Ischemic Stricture and Perforation An Unusual
Complication After Successful John
F.
Valente, MD; William
D.
Barium Reduction of an
Rappaport, MD;
Intussusception
C. Peter Crowe, Jr, MD
Intussusception is a common cause of intestinal obstruction in infants. Use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical reduction of the intussusception. While failed hydrostatic reduction is an indication for surgical intervention, delayed complications of hydrostatic reduction have not been described. We present a case of ischemic stricture and perforation developing after the successful reduction of an intussusception. \s=b\
(Arch Surg. 1992;127:1252-1253) a barium mation
both
affords diagnostic confir¬ intestinal obstruction and possible op¬ Use of for ofhydrostatic of reduction enema
a
intussus¬ in cases portunity ception. Failed reduction or perforation during reduction are indications for immediate surgical intervention. Ad¬ vanced swelling and ischemia of the intussusceptum may
while easy reduction is indication that complications will not develop. We present a case of ischemie stricture and even¬ tual perforation after successful hydrostatic reduction of an intussusception. Proposed pathophysiologic mecha¬ nisms and a review of the literature are presented.
preclude hydrostatic reduction, often considered
an
REPORT OF A CASE A four-month-old boy presented to the University of Arizona Medical Center emergency room with a 24-hour history of inter¬ mittent abdominal pain and bloody stools. The patient was afebrile, with a pulse of 140 beats per minute and a white blood cell count of 13.6X109/L. A roentgenogram obtained after patient se¬ dation with meperidine hydrochloride and administration of a barium enema demonstrated an intussusception at the sigmoid colon, which reduced without unusual difficulty (Fig 1). The height of the barium column was kept at 90 cm, and reduction at¬ tempts were limited to periods of 3 minutes. The fluoroscopic procedure was ended when barium was noted to reflux freely into the terminal ileum. No roentgenographic evidence of perforation was noted, and results of the postreduction abdominal examina¬ tion were normal. One temperature spike of 38.3° C was noted on the evening of the reduction, but the patient rapidly became afebrile and was discharged from the hospital the next morning. He returned 3 days later because of vomiting and a tempera¬ ture of 39.3°C. Results of abdominal examination revealed no tenderness, mass, or peritoneal signs, and results of guaiac tests of the stool were negative. Roentgenograms of the abdomen were within normal limits, and the patient recovered rapidly. He was again discharged from the hospital but returned 2 weeks later with a temperature of 39.0°C, pulse of 190 beats per minute, vomiting, and severe diarrhea. His white blood cell count was 16.3 X10V L, with 0.76 segmented neutrophils, 0.20 band cells, and
Fig 1.—The original intussusception early in the course of reduction with a
barium
enema.
lymphocytes. The abdomen was quiet, distended, and slightly tender. Plain films showed dilated small bowel with multiple air-fluid levels. A roentgenogram obtained during
0.03
administration of a barium enema showed a normal colon and free reflux of contrast medium into multiple, dilated loops of the small bowel. No stricture, perforation, or area of obstruction was identified. Empiric treatment for sepsis with ceftazadime and ampicillin sodium was stopped after the patient became afebrile. Cultures of spinal fluid, blood, and urine taken on admission were negative for bacteria and other organisms 48 hours later. The pa¬ tient recovered and was tolerating a normal diet at discharge from the hospital. He returned 6 days later with vomiting, abdominal distension, and low-volume diarrhea. Abdominal roentgeno¬ grams indicated a possible small-bowel obstruction, and a barium enema was again administered. Roentgenography showed a nor¬ mal colon and reflux of contrast material into the dilated small bowel (Fig 2). At exploratory laparotomy, a segment of severely strictured terminal ileum about 12 cm proximal to the ileocecal valve was found. As surrounding adhesions were lysed, a sealed perforation in the strictured segment was uncovered. The in¬ volved bowel was resected and repaired with creation of a primary anastomosis. The patient recovered quickly and was discharged from the hospital 6 days after surgery. He was afebrile and tolerating a full diet. Results of pathologic examination of the resected segment revealed a fibrotic ischemie stricture. No further problems were encountered by the patient.
Accepted for publication September 26, 1991. From the Department of Surgery, University of Arizona Medical Cen-
ter, Tucson.
