Pediatric Seong
Ku Woo,
MD
#{149} Jung
Childhood Hydrostatic
Sik Kim,
as demonstrated
with
US
and
resolution of signs and symptoms of intussusception. Negative sonograms were confirmed with clinical followup. Among 11 failed cases, reduction with barium enema was attempted in six, but all attempts failed. No complications
authors
have
occurred
conclude
diagnostic
that
screening
cases of suspected and that US-guided duction
to date.
The
US is a reliable modality
intussusception hydrostatic
is a promising
nonoperative
#{149} Soo
technique
in
rein
treatment.
Index
terms: Children, gastrointestinal tract, 70.73 #{149} Gastrointestinal tract, interventional procedure. 70.1299 #{149} Gastrointestinal tract, US studies, 70.12981 #{149} Intussusception, 70.73 #{149} UItrasound (US) guidance. 70.12986 1992;
I
182:77-So
efficacy of sonography childhood intussusception value of US guidance reduction performed ema.
MATERIALS March with
the
evaluation
period
with
cases
of intussusception
attempt
made
sonogra-
studied only. ranging
all
during
patients There in age
that
seen were 84 from 2
performed
with
transducer
a
(Acuson,
Calif). Before the of the abdomen
on transverse
echoic
edematous area
images, bowel
of increased image
US criteria
were ring
sign
MD
sign
with
a fluid-filled
a double 2) and
When was
the
made
diagnosis
by
tempted
cases
in all cases.
in our
formed
by
Our
but
series.
atypical
The
All
reduction
method
of conventional a barium enema,
premedication
were shock no such were
per-
(5KW.,
was
J.S.K.).
the same
hydrostatic but barium
were replaced In most cases,
atUS
contraindica-
studies
radiologists
we under
reduction there were
two
oroscopy time US.
studies,
reduction
to hydrostatic peritonitis,
that with
of US
hydrostatic
monitoring tions and
of intussusception
means
as
reduction and flu-
by water and we did not use
or an
antispasmodic
real-
agent,
nor did we attempt any manual on the abdomen. If a child was
pressure agitated,
a
mild sedative, 2% chloral hydrate, was administered rectally in a dose of 1-2 mL/ kg. Under US control, 500-1,000 mL of normal istered
tap water at 35#{176}C-37#{176}C was through an appropriate-sized
i8-F)
Foley
flated securely ion, best
catheter
with
in the rectum bandaged.
head
of an intussuscepin the distal colon),
process
was
ileocecal
pressure. of water
The
traced
was rose (124
was
filled
3.5
feet
the
the
inreser-
(82
to a maximal mm Hg). The
with
water from the abdomen
with of the
was not stopped until disappeared completely ileum
by along intussusbackward
region height
initially
Hg) and gradually height of 5.75 feet cedure ceptum
opin-
After an intussuscepwith a water enema fluid
to the
in-
is the
of real-time US scanning course of the colon. The was observed to move
creasing voir
the balloon
and the buttocks In the authors’
the balloon inflation method way to achieve a pressure
gradually
admin(10-
mm pro-
intussusand the
water.
We
the colon and to see whether
reexthere
a (Fig
with
1). Additional an
(Fig
was any residual or immediate recurrence of intussusception. The entire sequence of reduction is shown in Figure 3. If hydrostatic reduction was unsuccessful, we emptied the water from the colon and attempted a hydrostatic reduction
on the
or multiple
center
(12-14).
evacuated amined
hypo-
appearance (4,10,1
(Fig
with
surrounding echogenicity
a pseudokidney
longitudinal
3a)
distal
study, were
obtained in all cases. The main US critenon for a diagnosis of intussusception was visualization of an intussusceptum, seen as a doughnutor target-shaped configu-
ration
target
means entire ceptum
children under-
to include
seen
linear-array
Mountain View, plain radiographs
centric
Ok Choi,
the reduction
from 116
real-time
was
to iO years. US studies were
1) and
#{149} Soon
(ie, by demonstration tion outlined by
METHODS
to August 1990, intussusception
No
central
MD
within the abdomen. tion was confirmed
30-month
1988 suspected
5-MHz
1992
Paik,
in suspected and the in hydrostatic with saline en-
AND
phy.
months All
From the Departments of Radiology (5KW., J.S.K., S.J.S.), Pediatrics (T.W.P.), and Pediatric Surgery (SOC.), Keimyung University School of Medicine, 194 Dongsan-dong, Chungku, Taegu, 700-310, Korea. From the 1990 RSNA scientific assembly. Received November 5, 1990; revision requested January 8, 1991; final revision received August 19; accepted August 23. Supported by the Special Fund (1991) of Dongsan Medical Center, Keimyung University. Address reprint requests to 5KW.
