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: 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.     

The efficiency and limitations of barium enema in the treatment of intussusception in infancy and childhood

Sixty-one children with intussusception were treated during a period of 7 years. A barium enema was routinely performed for diagnosis and treatment unless signs of gangrenous bowel were present. Hydrostatic reduction was successful in 50% of attempts in the idiopathic cases. There were no complications from this procedure and no recurrence of intussusception. At surgery the intussusception was found to be reduced in 6 of 32 patients; 19 underwent operative reduction; and resection was performed in 7. A higher failure rate of hydrostatic reduction was associated with older patient age, longer duration of symptoms, and the presence of a pathological leading point.     

Minimizing surgery in complicated intussusceptions in the Third World

When presentation is delayed, intussusceptions may be difficult to reduce using standard enema regimens. Our endeavour to minimize the need for surgery in an environment where failed reductions are common has led to the development of an aggressive, non-operative method of reducing intussusceptions. One hundred and six patients with intussusception were reviewed with the aim of evaluating a new method of reducing intussusceptions suited to our Third World environment. In our cohort, delayed presentation was common, with 32% of patients presenting more than 48 h after the onset of the intussusception. On clinical grounds alone, 41% of patients required a primary laparotomy. Standard barium and air reductions for intussusception were rarely successful under these conditions i.e. 13% and 22%, respectively. By using an air enema under general anaesthesia in the operating theatre, the reduction rate has improved to 53%. This approach is suggested as a last attempt at reducing an intussusception prior to laparotomy following failed standard enema reduction, and as the first line of management in the attempted reduction in the patient with delayed presentation without symptoms of peritonitis.     

Success with hydrostatic reduction of intussusception in relation to duration of symptoms

Background: It is widely believed that hydrostatic reduction of intussusception is less successful in children with prolonged symptoms prior to presentation. Aim: To prospectively evaluate success in relation to duration of symptoms. Methods: Prospective study in which children, regardless of symptom duration, underwent an attempt at hydrostatic reduction. Results: Of 113 children presenting with intussusception, 16 had peritonitis and required immediate laparotomy. A hydrostatic reduction was attempted in 97 and was successful in 77 (79%). There were 26 successful reductions with symptoms <12 hours (81%), 30 with symptoms for 12–24 hours (81%), and 21 with symptoms >24 hours (75%). Conclusion: The success rate with hydrostatic reduction was not significantly influenced by symptom duration.     

Success with hydrostatic reduction of intussusception in relation to duration of symptoms.

BACKGROUND: It is widely believed that hydrostatic reduction of intussusception is less successful in children with prolonged symptoms prior to presentation. AIM: To prospectively evaluate success in relation to duration of symptoms. METHODS: Prospective study in which children, regardless of symptom duration, underwent an attempt at hydrostatic reduction. RESULTS: Of 113 children presenting with intussusception, 16 had peritonitis and required immediate laparotomy. A hydrostatic reduction was attempted in 97 and was successful in 77 (79%). There were 26 successful reductions with symptoms <12 hours (81%), 30 with symptoms for 12-24 hours (81%), and 21 with symptoms >24 hours (75%). CONCLUSION: The success rate with hydrostatic reduction was not significantly influenced by symptom duration.     

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.     

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 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     

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.     

Is barium enema reduction safe and effective in patients with a long duration of intussusception?

The aim of this study was to determine whether barium enema reduction (BER) is safe and effective in patients with a long duration of intussusception. Over the last 17 years, 104 patients were admitted to our hospital with a diagnosis of intussusception. All except 1 with peritonitis underwent BER primarily. Of the 103 intussusceptions treated primarily by BER, 84 (82%) were reduced by the enema alone, whereas 19 (18%) underwent surgical reduction. There were no differences in mean duration of disease between the patients with successful and failed enema reduction (successful: 15 ± 14 h; failures: 14 ± 11 h, P = 0.6). The success rate of BER was 85% within 12 h of symptoms, 76% for 12–24 h, and 71% for more than 24 h. Of 8 cases with a second trial, 4 (50%) were reduced by repeated barium enema. There were no deaths and no intestinal perforations. The success rate of more than 70% even in patients with a long duration of intussusception suggests that BER is safe and effective regardless of the duration of the disease. Accepted: 4 September 1998     

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.     

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.     

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.     

Are hydrostatic and pneumatic methods of intussusception reduction comparable?

The hydrostatic pressures and flow rates of barium sulphate and water soluble contrast in concentrations representative of those used for intussusception reduction were measured. The change of height with discharge of fluid from the filled kit was also assessed. A group of experienced paediatric radiologists and radiographers significantly underestimated the height to which contrast should be placed for intussusception reduction. The results indicate that baseline hydrostatic reduction pressures tend to be less and maximum pressures significantly less than those presently advocated for pneumatic reduction. This disparity may account for the apparent improvement in intussusception reduction rates reported for air enema when compared with barium enema. Intraluminal pressure monitoring during contrast enema would aid control of intussusception reduction but hydrostatic reduction would still be at a disadvantage because of lower flow rates. Where hydrostatic reduction is performed, the contrast density and height used should be set to give known pressure, according to local guidelines.     

Intussusception--current trends in management.

Barium enema reductions were attempted in 65 (90%) of 72 intussusceptions, of which 51 (79%) were successful. This represents a success rate of 70% overall. The average hospital stay was 3 1/2 days. There was no mortality and, apart from a recurrence rate of 10%, no morbidity. It is suggested that barium enema reduction should be the treatment of choice provided that there is an emergency service of a paediatric radiologist and the patient is adequately resuscitated, the only absolute contraindication being evidence of pneumatosis intestinalis or peritonitis. Those patients who presented with shock, rectal bleeding, duration of symptoms longer than 48 hours, and pronounced degree of bowel obstruction had a higher rate of unsuccessful reduction. However, only the last two were significant. Further, provided that the clinical condition remains satisfactory and the reduction has been achieved to the caecum a repeat barium enema after some hours may be successful in achieving reflux of contrast into the ileum, confirming complete reduction.     

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. Part 2: An update on the evolution of management

Children with symptomatic ileocolic or ileo-ileocolic intussusceptions can be successfully managed in one of a number of different ways. The nonoperative enema reduction technique has major advantages over surgical reduction and high success rates can be achieved using pneumatic or hydrostatic reduction techniques under fluoroscopic or sonographic guidance. This article highlights current concepts and some controversial issues related to management of intussusception, including patient selection for attempted enema reduction, the advantages and disadvantages of each technique, complications, the value of delayed, repeated reduction attempts, the role of imaging after attempted enema reduction, and recurrence of intussusception.     

Intussusception

Children with symptomatic ileocolic or ileo-ileocolic intussusceptions can be successfully managed in one of a number of different ways. The nonoperative enema reduction technique has major advantages over surgical reduction and high success rates can be achieved using pneumatic or hydrostatic reduction techniques under fluoroscopic or sonographic guidance. This article highlights current concepts and some controversial issues related to management of intussusception, including patient selection for attempted enema reduction, the advantages and disadvantages of each technique, complications, the value of delayed, repeated reduction attempts, the role of imaging after attempted enema reduction, and recurrence 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