Reprint requests to 5402 E Grant Rd, Bldg K-D, Tucson, AZ 85712 (Dr
Crowe).
COMMENT Intestinal perforation during hydrostatic reduction of an intussusception is a rare complication, with a reported in
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/04/2015
complete reduction or recurrent intussusception seems unlikely. Our patient's delayed return to the hospital after reduction, with evidence of small-bowel obstruction,
Fig 2.—Some delay was encountered in showing reflux of barium into the small bowel. An area of narrow ileum was eventually identified at surgery.
cidence of .39%.1 Multiple sites of perforation are de¬ scribed, including the intussuscipiens,2'5 the colon distal to the intussusceptum,6 and some combination of perfora¬ tions that included the intussusceptum itself.610 Four fac¬ tors associated with a high rate of intestinal gangrene, a low rate of successful hydrostatic reduction, and an increased risk of perforation are (1) age greater than 2 years or less than 3 months; (2) duration of symptoms greater than 24 hours; (3) presence of small-bowel obstruction; and (4) dehydration greater than 5%.n The duration of vascu¬ lar compromise of the intussusceptum and the subsequent degree of swelling would seem to dictate both the risk of necrosis of the intussusceptum and perforation during hydrostatic reduction. Accepted practice limits the height of the barium column and the duration of reduction attempts to reduce the risk of perforation.1214 The presence of small-bowel obstruction is considered by some to indicate an advanced degree of swelling of the intussusceptum and an increased risk of perforation with hydrostatic reduction.915 Given the more recent realization that intraperitoneal barium is not necessarily associated with a bleak outcome5 and the application of decision analysis favoring the use of hydrostatic reduction in the presence of small-bowel obstruction,16 we use a barium enema as the first step in the treatment of all patients without signs of preexisting perforation. Using this ap¬ proach, a success rate of 71% has been reported.17 Premedication with meperidine hydrochloride has value,18 but we do not use glucagon during hydrostatic reduction.19 The possibility of an incomplete reduction, even with free flow of contrast medium into the small bowel in the face of a segment of nonviable terminal ileum, has been reported.20 In that reported case, a persistent filling defect in the cecum, residual mechanical small-bowel obstruc¬ tion, and poor evacuation of the colon were present. None of this occurred in our patient. Given the intraoperative findings of a stiff, strictured segment of ileum with mul¬ tiple surrounding adhesions in the area of perforation, in-
re¬
flects the time course of the development of stricture for¬ mation after ischemie insult. Given the perforation found at laparotomy, full-thickness bowel necrosis occurred in at least one area. A successful reduction of irreversibly ischemie ileum occurred in this case. This case demonstrates that ischemie stricture and sub¬ sequent perforation of an easily reduced intussusceptum may occur. The intussusception was met in the proximal sigmoid colon, implying a significant length of intussuscepted mesenteric vessels. The simultaneous obstruction of arterial inflow and venous return might be expected to allow ischemie necrosis at the lead point without extensive venous engorgement and swelling. Whether this rare complication is more likely after intussusceptions of greater than average length is unknown. Delayed recurrence of symptoms and roentgenographic evidence of small-bowel obstruction in patients who have undergone hydrostatic reduction of intussusceptions should prompt careful investigation of the terminal ileum for is¬ chemie changes if recurrent intussusception is not found. References 1. Campbell 19:293-296. 2. Mercer S,
tussuscipiens
JB. Contrast media in
intussusception. Pediatr Radiol. 1989;
Carpenter B. Mechanism of perforation occurring in the induring hydrostatic reduction of intussusception. Can J Surg.
