Solar eclipse sign of intussusception on barium enema

The colographic appearance of intussusception is variously described as a claw sign, pincer defect, shouldering effect, and coiled-spring pattern. This report adds a new radiographic sign to the list. An end-on view of an intussusception on barium enema shows a ring of contrast resembling a solar eclipse. Familiarity with this bizarre appearance is desirable, lest it may be mistaken for spillage of barium due to a colonic perforation. Accepted: 16 February 2001     

Childhood intussusception: Hydrostatic reducibility and incidence of leading points in different age groups

A series consisting of 658 radiologically diagnosed intussusceptions is analysed. Hydrostatic reduction was successful in 85.2% of cases, the incidence of failure amounting to 14.8%. Analysis demonstrated a marked difference in reduction rate in different age groups. The lowest rate of success was recorded in children over 5 years of age, the group with the highest incidence of leading points. The next lowest rate of success was in those below age 1 year where the frequency of failure was more than 50% higher than in the ages between 1 and 5 years. However, the rate of leading points was approximately the same in both the latter groups and close to the average in entire series. There is no reason to refrain from barium enema reduction in any age group although special care should be exercised in the neonate. With a reasonable experience of method, the risk of overlooking a surgically significant lesion is negligible.     

The diagnostically difficult intussusception: its characteristics and consequences

In the absence of classical symptomatology, the diagnosis of intussusception may be difficult to make. A retrospective review of 630 episodes of intussusception admitted to the Royal Children's Hospital, Melbourne, over a 15-year period revealed difficulties in diagnosis in 318 cases. The adverse effect of an incorrect initial diagnosis on duration of symptoms at the commencement of treatment, need for surgery, resection rate, complications, and hospital stay is examined. Problems in the assessment of children with intussuception are identified and discussed in the hope that an increased awareness of the diagnostic difficulties and potential pitfalls will reduce the morbidity of this common paediatric condition. Offprint requests to: S. W. Beasley     

Atypical ileocolic intussusception diagnosed by barium follow-through

Barium follow-through studies of the bowel demonstrated clinically undiagnosed ileocolic intussusception in two children. Because intussusception may present with atypical symptoms a high index of suspicion for this entity is mandatory.     

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     

Intussusception in the 1990s: has 25 years made a difference?

To evaluate the current management of the infant and child with intussusception, the medical records of 188 consecutive intussusception patients over 5 years (1985–1990) were reviewed and compared to our series from 25 years ago (1959–1968). The peak months changed from May and June to January and July. Duration of symptoms and signs prior to diagnosis increased by one-third to 35 h with, however, a decrease in the incidence of pain, vomiting, abdominal mass, and rectal blood. Air was the only contrast used for the hydrostatic enema in the present series and was tried in every case with 81% success; this is a major improvement from 45% in the old series. There were three perforations (1.4%) with air-enema attempts compared with 1 (0.2%) 25 years ago. Recently only 19% of patients required operation but 30% needed resection; 55% of the patients in the older series required operation and 20% needed resection. Ten percent of intussusceptions continue to be found spontaneously reduced at operation. There were many less pathologic lead points in the newer series. The recurrences increased from 4% to 7%, but their reduction rate also increased from 31% with barium to 100% with air. There were no deaths in the last 25 years.     

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.     

Ultrasound guided hydrostatic reduction in the management of intussusception

Objective: A case series study was conducted for two years from 01 June 2002 to 01 June 2004 to study the efficiency of ultrasound guided hydrostatic reduction in the management of intussusception in children.Methods: A total of 25 patients who underwent the procedure were evaluated. All the patients were diagnosed by High Resolution Ultrasonography (HRUSG). Continuous monitoring of the progress of reduction during the procedure was done by HRUSG. 500–1000 ml (average 600 ml) of normal saline was used.Results: 24 out of 25 (96%) intussusceptions were successfully reduced. Average time taken was 15 minutes. All the patients were reviewed after 24 hrs for recurrence. None of them showed recurrence within 24 hrs. No complications were observed.Conclusion: The study concludes that ultrasound guided hydrostatic reduction is a safe, simple and effective method for treatment of intussusception in children.     

Reduction of intussusception in infants by a pediatric surgical team: improvement in safety and outcome

Commonly, reduction of intussusception is performed by experienced radiologists. We review the performance of a pediatric surgical team for treating intussusception according to a standard protocol and present our findings. Three hundred and seventy eight patients with signs and symptoms of intussusception we treated from 1980 to 2005 were reviewed. Hydrostatic reduction (HR) was performed using a water-soluble contrast agent under fluoroscopy unless there was a serious condition clinically. Before 1998, HR was performed exclusively by pediatric surgical trainees (period A). In 1998, a standard protocol (double-balloon tube, maximum pressure of 120 cmH₂O, repeated a maximum of five times, and HR performed by a pediatric surgical trainee under the supervision of a consultant pediatric surgeon) was adopted (period B). As part of the protocol, the operating room was notified of the HR procedure and placed on call for emergency surgery. Of the 378 patients, 21 required immediate laparotomy due to serious general condition, leaving 138 during period A and 219 during period B who had HR. Patient age, sex, and duration of symptoms (period A, 14.5 ± 7.8 h; period B, 13.1 ± 9.9 h) were not statistically significant. Success of HR during period A was 64.5%, and significantly improved for period B at 94.5% (P < 0.01). During period B, 128 of our patients had been referred from elsewhere for failed reduction attempted by radiologists or pediatricians. We were able to perform HR successfully in 118 of these (92.2%). During period A, it was significantly less at 54.0% (P < 0.01). Bowel perforation during HR occurred in two patients during period A (1.4%) and two patients during period B (0.9%), but the latter cases were transferred immediately for emergency surgery with good outcome. Reduction of intussusception by a pediatric surgical team would appear to be significantly safer with better outcome, and is thus more efficient.     