Won
is a common abdominab emergency in infants and children, but there is considerable variability concerning diagnosis and therapy. Although barium enema is the standard for the diagnosis and therapeutic reduction of intussusception, an alternative method involving the use of aim has been described (13). Several studies recently have emphasized the value of sonography as an initial screening procedure in patients with suspected intussusception (4,5). Furthermore, some authors have advocated a new therapeutic method for hydrostatic reduction of intussusception by using a saline enema under ultrasound (US) guidance (6-9). The purpose of this prospective study was to assess the diagnostic screening
time interval; we during the daytime boys and 32 girls
RSNA,
#{149} Tae
NTUSSUSCEPTION
went
(
MD
US-guided
During Radiology
Jhi Suh,
Intussusception: Reduction’
Over a 30-month period, real-time ultrasound (US) was performed in 116 children with suspected intussusception. US findings were positive in all 75 cases of intussusception. Except in one case of transient smallbowel intussusception, the authors immediately attempted US-guided hydrostatic reduction in all cases. Reduction was successful in 63 cases (85%),
MD
Radiology
con-
barium
period
in six
of this
discontinued this barium reductions after
the
failure
cases
study.
during
Later, procedure that were
of US
the
however,
reductions
initial
we
because attempted
all
also
77
failed.
All
managed.
failed
reductions
Those
patients
tussusception
underwent
tion
to explain
clinically
rectal
bleeding
were who
no
further the
inof
pain.
RESULTS Of the 116 children with suspected intussusception, 74 were proved to have intussusception by means of hydrostatic reduction, which demonstrated the intussusceptum outlined by fluid in the distal colon. The mass is similar in appearance to that outlined by barium or air with conven-
tional
radiographic
mass
moves
ing height operation cases that
reduction.
This
with
increas-
proximally
of a reservoir in unreduced were diagnosed
be intussusceptions patient was shown
bowel
intussusception
clinical bowel With
findings and follow-through sonography,
had
correct
diagnoses.
total
One
by means
of
were
with sonography, with small-bowel
52
the
Table.
Reduction
was
successful
in
in
62 (84%) were of the ibeocobic type and 12 (16%) were ileoileocobic. Among 11 unreduced intussusceptions, eight cases were of the ileoileocolic type and three were ileocobic. Four cases were recurrent intussusception, but 78
#{149} Radiology
of
:
:t
Figure
1. Transverse US scan of the left upper abdomen demonstrates the doughnut sign of intussusception, consisting of a thin anechoic rim and dense central echoes.
US-guided hywas 15 minutes.
a diagnostic
enema
clinical
suspicion
of intus-
susception was high. All these patients, however, were shown not to have intussusception by observance of a back of detectable intussusceptum, free passage of water into the ibeum through the ileocecab valve, and follow-up clinical observation.
The
63 cases, as confirmed with US and the resolution of signs and symptoms of intussusception. In six patients with unsuccessful reductions, an attempt was made to reduce the intussusception with a barium enema guided by means of fluoroscopy before or after US-guided hydrostatic reduction, but the attempt failed in all cases. Two intussusceptions that could not be reduced with barium at other hospitals were successfully me-
duced by us with a water enema. Of 74 cases of intussusception,
for diagnosis and
S
,
S.
DISCUSSION
except intus-
susception associated with allergic purpura, which reduced spontaneousby. The results are summarized
required
We attempted
in whom
boys and 23 girls ranging in age from 2 months to 4 years (average, 10 months), except for one 10-year-old child with small-bowel intussusception. No case found to be negative by means of US was later shown with follow-up clinical observation to have been positive. Therefore, the accuracy of US diagnosis was 100% before hydrostatic reduction. We tried US-guided hydrostatic reduction in 74 cases immediately af-
ten diagnosis in one patient
without
with US guidance in seven patients in whom an intussusceptum was not identified during US examination but
barium smallexamination. all 75 patients
There
time
intussusception drostatic reduction
to
at operation. to have small-
successfully
drostatic reduction was 10 minutes (range, a few minutes to 60 minutes). Two or three attempts of 5 minutes each usually were made, although the maximum was six times. The average
and/or after cases. All by means
of hydrostatic reduction but that could not be reduced were proved
reduced
difficulty. Eleven patients with unreduced intussusceptions underwent surgery. In three of these, hemicolectomy was necessary. In two, segmental resection of the ileum was performed. In the remaining six, the bowel was reduced manually, with difficulty in some cases. Our patients have had no complications during or after hydrostatic meduction with water. The average time required for hy-
evalua-
presence
or abdominal
all were
surgically had
sonographic
findings
of intus-
susception are highly suggestive of the diagnosis, although not totally pathognomonic (4,10-14). When compared with the data of Tran-Minh et al (5) and Wang and Liu (8), our results reveal the same overall diagnostic accuracies (100%). There was no false-negative case in three series, including ours. Therefore, US proved to be a suitable substitute for barium or air in the initial screening of patients with suspected intussusception. Bissett and Kirks (15) pointed out
the
limitations
routine
of US examination
screening.
