•
•
Glucagon-Aided Reduction of
Intussusception 1
Pediatric Radiology
James K. Fisher, M.D., and Donald R. Germann, M.D. Intramuscular glucagon was used in 2 patients with ileocolic intussusception when standard therapeutic barium enema reduction failed. Reduction was accomplished following administration of glucagon and a repeat barium enema. Use of the two methods together may improve the success rate of nonoperative reduction of intussusception. INDEX TERMS: Glucagon (Colon examination, use of pharmacological agent, 7 [5] .1289) • Intussusception (Ileocolic intussusception, 7 [8] .730) Radiology 122: 197-198, January 1977
reduction of intussusception is one of the few therapeutic procedures in diagnostic radiology; however, it is not infallible. We wish to present 2 cases in which an ileocolic intussusception was reduced with intramuscular glucagon followed by a barium enema when the standard therapeutic enema failed. This combination may improve the nonoperative reduction success rate and should be considered when the standard approach fails, or perhaps during the initial attempt at reduction.
B
ARIUM ENEMA
CASE REPORTS CASE I (W.H.): A 19-month-old male infant presented with cramping abdominal pain and vomiting which had developed four hours earlier. A walnut-sized mass was palpated in the mid-epigastrium. Although the intussusception could be moved from the transverse colon using a standard barium enema, it could not be reduced beyond the proximal ascending colon area. The patient was given 0.5 mg of glucagon intramuscularly and the enema was repeated successfully (Fig. 1). CASE II (C.A.): A 4 %-month-old male infant presented with cramping abdominal pain and bloody stools which had developed several hours earlier. A fullness was palpated in the upper abdomen. A standard barium enema study revealed an intussusception at the level of the transverse colon. It was reduced to the cecal area, but the last few centimeters could not be moved until 0.5 mg of glucagon was given. Reduction was then promptly completed.
DISCUSSION
Intussusception is the telescoping of the bowel inside itself, causing intestinal obstruction and vascular compression which in turn lead to edema and gangrene. 900/0 of them are ileocolic in location (2), and many can be successfully reduced with a barium enema, thereby avoiding surgery; however, not all intussusceptions can be reduced in this manner, as the bowel mass frequently persists in the region of the proximal ascending colon. The 1
Fig. 1. Frames A-C demonstrate unsuccessful attempts to reduce an intussusception in the area of the ileocecal valve. Frame D shows prompt reduction following a combination of glucagon plus a repeat barium enema.
success rate has been reported to be 30-80 % (2). There appears to be no relationship between the success rate
From the Department of Radiology, St. Luke's Hospital, Kansas City, Mo. Accepted for publication in August 1976.
197
sjh
198
JAMES K. FISHER AND DONALD
and the age of the patient, duration of symptoms, or type of intussusception (2, 3). The standard approach to intussusception is to securely tape an enema tip in the rectum. This is one of the few times a balloon tip may be used, but it must be done carefully. The bore must be large enough to transmit pressure to the colon from a bag of barium hung 76-91 cm (30-36 in.) above the table top. An enema is then given, reducing the intraluminal bowel mass as far as possible and preferably filling several centimeters of the distal small bowel. If reduction is not accomplished with reasonable effort, surgery is necessary; however, reduction has been seen with sedation or anesthesia prior to or at surgery; when both the patient and the bowel are relaxed. In our department, glucagon is used to relax the bowel in hypotonic duodenography, spasm during barium enemas, and air/contrast studies. By some unknown mechanism, glucagon is known to relax smooth muscle, decrease peristalsis, and reduce gastrointestinal spasm (5, 7). We felt that by inducing muscular relaxation in the bowel, uniform continuous pressure could be applied by the enema, thus reducing the intussusception even when it could not be done with a standard barium enema. In 2 cases in which we have used this procedure, the intussusception was reduced successfully. Glucagon is a relatively harmless drug. Intramuscularly, it is fast-acting with effects beginning within 5 minutes and lasting 30 minutes (6). Nausea, vomiting, dizziness, a dry mouth, weakness, a flush, headache, and abdominal stress are infrequent side effects (1, 6, 8). It is contraindicated in hypoglycemia caused by insulinoma, release of catecholamines caused by pheochromocytoma, and in high
R.
