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.     

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.     

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.     

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: 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.     

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.     

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。     

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.     

Invagination ileus--stages and progress of treatment

Result from the historic development of the treatment of the intussusception was given an epidemiologic study of the different kinds of possible treatment of infantile intussusception from 1963 to 1988 including 246 affected children. Correlations are established between the duration of anamnesis, the general condition, form of intussusception and possible therapies. Besides indications and contraindications are recommended for hydrostatic and operative evagination as well as for treatment by resection. Furthermore, some conservative methods of treatment are briefly introduced, such as hydrostatic reduction by means of barium enema under x-ray control or by means of visotrast under ultrasonic visualisation, as well as pneumatic reduction.     

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.     

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.     

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 at the pediatric ward of Dr. Pirngadi Hospital, Medan

A retrospective study had been conducted on hospitalized infants and children in the Pediatric ward of Dr. Pirngadi Hospital, Medan from January 1, 1987 through December 31, 1988. The purpose is to assess the incidence and clinical manifestations of intussusception. During the same period, there were 6484 infants and children hospitalized, 39 (0.6%) with intussusception, consisting of 23 (58.9%) males and (41.1%) females. Most of the cases (53.85%) were in age group of 4-6 months. Thirty four patients (87.12%) were wellnourished, and 5 patients (12.82%) undernourished. The major symptoms of intussusception were bloody diarrhoea (87.17%), vomiting (82.05%) and abdominal distention (66.41%). Successful reposition with barium enema occurred in 1 (20%) out of 5 patients. The major symptoms of intussusception were bloody diarrhoea (87.17%), vomiting. Surgical intervention was performed in 22 patients (56.41%). The result was as follows: discharged in good condition in 15 (68.18%) and deaths occurred in the remaining cases (7 cases = 31.82%). Of those 7 cases who died after operation, 2 cases were hospitalized in less than 2 days, 3 cases in less than 3 days and the remaining 2 cases in more than 3 days, after the symptoms developed.     

Pseudotumoral cecum after hydrostatic reduction of intussusception

The authors report two cases of intestinal intussusception successfully reduced by hydrostatic pressure. A postreduction filling defect in the cecum disappeared spontaneously on follow-up barium enema, and is therefore consistent with cecal edema. It appears an initial period of close observation for such cases is worthwhile, delaying the decision about surgery until after a follow-up barium enema; this may confirm the disappearance of the filling defect.     

超声诊断和水压灌肠治疗小儿肠套叠

目的：　评价超声诊断和超声监视下水压灌肠治疗小儿急性肠套叠的方法和疗效。方法：　对173例可疑肠套叠患儿进行超声检查,发现有“同心圆”征的同时在超声监视下进行水压灌肠复位治疗。结果：　超声确诊肠套叠32例,诊断准确率100%,其中30例水压灌肠复位成功,复位成功率93.8%。3例回回结型中1例水压灌肠成功,2例失败改手术治疗。结论：　超声诊断小儿肠套叠准确率高,水压灌肠复位成功率高。对回回结型超声可以确诊,但复位成功率低     

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.     

Clinical application of ultrasonography in the diagnosis of intussusception.

Sixty-five consecutive patients seen in a pediatric emergency department, in whom the diagnosis of intussusception was considered, had an ultrasound examination of the abdomen before a barium enema. The mean age of the patients was 1.7 years (range 2 weeks to 5 years). Intussusception was detected by ultrasonography in all 20 cases proved by barium enema. There were three false-positive ultrasound results (sensitivity = 100%, confidence interval (Cl) = 86% to 100%; specificity = 93%, Cl = 86% to 96%). Normal findings on ultrasonography correlated with a negative barium enema results in 42 of 42 cases (negative predictive value = 100%, Cl = 94% to 100%). No intussusception was missed by ultrasonography. To determine which patients would most benefit from ultrasonography, we divided patients into either a high-risk group (81% with intussusception) or a low-risk group (14% with intussusception) on the basis of clinical symptoms (p less than 0.01). If each high-risk child had a barium enema and each low-risk child had an ultrasound study as their initial diagnostic test, 89% of the patients in this study would have undergone only one examination. We conclude that ultrasonography can be used as a rapid, sensitive screening procedure in the diagnosis or exclusion of childhood intussusception. Children considered at low risk of having intussusception on the basis of clinical symptoms should initially have an ultrasound examination; patients at high risk should have an immediate 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     

Value of sonography including color Doppler in the diagnosis and management of long standing intussusception

15 cases of intussusception with presenting symptoms of more than 24 h duration were studied by sonography and Doppler. The aim of the study was to determine the validity of the sonographic criteria of peritonitis and bowel ischaemia in order to reduce the risk of colonic perforation and to increase confidence in achieving a successful hydrostatic reduction. The results were reviewed retrospectively and cases divided into 2 groups. Cases in group 1 were reducible by barium enema while those in group 2 required surgical intervention. Sonographic features of peritonitis were absent in all cases of group 1 and 3 cases of group 2. These 3 cases were reduced manually at surgery while the other 5 cases in group 2 with positive features of peritonitis required bowel resection. Blood flow was documented by colour flow Doppler in all cases except the 3 cases with gangrenous bowel in group 2. When sonographic features of peritonitis and loss of blood flow to the intussusception are present in late intussusception, surgical intervention is required. On the other hand, enema reduction should be pursued when such features are absent.Presented at the 42nd RACR Annual Scientific Meeting, Adelaide, Australia, 1991     

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。