First,
US
for
findings
Figure 2. Transverse US scan of the left middle part of the abdomen shows the multiple concentric ring sign of a multilayered anechoic area surrounding dense central echogenic foci, a specific sign for intussusception.
signs
suggestive
ception
diagnosis
of
intus-
and
symptoms exist.
US examination,
we
a radiograph of the for free intrapenitoneal
and the amount of bowel loops. of the abdomen patients
distention;
turn
clinical
intussusception
Before
those
the
of
viewed to check
are suggestive of the diagnosis of intussusception but are not pathognomonic because other causes of bowelwall edema may mimic these findings. Second, if there is moderate gaseous distention in the crying child or in patients with small-bowel obstruction, the examination is difficult to perform. Third, the success of the study is operator-dependent. Finally, the study is not therapeutic. In our expenience, however, such limitations were not an obstacle to the sonographic study. US findings are highly of
if
susception
can
of gaseous dilatation A pne-US radiograph can aid in identifying with
in
me-
abdomen air
such
much cases,
be detectable view through
gaseous intussuscep-
a coronal flank. Furthermore, one can perform a diagnostic enema with US guidance if suspicion is great. One should keep in mind that in many cases, an atypical sonographic appearance of intussusception is demonstrated (13,14). It is on oblique
our
policy
to
ter enema only; thus, tive
case in
perform
with
the
diagnostic
wa-
in very suspicious cases there was no false-negain the diagnosis of intussusour
series.
January
1992
.,i
Figure 3. Sequential ultrasonograms obtained during hydrostatic reduction of an ileoileocolic intussusception. (a) Transverse scan of the left lower abdomen reveals an atypical appearance of an intussusceptum with a fluid-filled rather than an echogenic center. (b) Longitudinal scan of the left lower abdomen. Water enema confirms an intussusceptum (arrows) in the distal descending colon outlined by introduced water, a configuration similar to that seen at radiographic reduction. DC = descending colon. (c) Transverse scan of the upper middle part of the abdomen. TC = transverse colon. (d) Longitudinal scan of the right upper abdomen. With increasing pressure, the intussusceptum head (arrows in C and d) was pushed and moved back to the transverse colon (c) and ascending colon (AC in d). (e) Transverse scan of right lower abdomen. The head is at the ileocecal valve (arrows) and pushed back. (1) Transverse scan of the ileocecal valve (arrows) obtained after the head had passed through the valve shows a patulous lumen. (g) Transverse scan of the lower middle part of the abdomen. The head (arrows) has become smaller at the terminal ileum (TI). Immediately after this scan was obtained, the head disappeared suddenly. (h) Transverse scan of the middle part of the abdomen reveals distended small bowel that had been rapidly filled with water, indicating complete reduction. At postevacuation US examination, residual intussusceptum was absent.
Summary
of Clinical Clinical
Results No. or Percentage
Parameter
Patients examined Patients in whom intussuscephon was proved Diagnostic accuracy of US Patients in whom reduction wastried Overall success rate Manual reductions Surgical resections Lead masses identified with US Complications during or after hydrostatic reduction Note-Numbers ages.
in parentheses
116 75(64.7) 100%
74 63 (85) 6 5 0 0 are percent-
Performance of an enema with normal saline and US control for the hydrostatic reduction of childhood inwas described first by et ab in 1982 (6). Thereafter, some authors (7-9) reported its efficacy in the nonoperative management of intussusception with the use of saline solution or water-soluble contrast medium. Although success rates of up to tussusception
Kim
Volume
182
#{149} Number
1
95.5% have been reported (8), this new technique of reduction of intussusception is still not a therapeutic modality familiar throughout the world. We used warm tap water because of its ready availability, but the results were similar to those of salineenema reduction. There is a pressure difference between a column of a barium suspension and that of tap water. In our senies, the height of the reservoir was much higher than that with conventional barium enemas. Yoon and Kim (9) maintained the height of the saline reservoir at 3.3 feet, but their success rate was only 55%. We usually performed reduction with a height of 4-5 feet. In several difficult cases, we carefully raised the height to 5.75 feet, but no problem occurred in our series. The advantages of US-guided hydrostatic reduction are the absence of radiation exposure to the patients and the examiners and the possible detection of a lead mass. There has been no report of serious complication during or after hydrostatic reduction with US guidance. Perforation was the only
complication in one series (8), but no death was reported. To date, theme have been no complications in our series. This may reflect the small numben of patients. During hydrostatic reduction, intestinal perforation can be accurately recognized at once. At the moment of intestinal perforation during reduction, warning features are immediately found (8) and indude the presence of a moderate vobume of liquid in the abdominal cavity, disappearance of liquid from the cobon, and the bowel floating on the upper abdominal cavity. Our success mate (85%) with water enema is similar to that achieved with air enema but higher than that achieved with barium (3). We anticipate that with increasing experience, we could improve the success mate to approach that of 95% achieved in
China tion, tis, series.