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     

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.     

Infantile Hirschsprung's disease — is a barium enema useful?

This study examined the usefulness of barium enema examination in the diagnosis and evaluation of extent of aganglionosis in the 1st year of life. Twenty-four cases of Hirschsprung's disease in children less than 1 year of age were diagnosed from 1981 to 1989; 17 infants had a barium enema performed. A correct diagnosis was made by barium enema in 13 of the 17 infants, with the level of transition being correctly identified in only 8. Operative assessment of the cone was accurate in 14 of 24 infants, indicating that operative biopsy is always required. Therefore, the barium enema had a 24% false-negative rate in the diagnosis of Hirschsprung's disease and a 53% error rate in determining the level of transition. In the investigation of an infant with a low bowel obstruction, the initial procedure suggested is a rectal washout. If this results in relief of the obstruction, it should be followed by a rectal biopsy. A barium enema adds insignificant information. Offprint requests to: D. CassPaper presented at the Australian Association of Paediatric Surgeons Annual meeting, October 1989     

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.     

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.     

The clinical implications of non-idiopathic intussusception

A pathological lesion can be identified at the leadpoint of intussusception in about 6% of episodes. Occasionally, general manifestations of an underlying disease indicate the specific cause of an intussusception (e.g., perioral pigmentation in Peutz-Jeghers syndrome), but usually the clinical features provide no clues as to the aetiology. Neonatal intussusception may be caused by a duplication cyst or Meckel's diverticulum. Beyond 12 months, the proportion of intussusceptions due to a pathological lesion at the leadpoint increases with age. There is an identifiable lesion in the majority of children over 5 years of age. Postoperative intussusception accounts for between 0.5% and 16% of intussusceptions, although it has a variety of causes; it typically follows retroperitoneal dissection. It is unusual for an intussusception due to a pathological lesion at the leadpoint to be reduced by enema. If it is reduced, the lesion may be seen at the time of reduction or fluoroscopy, or subsequently on ultrasonography.     

Postoperative intussusception in childhood

Over a period of 10 years, five children developed postoperative intussusception after intra-abdominal procedures at the Department of Pediatric Surgery of the Johannes Gutenberg University Mainz. Two appendectomies, one ileal resection for a Meckel's diverticulum, one operative procedure for Hirschsprung's disease plus intestinal neuronal dysplasia type B, and one hiatoplasty with jejunostomy preceded the intussusception. Three of the five children were older than 2 years. The clinical symptoms consisted primarily of abdominal distension, diffuse abdominal pain, bilious vomiting, and rectal bleeding in one case. Preoperative diagnosis was achieved in four cases by abdominal ultrasound. Plain abdominal radiographs demonstrated dilated loops of small intestine with air-fluid levels in four of the five cases. In the case without radiographic findings, the jejunojejunal intussusception was missed even by a bowel follow-through. The intussusceptions were ileocolic (3), ileoileal (1), and jejunojejunal (1). A hydrostatic procedure to reduce an ileocolic intussusception was not successful. Operative treatment of the intussusception was performed in three cases within 5 days, once at 32 days, and once 3 months after the primary operation, in all cases by laparatomy and simple manual reduction without intestinal resection. In contrast to idiopathic intussusception, noninvasive hydrostatic procedures are not indicated in postoperative intussusception, since protection of intestinal anastomoses from hydrostatic pressure and exclusion of other causes of postoperative ileus are mandatory.     

B超引导下改良水压灌肠治疗小儿肠套叠

分析Ｂ超引导下改良水压灌肠治疗小儿肠套叠的疗效，介绍使用方法和意义。本组为１６８例小儿肠套叠，男１３０例，女３８例，全部采用Ｂ超引导下改良水压灌肠法治疗。灌肠特点是以自制密闭式手控加压灌肠器连接直径为０．６～０．８ｃｍ的肛管进行。１６８例患儿中，１５４例（９１．７％）为回结型肠套叠，１０３例病程不满４８小时。小儿的年龄为２．５月～４岁。１６１例复位成功，治愈率９５．８％（１６１／１６８）。７例非回结型套叠复位失败。我们认为，本灌肠技术简易、安全可靠。使用这种技术，监测压力方便，疗效满意。     

Reactive lymphocytes and intussusception in childhood

The peripheral blood smears of 15 infants with idiopathic intussusception and 23 controls with acute gastroenteritis were examined. We found an increased absolute number of reactive lymphocytes in the infants with intussusception compared to the controls (0.14×10⁹/1 +/– 0.08 and 0.07×10⁹/l +/– 0.07, respectively). This finding could reflect the irritation and enlargement of the intestinal lymphatic system that is believed to act as the lead point in idiopathic intussusception. Another explanation could be adenovirus infection, often associated with idiopathic intussusception, which is known to provoke morphologic changes in lymphocytes. These changes in the peripheral blood smear are mainly of pathogenetic interest and do not have a significant diagnostic impact in infants presenting with the typical clinical picture. However, in a child with suspected intussusception lacking typical clinical signs, the finding of reactive lymphocytes will recommend careful supervision.     

Multimodality imaging of an appendiceal intussusception

Appendiceal intussusception is a rare entity. The majority of cases reported in the literature address surgical and colonoscopic approaches to treatment of the condition. The existing radiologic literature largely describes the sonographic and double-contrast enema findings of appendiceal intussusception. We present a case of appendiceal intussusception and describe the air-contrast enema, sonographic and CT findings.