1982;25:481-483. 3. Humphrey A, Ein SH, Mok PM. Perforation of the intussuscepted colon. AJR AmJ Roentgenol. 1981;137:1135-1138. 4. Ein SH, Mercer S, Humphrey A, MacDonald P. Colon perforation during attempted barium enema reduction of intussusception. J Pediatr Surg. 1981;16:313-315. 5. Eklof O, Hald J, Thomasson B. Barium peritonitis, experience of five pediatric cases. Pediatr Radiol. 1983;13:5-9. 6. Armstrong EA, Dunbar JS, Graviss ER, Martin L, Rosenkrantz J. Intussusception complicated by distal perforation of the colon. Radiology. 1980;
136:77-81. 7. Naylor HG. Hydrostatic perforation of intussusception. Br J Surg. 1970; 57:79-80. 8. Bashour SB, Pierce RJ. Perforation of normal colon by barium enema in an infant with gangrenous ileocolic intussusception. Am J Su1966;112: rg. 787-790. 9. Mahboubi S, Sherman NH, Ziegler MM. Barium peritonitis following attempted reduction of intussusception. Clin Pediatr. 1984;23:36-38. 10. Dibbell DG, Cohn R. Perforation of the colon during hydrostatic reduction. Am J Surg. 1966;111:715-717. 11. Bettenay F, Beasley SW, De Campo JF, Auldist AW. Intussusception: clinical prediction of outcome of barium reduction. Aust N Z J Surg. 1988; 58:899-902. 12. Bisset GS, Kirks DR. Intussusception in infants and children: diagnosis and therapy. Radiology. 1988;168:141-145. 13. Wang G, Liu S. Enema reduction of intussusception by hydrostatic pressure under ultrasound guidance: a report of 377 cases. J Pediatr Surg.
1988;23:814-818.
14. Kuta AJ, Benator RM. Intussusception: hydrostatic pressure equivalents for barium and meglumine sodium diatrizoate. Radiology. 1990;175:125-126. 15. Du JNH. Ten years' experience in the management of intussusception in infants and children by hydrostatic reduction. Can Med Assoc J. 1978; 119:1075-1076. 16. Leonidas JC. Treatment of intussusception with small bowel obstruction: application of decision analysis. AJR Am J Roentgenol. 1984;145:665-669. 17. Pues RA, Hyde I, Griffiths DM. The management of intussusception. Br J Radiol. 1988;61:187-189. 18. Touloukian RJ, O'Connell JB, Markowitz RI, Rosenfield N, Seashore JH, Ablow RC. Analgesic premedication in the management of ileocolic intussusception. Pediatrics. 1987;79:432-434. 19. Franken EA, Smith WL, Chernish SM, Campbell, JB, Fletcher BD, Goldman HS. The use of glucagon in hydrostatic reduction of intussusception: a double blind study of 30 patients. Radiology. 1983;146:687-689. 20. Fitch SJ, Magil HL, Benator RM, Parvey LS, Hixson SD. Pseudoreduction of intussusception: is ileal reflux and the end point? Gastrointest Radiol.
1985;10:181-183.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/04/2015
Complication After Successful John
F.
Valente, MD; William
D.
Barium Reduction of an
Rappaport, MD;
Intussusception
C. Peter Crowe, Jr, MD
Intussusception is a common cause of intestinal obstruction in infants. Use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical reduction of the intussusception. While failed hydrostatic reduction is an indication for surgical intervention, delayed complications of hydrostatic reduction have not been described. We present a case of ischemic stricture and perforation developing after the successful reduction of an intussusception. \s=b\
(Arch Surg. 1992;127:1252-1253) a barium mation
both
affords diagnostic confir¬ intestinal obstruction and possible op¬ Use of for ofhydrostatic of reduction enema
a
intussus¬ in cases portunity ception. Failed reduction or perforation during reduction are indications for immediate surgical intervention. Ad¬ vanced swelling and ischemia of the intussusceptum may
while easy reduction is indication that complications will not develop. We present a case of ischemie stricture and even¬ tual perforation after successful hydrostatic reduction of an intussusception. Proposed pathophysiologic mecha¬ nisms and a review of the literature are presented.