(8). There
was
no contraindica-
such as shock, sepsis, to hydrostatic reduction Even
not an ominous static reduction, had accumulated
peritoneab
or penitoniin our
effusion
was
sign. Prior to hydrosome amount of fluid in the penitoneal
Radiology
#{149} 79
cavity in 13 cases, but nine cases were reduced easily without any complication. Four distinct events provide evidence of a successful reduction of intussusception. They are (a) the disappearance of the intussusceptum,
(b) visualization
of reflux of water with aim bubbles from the cecum and ascending colon into the terminal ileum through the ibeocecal valve, (c) demonstration tended ileum, intussusceptum
of a water-disand (d) absence at postevacuation
examination.
of the US
We encountered
situations in which used in the evaluation reduction. In cases
two
caution should be of successful of moderate swell-
ing of the valve, the edematous mimicked an intussusceptum, could observe a continuous
valve but we move-
ment
from
of air bubbles
floating
the
cecum into the ibeum through the central lumen of the swollen valve (Fig 4). In cases of ileoileocolic intussusception, observation of the continuous flow of water from the cecum into the ileum was an important sign
a.
4. Edematous ileocecal valve mimicking residual intussusceptum. (a) Transverse scan of the ileocecal valve (arrows) shows marked symmetric wall thickening, resulting interpretation of it as an incompletely reduced head of intussusception. (b) Longitudinal scan of the ileocecal valve reveals free reflux of water and echoes of air bubbles floating the cecum into the terminal ileum through its canal, indicating posttraumatic swelling ileocecal valve. C = cecum.
References 1.
2.
in the evaluation of successful reduction, because there was difficulty in finding an intussusceptum sequen-
3.
tially
4.
at the
tended
ileum
cobonic
between
loops.
fluid-dis-
Stagnation
flow at the cecum implies reduction, even though cecal valve and fluid-filled
of
incomplete a patent ileoterminal
5.
ileum are visible. In summary, we believe US is a simple, reliable diagnostic screening modality in cases of suspected intussusception, and hydrostatic reduction performed with US guidance is a promising technique for therapeutic reduction of intussusception. USguided hydrostatic reduction of intussusception has superseded hydrostatic barium reduction at our institution. #{149}
80
#{149} Radiology
b.
Figure
6.
7.
Fiorito ES, Cuestas LAR. Diagnosis and treatment of acute intestinal intussuscephon with controlled insufflation of air. Pediatrics 1959; 24:241-244. Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986; 21:1201-1203. Phelan E, de Campo JF, Malecky G. Comparison of oxygen and barium reduction of ileocolic intussusception. AIR 1988; 150: 1349-1352. Swischuk LE, Hayden CKJr, Boulden T. Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney sign. Pediatr Radiol 1985; 15:388-391. Tran-Minh VA, Pracros JP, Massard PE, Louis D, Pracros-Deifrenne P. Diagnosis of acute intestinal intussusception (All) by real-time ultrasonography: evaluation in 176 children with symptoms suspicious for All (abstr). Pediatr Radiol 1985; 15:267-268. Kim YG, Choi BI, Yeon KM. Kim CW. Diagnosis and treatment of childhood intussusception using real-time ultrasonography and saline enema: preliminary report. J Korean Soc Med Ultrasound 1982; 1:6670. Bolia AA. Case report: diagnosis and hydrostatic reduction of an intussusception under ultrasound guidance. Clin Radiol 1985; 36:655-657.
8.
9.
10.
US in an US from of the
Wang GD, Liu SJ. Enema reduction of intussusception by hydrostatic pressure under ultrasound guidance: a report of 377 cases. J Pediatr Surg 1988; 23:814-818. Yoon CH, Kim HS. Ultrasound guided reduction of childhood intussusception. Korean Radiol Soc 1986; 22:788-793. Bowerman RA, Silver TM, Jaffe MH. Realtime ultrasound diagnosis of intussusception in children. Radiology 1982; 143:527530.
11.
Montali G, Croce F, Dc Pra L, Solbiati L. Intussuception of the bowel: a new sonographic pattern. Br J Radiol 1083; 56:621623.
12.
Holts 5, Samuel ring sign in the of intussusception. 1978;
13.
E. Multiple ultrasonographic Gastrointest
concentric diagnosis Radiol
3:307-309.
Alzen G, Funke G, Truong S. the diagnosis of intussusception.
Pitfalls JCU
in 1989;
177:448-488. 14.
Kenney a false 1990;
15.
Bisset infants ment.
IJ. cystic
Ultrasound lead point.
in intussusception: Pediatr Radiol
20:38.
III GS, Kirks DR. Intussusception and children: diagnosis and treatRadiology 1988; 168:141-145.