GERMANN
January 1977
doses potentiates warfarin-induced hypothrombinemia (6), all of which are unusual in pediatrics. Dosages for children range from 0.5 to 1.0 mg (4). We recommend that a standard barium enema approach be done first, after contraindications of peritonitis and shock have been excluded. If reduction cannot be accomplished promptly, we suggest that glucagon be administered and the enema continued or repeated. Consideration might be given to using glucagon prior to any attempt to reduce the intussusception. Department of Radiology St. Luke's Hospital Wornall Rd. at 44th St. Kansas City, Mo. 64111
REFERENCES 1. Chernish SM, Miller RE, Rosenak BD, et al: Hypotonic duodenography with the use of glucagon. Gastroenterology 63:392-398, Sep 1972 2. Franken EA Jr: Gastrointestinal Radiology in Pediatrics. Hagerstown, Md., Harper & Row, 1975 3. Gierup J, Jorulf H, Livaditis A: Management of intussusception in infants and children: a survey based on 288 consecutive cases. Pediatrics 50:535-546, Oct 1972 4. Gohel VK, Oalinka MK, Coren GS: Hypotonic examination of the colon with glucagon. Radiology 115:1-4, Apr 1975 5. Meeroff JC, Jorgens J, Isenberg JI: The effect of glucagon on barium-enema examination. Radiology 115:5-7, Apr 1975 6. Miller RE, Chern ish SM, Rosenak BO, et al: Hypotonic duodenography with glucagon. Radiology 108:35-42, Jul 1973 7. Miller RE, Chern ish SM, Skucas J, et al: Hypotonic colon examination with glucagon. Radiology 113:555-562, Dec 1974 8. Miller RE, Chern ish SM, Skucas J, et al: Hypotonic roentgenography with glucagon. Am J Roentgenol 121:264-274, Jun 1974
•
Glucagon-Aided Reduction of
Intussusception 1
Pediatric Radiology
James K. Fisher, M.D., and Donald R. Germann, M.D. Intramuscular glucagon was used in 2 patients with ileocolic intussusception when standard therapeutic barium enema reduction failed. Reduction was accomplished following administration of glucagon and a repeat barium enema. Use of the two methods together may improve the success rate of nonoperative reduction of intussusception. INDEX TERMS: Glucagon (Colon examination, use of pharmacological agent, 7 [5] .1289) • Intussusception (Ileocolic intussusception, 7 [8] .730) Radiology 122: 197-198, January 1977
reduction of intussusception is one of the few therapeutic procedures in diagnostic radiology; however, it is not infallible. We wish to present 2 cases in which an ileocolic intussusception was reduced with intramuscular glucagon followed by a barium enema when the standard therapeutic enema failed. This combination may improve the nonoperative reduction success rate and should be considered when the standard approach fails, or perhaps during the initial attempt at reduction.
B
ARIUM ENEMA
CASE REPORTS CASE I (W.H.): A 19-month-old male infant presented with cramping abdominal pain and vomiting which had developed four hours earlier. A walnut-sized mass was palpated in the mid-epigastrium. Although the intussusception could be moved from the transverse colon using a standard barium enema, it could not be reduced beyond the proximal ascending colon area. The patient was given 0.5 mg of glucagon intramuscularly and the enema was repeated successfully (Fig. 1). CASE II (C.A.): A 4 %-month-old male infant presented with cramping abdominal pain and bloody stools which had developed several hours earlier. A fullness was palpated in the upper abdomen. A standard barium enema study revealed an intussusception at the level of the transverse colon. It was reduced to the cecal area, but the last few centimeters could not be moved until 0.5 mg of glucagon was given. Reduction was then promptly completed.
