pediatric emergency physicians in a blinded, randomized sequence without any additional clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% (range, 71-93%), and the mean specificity was 58% (range, 48-69%). This compares favorably to the sensitivity of signs and symptoms, and we conclude that plain and upright abdominal films are a useful adjunct for the clinician evaluating patients for suspected intussusception.     

Air reduction of intussusception.

AIM: To show that intussusception in children is reducible in most cases, using air. METHODS: Initially we used a barium enema to treat paediatric intussusception. Now we use an air enema. We consider the latter reduction technique to be the method of choice in the treatment of intussusception in childhood. RESULTS: Over a period of 21 years, we have treated 151 patients presenting with intussusception. In a group of 130 children treated with barium enema we managed to reduce the intussusception in 110 cases (84.6 %). We used air pressure to treat a second group of 21 children; the success rate in this group was 100 %. CONCLUSIONS: In order to avoid a surgical operation this technique must become more generally known. We are of the opinion that if the method is applied correctly, it is almost always possible to correct intussusception using air.     

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.     

Pediatric barium enema examination: Optimizing patient selection with univariate and multivariate analyses

We prospectively evaluated a total of nineteen symptoms, signs, and laboratory findings in 471 of 557 consecutive pediatric patients (from newborn to age 17) referred for barium enema examinations, to determine predictors of an abnormal study. A univariate analysis was performed, and a logistic regression model was developed. The most frequent indicators for the barium enema examinations were abdominal pain (48%), constipation (27%) and tenderness (25%). Twenty-two percent of the examination were abnormal, and the most common diagnoses were intussusception (n=22), appendicitis (n=17), infectious colitis (n=15), and Hirschsprung disease (n=14). The indicators that were most helpful to predict a barium enema abnormality were abdominal mass, leukocytosis, guaiac-positive stools, diarrhea, anemia, tenderness, and age less than 1 year. If barium enema examinations were performed only when at least one of the predictive indicators was present, 29% of examinations would be eliminated, and 4.8% of patients with detectable disease would be missed. The data indicate that identification of certain clinical variables can provide an effective initial strategy for selecting patients to undergo barium enema examinations.     

Hypertensive manifestation of an acute intestinal intussusception]

BACKGROUND: Hypertension may be associated with intussusception. CASE REPORT: An 8-month-old infant showed the following symptoms: lethargy, vomiting and hypertension. Abdominal ultrasound suggested the diagnosis of intussusception, which was confirmed by barium enema. The hypertension resolved after the intussusception was reduced. CONCLUSION: Intussusception should be considered a diagnostic possibility in infants who show a history of vomiting and in whom lethargy and systematic hypertension are noted. This case re-affirms the diagnostic usefulness of abdominal ultrasonography.     

The effect of screening sonography on the positive rate of enemas for intussusception

BACKGROUND: The referring physicians at our institution used the enema as a diagnostic test in children with suspected intussusception. OBJECTIVE: To determine the change in rate of positive enema findings performed for suspected intussusception with the intervention of screening ultrasound (US). MATERIALS AND METHODS: Since October 1995, 224 children (mean age 2.2 years) with suspected intussusception were referred for enema examination. In January 2001, US was introduced as a screening test for intussusception. Enemas were performed for all children with positive US findings and were offered for those with negative US findings if clinical suspicion persisted. RESULTS: Before 2001, 184 children underwent enema with intussusception documented in 40 (22%). Since January 2001, 40 children have been seen with suspected intussusception (12/40 positive or 30%). Two directly underwent enema (1/2 positive); 38 children underwent US. In 12 of 38 children, the US finding was positive, and an intussusception was found at enema examination in 11 of 12. In 26 cases, the US finding was negative. Seven of the 26 children with a negative sonogram finding had an enema, which was also negative. Nineteen enemas were canceled. With a screening US, the positive rate for enemas is now 58% (11/19). We know of no case of intussusception missed at US. CONCLUSION: Screening US has decreased unnecessary enemas for clinically suspected intussusception, increasing positive findings from 22% to 58%. This has in turn reduced children's exposure to radiation.     

Adenovirus infection and childhood intussusception.