January
1992
in
Ku Woo,
MD
#{149} Jung
Childhood Hydrostatic
Sik Kim,
as demonstrated
with
US
and
resolution of signs and symptoms of intussusception. Negative sonograms were confirmed with clinical followup. Among 11 failed cases, reduction with barium enema was attempted in six, but all attempts failed. No complications
authors
have
occurred
conclude
diagnostic
that
screening
cases of suspected and that US-guided duction
to date.
The
US is a reliable modality
intussusception hydrostatic
is a promising
nonoperative
#{149} Soo
technique
in
rein
treatment.
Index
terms: Children, gastrointestinal tract, 70.73 #{149} Gastrointestinal tract, interventional procedure. 70.1299 #{149} Gastrointestinal tract, US studies, 70.12981 #{149} Intussusception, 70.73 #{149} UItrasound (US) guidance. 70.12986 1992;
I
182:77-So
efficacy of sonography childhood intussusception value of US guidance reduction performed ema.
MATERIALS March with
the
evaluation
period
with
cases
of intussusception
attempt
made
sonogra-
studied only. ranging
all
during
patients There in age
that
seen were 84 from 2
performed
with
transducer
a
(Acuson,
Calif). Before the of the abdomen
on transverse
echoic
edematous area
images, bowel
of increased image
US criteria
were ring
sign
MD
sign
with
a fluid-filled
a double 2) and
When was
the
made
diagnosis
by
tempted
cases
in all cases.
in our
formed
by
Our
but
series.
atypical
The
All
reduction
method
of conventional a barium enema,
premedication
were shock no such were
per-
(5KW.,
was
J.S.K.).
the same
hydrostatic but barium
were replaced In most cases,
atUS
contraindica-
studies
radiologists
we under
reduction there were
two
oroscopy time US.
studies,
reduction
to hydrostatic peritonitis,
that with
of US
hydrostatic
monitoring tions and
of intussusception
means
as
reduction and flu-
by water and we did not use
or an
antispasmodic
real-
agent,
nor did we attempt any manual on the abdomen. If a child was
pressure agitated,
a
mild sedative, 2% chloral hydrate, was administered rectally in a dose of 1-2 mL/ kg. Under US control, 500-1,000 mL of normal istered
tap water at 35#{176}C-37#{176}C was through an appropriate-sized
i8-F)
Foley
flated securely ion, best
catheter
with
in the rectum bandaged.
head
of an intussuscepin the distal colon),
process
was
ileocecal
pressure. of water
The
traced
was rose (124
was
filled
3.5
feet
the
the
inreser-
(82
to a maximal mm Hg). The
with
water from the abdomen
with of the
was not stopped until disappeared completely ileum
by along intussusbackward
region height
initially
Hg) and gradually height of 5.75 feet cedure ceptum
opin-
After an intussuscepwith a water enema fluid
to the
in-
is the
of real-time US scanning course of the colon. The was observed to move
creasing voir
the balloon
and the buttocks In the authors’
the balloon inflation method way to achieve a pressure
gradually
admin(10-
mm pro-
intussusand the
water.
We
the colon and to see whether
reexthere
a (Fig
with
1). Additional an
(Fig
was any residual or immediate recurrence of intussusception. The entire sequence of reduction is shown in Figure 3. If hydrostatic reduction was unsuccessful, we emptied the water from the colon and attempted a hydrostatic reduction
on the
or multiple
center
(12-14).
evacuated amined
hypo-
appearance (4,10,1
(Fig
with
surrounding echogenicity
a pseudokidney
longitudinal
3a)
distal
study, were
obtained in all cases. The main US critenon for a diagnosis of intussusception was visualization of an intussusceptum, seen as a doughnutor target-shaped configu-
ration
target
means entire ceptum
children under-
to include
seen
linear-array
Mountain View, plain radiographs
centric
Ok Choi,
the reduction
from 116
real-time
was
to iO years. US studies were
1) and
#{149} Soon
(ie, by demonstration tion outlined by
METHODS
to August 1990, intussusception
No
central
MD
within the abdomen. tion was confirmed
30-month
1988 suspected
5-MHz
1992
Paik,
in suspected and the in hydrostatic with saline en-
AND
phy.
months All
From the Departments of Radiology (5KW., J.S.K., S.J.S.), Pediatrics (T.W.P.), and Pediatric Surgery (SOC.), Keimyung University School of Medicine, 194 Dongsan-dong, Chungku, Taegu, 700-310, Korea. From the 1990 RSNA scientific assembly. Received November 5, 1990; revision requested January 8, 1991; final revision received August 19; accepted August 23. Supported by the Special Fund (1991) of Dongsan Medical Center, Keimyung University. Address reprint requests to 5KW.