DISCUSSION
Intussusception is the telescoping of the bowel inside itself, causing intestinal obstruction and vascular compression which in turn lead to edema and gangrene. 900/0 of them are ileocolic in location (2), and many can be successfully reduced with a barium enema, thereby avoiding surgery; however, not all intussusceptions can be reduced in this manner, as the bowel mass frequently persists in the region of the proximal ascending colon. The 1
Fig. 1. Frames A-C demonstrate unsuccessful attempts to reduce an intussusception in the area of the ileocecal valve. Frame D shows prompt reduction following a combination of glucagon plus a repeat barium enema.
success rate has been reported to be 30-80 % (2). There appears to be no relationship between the success rate
From the Department of Radiology, St. Luke's Hospital, Kansas City, Mo. Accepted for publication in August 1976.
197
sjh
198
JAMES K. FISHER AND DONALD
and the age of the patient, duration of symptoms, or type of intussusception (2, 3). The standard approach to intussusception is to securely tape an enema tip in the rectum. This is one of the few times a balloon tip may be used, but it must be done carefully. The bore must be large enough to transmit pressure to the colon from a bag of barium hung 76-91 cm (30-36 in.) above the table top. An enema is then given, reducing the intraluminal bowel mass as far as possible and preferably filling several centimeters of the distal small bowel. If reduction is not accomplished with reasonable effort, surgery is necessary; however, reduction has been seen with sedation or anesthesia prior to or at surgery; when both the patient and the bowel are relaxed. In our department, glucagon is used to relax the bowel in hypotonic duodenography, spasm during barium enemas, and air/contrast studies. By some unknown mechanism, glucagon is known to relax smooth muscle, decrease peristalsis, and reduce gastrointestinal spasm (5, 7). We felt that by inducing muscular relaxation in the bowel, uniform continuous pressure could be applied by the enema, thus reducing the intussusception even when it could not be done with a standard barium enema. In 2 cases in which we have used this procedure, the intussusception was reduced successfully. Glucagon is a relatively harmless drug. Intramuscularly, it is fast-acting with effects beginning within 5 minutes and lasting 30 minutes (6). Nausea, vomiting, dizziness, a dry mouth, weakness, a flush, headache, and abdominal stress are infrequent side effects (1, 6, 8). It is contraindicated in hypoglycemia caused by insulinoma, release of catecholamines caused by pheochromocytoma, and in high
R.
GERMANN
January 1977
doses potentiates warfarin-induced hypothrombinemia (6), all of which are unusual in pediatrics. Dosages for children range from 0.5 to 1.0 mg (4). We recommend that a standard barium enema approach be done first, after contraindications of peritonitis and shock have been excluded. If reduction cannot be accomplished promptly, we suggest that glucagon be administered and the enema continued or repeated. Consideration might be given to using glucagon prior to any attempt to reduce the intussusception. Department of Radiology St. Luke's Hospital Wornall Rd. at 44th St. Kansas City, Mo. 64111
REFERENCES 1. Chernish SM, Miller RE, Rosenak BD, et al: Hypotonic duodenography with the use of glucagon. Gastroenterology 63:392-398, Sep 1972 2. Franken EA Jr: Gastrointestinal Radiology in Pediatrics. Hagerstown, Md., Harper & Row, 1975 3. Gierup J, Jorulf H, Livaditis A: Management of intussusception in infants and children: a survey based on 288 consecutive cases. Pediatrics 50:535-546, Oct 1972 4. Gohel VK, Oalinka MK, Coren GS: Hypotonic examination of the colon with glucagon. Radiology 115:1-4, Apr 1975 5. Meeroff JC, Jorgens J, Isenberg JI: The effect of glucagon on barium-enema examination. Radiology 115:5-7, Apr 1975 6. Miller RE, Chern ish SM, Rosenak BO, et al: Hypotonic duodenography with glucagon. Radiology 108:35-42, Jul 1973 7. Miller RE, Chern ish SM, Skucas J, et al: Hypotonic colon examination with glucagon. Radiology 113:555-562, Dec 1974 8. Miller RE, Chern ish SM, Skucas J, et al: Hypotonic roentgenography with glucagon. Am J Roentgenol 121:264-274, Jun 1974