OBJECTIVE--To investigate the possible relationship between enteric adenovirus types 40 and 41 and intestinal intussusception in children. DESIGN--Prospective, case-control patient study. PATIENTS--Sixty-three consecutive children suspected clinically of having intestinal intussusception were enrolled in this study. Of these, 25 children (mean age, 1.4 years; range, 3 months to 5 years) had barium enema examination-proved intussusception. Age-matched normal controls (24) and controls with diarrhea (21) were obtained within 1 month of the index case. MEASUREMENTS AND RESULTS--Stools were tested for the presence of nonenteric adenovirus and enteric adenovirus using a monoclonal antibody-based enzyme immunoassay. Five (20%) of 25 children with intussusception had nonenteric adenovirus in their stools compared with one (4%) of 24 normal controls, none (0%) of 21 of the controls with diarrhea, and none (0%) of 37 patients suspected of having intussusception who had negative results on barium enema examination. However, no stool samples were positive for enteric adenovirus. CONCLUSIONS--Nonenteric adenovirus infection and intestinal intussusception may be associated. However, because enteric adenovirus was not found in any of the groups studied, no conclusions can be made regarding their possible influence on the risk for developing intussusception.     

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: a supplement to the mnemonic for coma

Expected clinical manifestations of intussusception include paroxysmal abdominal pain, vomiting, abdominal mass, and with time, rectal bleeding. We report a case where lethargy and vomiting are the presenting complaints. Diagnostic delay was encountered for this infant who had altered sensorium without accompanying pain, melena, or mass on initial examination. Either plain radiographs, supplemented by ultrasonography of the abdomen, or a barium enema should be performed in infants with unexplained lethargy.     

Perforation during gas reduction of intussusception

Perforation during attempted gas-enema reduction of intussusception is more common than during a barium enema. In a review of 650 consecutive attempted gas enemas, perforation occurred in 7 infants (1.1%). Gross abdominal distension from the pneumoperitoneum may be rapid and cause splinting of the diaphragm, which leads to acute respiratory distress. This complication is readily recognised at the time of the gas enema, and may require immediate intervention by paracentesis using a 14-gauge needle. A review of 7 children with intussusception in whom perforation occurred revealed that all had radiologic evidence of bowel obstruction (air-fluid levels) prior to the enema, and the patients had had a relatively long history since the onset of symptoms. No perforation occurred during a delayed repeat enema reduction. Perforation during gas enema produces minimal peritoneal contamination. No pathological lesion at the lead point of the intussusception was identified in any of the children in whom perforation occurred.     

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: recurrence following gas (oxygen) enema reduction

Over a 38-month period, prospective data were collected on all episodes of intussusception treated at the Royal Children's Hospital, Melbourne. There were 170 initial episodes for which a gas enema was performed, 127 of which were reduced successfully. Recurence occured in 10 patients following initial successful gas enema reduction, a recurrence rate of 7.9%, which compares with a recurrence rate of 8.9% with barium (P = 0.896). We conclude that the gas enema does not have a higher rate of recurrence than barium and that there is no evidence of a significant incidence of incomplete reduction unrecognised at the time of gas enema. Correspondence to: S. W. Beasley     

Incidence of recurrent intussusception following barium versus air enema

The aim of this study was to determine whether using air enema for acute intussusception is related to a higher rate of recurrence than other methods of treatment. A 10-y (1986-95) retrospective study was performed in a university-affiliated paediatric division. The overall recurrence rate for 97 patients with acute intussusception was 7.8% (10% of whom were treated non-surgically). There were no recurrences following the surgical treatment. In matched groups of patients, no risk factors were found for recurrence following air vs barium enema.     

Intussusception

Intussusception is the invagination of one portion of the intestine into another and is the most common form of intestinal obstruction in infants. This report reviews the clinical presentation and diagnostic and treatment options available for intussusception. The etiologies of childhood intussusception are discussed. Details and literature review are provided on the advantages and disadvantages of ultrasonography, barium enema, air contrast enema, and surgery in the diagnosis and treatment of intussusception.     

Radiological evidence of bowel obstruction in intussusception

Several criteria have been proposed to identify patients likely to be at risk from barium reduction of intussusception, those with a high probability of having a pathological lead point, and those in whom an enema is unlikely to be successful. Signs of peritonitis and septicaemia are regarded as absolute contraindications to attempted barium reduction of intussusception, but as yet the radiological appearance of small bowel obstruction per se has not been substantiated as a contraindication. The presence of small bowel obstruction indicates that therapeutic reduction is less likely to be successful than in patients with normal or nonspecific plain radiographs (31% vs 57%) but is not in itself an indication that the examination would be unsafe. Patients with small bowel obstruction are acceptable risks for safe and successful therapeutic enemas, provided there is no clinical evidence of gangrenous bowel. Offprint requests to: J. de Campo     

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 associated with transient hypertension

A three-month-old infant presented with vomiting, lethargy, and hypertension. Abdominal ultrasound suggested the diagnosis of intussusception, which was confirmed by barium enema. Hypertension, previously unreported with intussusception, only resolved after surgical resection of the lesion.