Won
is a common abdominab emergency in infants and children, but there is considerable variability concerning diagnosis and therapy. Although barium enema is the standard for the diagnosis and therapeutic reduction of intussusception, an alternative method involving the use of aim has been described (13). Several studies recently have emphasized the value of sonography as an initial screening procedure in patients with suspected intussusception (4,5). Furthermore, some authors have advocated a new therapeutic method for hydrostatic reduction of intussusception by using a saline enema under ultrasound (US) guidance (6-9). The purpose of this prospective study was to assess the diagnostic screening
time interval; we during the daytime boys and 32 girls
RSNA,
#{149} Tae
NTUSSUSCEPTION
went
(
MD
US-guided
During Radiology
Jhi Suh,
Intussusception: Reduction’
Over a 30-month period, real-time ultrasound (US) was performed in 116 children with suspected intussusception. US findings were positive in all 75 cases of intussusception. Except in one case of transient smallbowel intussusception, the authors immediately attempted US-guided hydrostatic reduction in all cases. Reduction was successful in 63 cases (85%),
MD
Radiology
con-
barium
period
in six
of this
discontinued this barium reductions after
the
failure
cases
study.
during
Later, procedure that were
of US
the
however,
reductions
initial
we
because attempted
all
also
77
failed.
All
managed.
failed
reductions
Those
patients
tussusception
underwent
tion
to explain
clinically
rectal
bleeding
were who
no
further the
inof
pain.
RESULTS Of the 116 children with suspected intussusception, 74 were proved to have intussusception by means of hydrostatic reduction, which demonstrated the intussusceptum outlined by fluid in the distal colon. The mass is similar in appearance to that outlined by barium or air with conven-
tional
radiographic
mass
moves
ing height operation cases that
reduction.
This
with
increas-
proximally
of a reservoir in unreduced were diagnosed
be intussusceptions patient was shown
bowel
intussusception
clinical bowel With
findings and follow-through sonography,
had
correct
diagnoses.
total
One
by means
of
were
with sonography, with small-bowel
52
the
Table.
Reduction
was
successful
in
in
62 (84%) were of the ibeocobic type and 12 (16%) were ileoileocobic. Among 11 unreduced intussusceptions, eight cases were of the ileoileocolic type and three were ileocobic. Four cases were recurrent intussusception, but 78
#{149} Radiology
of
:
:t
Figure
1. Transverse US scan of the left upper abdomen demonstrates the doughnut sign of intussusception, consisting of a thin anechoic rim and dense central echoes.
US-guided hywas 15 minutes.
a diagnostic
enema
clinical
suspicion
of intus-
susception was high. All these patients, however, were shown not to have intussusception by observance of a back of detectable intussusceptum, free passage of water into the ibeum through the ileocecab valve, and follow-up clinical observation.
The
63 cases, as confirmed with US and the resolution of signs and symptoms of intussusception. In six patients with unsuccessful reductions, an attempt was made to reduce the intussusception with a barium enema guided by means of fluoroscopy before or after US-guided hydrostatic reduction, but the attempt failed in all cases. Two intussusceptions that could not be reduced with barium at other hospitals were successfully me-
duced by us with a water enema. Of 74 cases of intussusception,
for diagnosis and
S
,
S.
DISCUSSION
except intus-
susception associated with allergic purpura, which reduced spontaneousby. The results are summarized
required
We attempted
in whom
boys and 23 girls ranging in age from 2 months to 4 years (average, 10 months), except for one 10-year-old child with small-bowel intussusception. No case found to be negative by means of US was later shown with follow-up clinical observation to have been positive. Therefore, the accuracy of US diagnosis was 100% before hydrostatic reduction. We tried US-guided hydrostatic reduction in 74 cases immediately af-
ten diagnosis in one patient
without
with US guidance in seven patients in whom an intussusceptum was not identified during US examination but
barium smallexamination. all 75 patients
There
time
intussusception drostatic reduction
to
at operation. to have small-
successfully
drostatic reduction was 10 minutes (range, a few minutes to 60 minutes). Two or three attempts of 5 minutes each usually were made, although the maximum was six times. The average
and/or after cases. All by means
of hydrostatic reduction but that could not be reduced were proved
reduced
difficulty. Eleven patients with unreduced intussusceptions underwent surgery. In three of these, hemicolectomy was necessary. In two, segmental resection of the ileum was performed. In the remaining six, the bowel was reduced manually, with difficulty in some cases. Our patients have had no complications during or after hydrostatic meduction with water. The average time required for hy-
evalua-
presence
or abdominal
all were
surgically had
sonographic
findings
of intus-
susception are highly suggestive of the diagnosis, although not totally pathognomonic (4,10-14). When compared with the data of Tran-Minh et al (5) and Wang and Liu (8), our results reveal the same overall diagnostic accuracies (100%). There was no false-negative case in three series, including ours. Therefore, US proved to be a suitable substitute for barium or air in the initial screening of patients with suspected intussusception. Bissett and Kirks (15) pointed out
the
limitations
routine
of US examination
screening.
First,
US
for
findings
Figure 2. Transverse US scan of the left middle part of the abdomen shows the multiple concentric ring sign of a multilayered anechoic area surrounding dense central echogenic foci, a specific sign for intussusception.
signs
suggestive
ception
diagnosis
of
intus-
and
symptoms exist.
US examination,
we
a radiograph of the for free intrapenitoneal
and the amount of bowel loops. of the abdomen patients
distention;
turn
clinical
intussusception
Before
those
the
of
viewed to check
are suggestive of the diagnosis of intussusception but are not pathognomonic because other causes of bowelwall edema may mimic these findings. Second, if there is moderate gaseous distention in the crying child or in patients with small-bowel obstruction, the examination is difficult to perform. Third, the success of the study is operator-dependent. Finally, the study is not therapeutic. In our expenience, however, such limitations were not an obstacle to the sonographic study. US findings are highly of
if
susception
can
of gaseous dilatation A pne-US radiograph can aid in identifying with
in
me-
abdomen air
such
much cases,
be detectable view through
gaseous intussuscep-
a coronal flank. Furthermore, one can perform a diagnostic enema with US guidance if suspicion is great. One should keep in mind that in many cases, an atypical sonographic appearance of intussusception is demonstrated (13,14). It is on oblique
our
policy
to
ter enema only; thus, tive
case in
perform
with
the
diagnostic
wa-
in very suspicious cases there was no false-negain the diagnosis of intussusour
series.
January
1992
.,i
Figure 3. Sequential ultrasonograms obtained during hydrostatic reduction of an ileoileocolic intussusception. (a) Transverse scan of the left lower abdomen reveals an atypical appearance of an intussusceptum with a fluid-filled rather than an echogenic center. (b) Longitudinal scan of the left lower abdomen. Water enema confirms an intussusceptum (arrows) in the distal descending colon outlined by introduced water, a configuration similar to that seen at radiographic reduction. DC = descending colon. (c) Transverse scan of the upper middle part of the abdomen. TC = transverse colon. (d) Longitudinal scan of the right upper abdomen. With increasing pressure, the intussusceptum head (arrows in C and d) was pushed and moved back to the transverse colon (c) and ascending colon (AC in d). (e) Transverse scan of right lower abdomen. The head is at the ileocecal valve (arrows) and pushed back. (1) Transverse scan of the ileocecal valve (arrows) obtained after the head had passed through the valve shows a patulous lumen. (g) Transverse scan of the lower middle part of the abdomen. The head (arrows) has become smaller at the terminal ileum (TI). Immediately after this scan was obtained, the head disappeared suddenly. (h) Transverse scan of the middle part of the abdomen reveals distended small bowel that had been rapidly filled with water, indicating complete reduction. At postevacuation US examination, residual intussusceptum was absent.
Summary
of Clinical Clinical
Results No. or Percentage
Parameter
Patients examined Patients in whom intussuscephon was proved Diagnostic accuracy of US Patients in whom reduction wastried Overall success rate Manual reductions Surgical resections Lead masses identified with US Complications during or after hydrostatic reduction Note-Numbers ages.
in parentheses
116 75(64.7) 100%
74 63 (85) 6 5 0 0 are percent-
Performance of an enema with normal saline and US control for the hydrostatic reduction of childhood inwas described first by et ab in 1982 (6). Thereafter, some authors (7-9) reported its efficacy in the nonoperative management of intussusception with the use of saline solution or water-soluble contrast medium. Although success rates of up to tussusception
Kim
Volume
182
#{149} Number
1
95.5% have been reported (8), this new technique of reduction of intussusception is still not a therapeutic modality familiar throughout the world. We used warm tap water because of its ready availability, but the results were similar to those of salineenema reduction. There is a pressure difference between a column of a barium suspension and that of tap water. In our senies, the height of the reservoir was much higher than that with conventional barium enemas. Yoon and Kim (9) maintained the height of the saline reservoir at 3.3 feet, but their success rate was only 55%. We usually performed reduction with a height of 4-5 feet. In several difficult cases, we carefully raised the height to 5.75 feet, but no problem occurred in our series. The advantages of US-guided hydrostatic reduction are the absence of radiation exposure to the patients and the examiners and the possible detection of a lead mass. There has been no report of serious complication during or after hydrostatic reduction with US guidance. Perforation was the only
complication in one series (8), but no death was reported. To date, theme have been no complications in our series. This may reflect the small numben of patients. During hydrostatic reduction, intestinal perforation can be accurately recognized at once. At the moment of intestinal perforation during reduction, warning features are immediately found (8) and indude the presence of a moderate vobume of liquid in the abdominal cavity, disappearance of liquid from the cobon, and the bowel floating on the upper abdominal cavity. Our success mate (85%) with water enema is similar to that achieved with air enema but higher than that achieved with barium (3). We anticipate that with increasing experience, we could improve the success mate to approach that of 95% achieved in
China tion, tis, series.
(8). There
was
no contraindica-
such as shock, sepsis, to hydrostatic reduction Even
not an ominous static reduction, had accumulated
peritoneab
or penitoniin our
effusion
was
sign. Prior to hydrosome amount of fluid in the penitoneal
Radiology
#{149} 79
cavity in 13 cases, but nine cases were reduced easily without any complication. Four distinct events provide evidence of a successful reduction of intussusception. They are (a) the disappearance of the intussusceptum,
(b) visualization
of reflux of water with aim bubbles from the cecum and ascending colon into the terminal ileum through the ibeocecal valve, (c) demonstration tended ileum, intussusceptum
of a water-disand (d) absence at postevacuation
examination.
of the US
We encountered
situations in which used in the evaluation reduction. In cases
two
caution should be of successful of moderate swell-
ing of the valve, the edematous mimicked an intussusceptum, could observe a continuous
valve but we move-
ment
from
of air bubbles
floating
the
cecum into the ibeum through the central lumen of the swollen valve (Fig 4). In cases of ileoileocolic intussusception, observation of the continuous flow of water from the cecum into the ileum was an important sign
a.
4. Edematous ileocecal valve mimicking residual intussusceptum. (a) Transverse scan of the ileocecal valve (arrows) shows marked symmetric wall thickening, resulting interpretation of it as an incompletely reduced head of intussusception. (b) Longitudinal scan of the ileocecal valve reveals free reflux of water and echoes of air bubbles floating the cecum into the terminal ileum through its canal, indicating posttraumatic swelling ileocecal valve. C = cecum.
References 1.
2.
in the evaluation of successful reduction, because there was difficulty in finding an intussusceptum sequen-
3.
tially
4.
at the
tended
ileum
cobonic
between
loops.
fluid-dis-
Stagnation
flow at the cecum implies reduction, even though cecal valve and fluid-filled
of
incomplete a patent ileoterminal
5.
ileum are visible. In summary, we believe US is a simple, reliable diagnostic screening modality in cases of suspected intussusception, and hydrostatic reduction performed with US guidance is a promising technique for therapeutic reduction of intussusception. USguided hydrostatic reduction of intussusception has superseded hydrostatic barium reduction at our institution. #{149}
80
#{149} Radiology
b.
Figure
6.
7.
Fiorito ES, Cuestas LAR. Diagnosis and treatment of acute intestinal intussuscephon with controlled insufflation of air. Pediatrics 1959; 24:241-244. Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986; 21:1201-1203. Phelan E, de Campo JF, Malecky G. Comparison of oxygen and barium reduction of ileocolic intussusception. AIR 1988; 150: 1349-1352. Swischuk LE, Hayden CKJr, Boulden T. Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney sign. Pediatr Radiol 1985; 15:388-391. Tran-Minh VA, Pracros JP, Massard PE, Louis D, Pracros-Deifrenne P. Diagnosis of acute intestinal intussusception (All) by real-time ultrasonography: evaluation in 176 children with symptoms suspicious for All (abstr). Pediatr Radiol 1985; 15:267-268. Kim YG, Choi BI, Yeon KM. Kim CW. Diagnosis and treatment of childhood intussusception using real-time ultrasonography and saline enema: preliminary report. J Korean Soc Med Ultrasound 1982; 1:6670. Bolia AA. Case report: diagnosis and hydrostatic reduction of an intussusception under ultrasound guidance. Clin Radiol 1985; 36:655-657.
8.
9.
10.
US in an US from of the
Wang GD, Liu SJ. Enema reduction of intussusception by hydrostatic pressure under ultrasound guidance: a report of 377 cases. J Pediatr Surg 1988; 23:814-818. Yoon CH, Kim HS. Ultrasound guided reduction of childhood intussusception. Korean Radiol Soc 1986; 22:788-793. Bowerman RA, Silver TM, Jaffe MH. Realtime ultrasound diagnosis of intussusception in children. Radiology 1982; 143:527530.
11.
Montali G, Croce F, Dc Pra L, Solbiati L. Intussuception of the bowel: a new sonographic pattern. Br J Radiol 1083; 56:621623.
12.
Holts 5, Samuel ring sign in the of intussusception. 1978;
13.
E. Multiple ultrasonographic Gastrointest
concentric diagnosis Radiol
3:307-309.
Alzen G, Funke G, Truong S. the diagnosis of intussusception.
Pitfalls JCU
in 1989;
177:448-488. 14.
Kenney a false 1990;
15.
Bisset infants ment.
IJ. cystic
Ultrasound lead point.
in intussusception: Pediatr Radiol
20:38.
III GS, Kirks DR. Intussusception and children: diagnosis and treatRadiology 1988; 168:141-145.
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1992
in