preclude hydrostatic reduction, often considered
an
REPORT OF A CASE A four-month-old boy presented to the University of Arizona Medical Center emergency room with a 24-hour history of inter¬ mittent abdominal pain and bloody stools. The patient was afebrile, with a pulse of 140 beats per minute and a white blood cell count of 13.6X109/L. A roentgenogram obtained after patient se¬ dation with meperidine hydrochloride and administration of a barium enema demonstrated an intussusception at the sigmoid colon, which reduced without unusual difficulty (Fig 1). The height of the barium column was kept at 90 cm, and reduction at¬ tempts were limited to periods of 3 minutes. The fluoroscopic procedure was ended when barium was noted to reflux freely into the terminal ileum. No roentgenographic evidence of perforation was noted, and results of the postreduction abdominal examina¬ tion were normal. One temperature spike of 38.3° C was noted on the evening of the reduction, but the patient rapidly became afebrile and was discharged from the hospital the next morning. He returned 3 days later because of vomiting and a tempera¬ ture of 39.3°C. Results of abdominal examination revealed no tenderness, mass, or peritoneal signs, and results of guaiac tests of the stool were negative. Roentgenograms of the abdomen were within normal limits, and the patient recovered rapidly. He was again discharged from the hospital but returned 2 weeks later with a temperature of 39.0°C, pulse of 190 beats per minute, vomiting, and severe diarrhea. His white blood cell count was 16.3 X10V L, with 0.76 segmented neutrophils, 0.20 band cells, and
Fig 1.—The original intussusception early in the course of reduction with a
barium
enema.
lymphocytes. The abdomen was quiet, distended, and slightly tender. Plain films showed dilated small bowel with multiple air-fluid levels. A roentgenogram obtained during
0.03
administration of a barium enema showed a normal colon and free reflux of contrast medium into multiple, dilated loops of the small bowel. No stricture, perforation, or area of obstruction was identified. Empiric treatment for sepsis with ceftazadime and ampicillin sodium was stopped after the patient became afebrile. Cultures of spinal fluid, blood, and urine taken on admission were negative for bacteria and other organisms 48 hours later. The pa¬ tient recovered and was tolerating a normal diet at discharge from the hospital. He returned 6 days later with vomiting, abdominal distension, and low-volume diarrhea. Abdominal roentgeno¬ grams indicated a possible small-bowel obstruction, and a barium enema was again administered. Roentgenography showed a nor¬ mal colon and reflux of contrast material into the dilated small bowel (Fig 2). At exploratory laparotomy, a segment of severely strictured terminal ileum about 12 cm proximal to the ileocecal valve was found. As surrounding adhesions were lysed, a sealed perforation in the strictured segment was uncovered. The in¬ volved bowel was resected and repaired with creation of a primary anastomosis. The patient recovered quickly and was discharged from the hospital 6 days after surgery. He was afebrile and tolerating a full diet. Results of pathologic examination of the resected segment revealed a fibrotic ischemie stricture. No further problems were encountered by the patient.
Accepted for publication September 26, 1991. From the Department of Surgery, University of Arizona Medical Cen-
ter, Tucson.
Reprint requests to 5402 E Grant Rd, Bldg K-D, Tucson, AZ 85712 (Dr
Crowe).
COMMENT Intestinal perforation during hydrostatic reduction of an intussusception is a rare complication, with a reported in
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/04/2015
complete reduction or recurrent intussusception seems unlikely. Our patient's delayed return to the hospital after reduction, with evidence of small-bowel obstruction,
Fig 2.—Some delay was encountered in showing reflux of barium into the small bowel. An area of narrow ileum was eventually identified at surgery.
cidence of .39%.1 Multiple sites of perforation are de¬ scribed, including the intussuscipiens,2'5 the colon distal to the intussusceptum,6 and some combination of perfora¬ tions that included the intussusceptum itself.610 Four fac¬ tors associated with a high rate of intestinal gangrene, a low rate of successful hydrostatic reduction, and an increased risk of perforation are (1) age greater than 2 years or less than 3 months; (2) duration of symptoms greater than 24 hours; (3) presence of small-bowel obstruction; and (4) dehydration greater than 5%.n The duration of vascu¬ lar compromise of the intussusceptum and the subsequent degree of swelling would seem to dictate both the risk of necrosis of the intussusceptum and perforation during hydrostatic reduction. Accepted practice limits the height of the barium column and the duration of reduction attempts to reduce the risk of perforation.1214 The presence of small-bowel obstruction is considered by some to indicate an advanced degree of swelling of the intussusceptum and an increased risk of perforation with hydrostatic reduction.915 Given the more recent realization that intraperitoneal barium is not necessarily associated with a bleak outcome5 and the application of decision analysis favoring the use of hydrostatic reduction in the presence of small-bowel obstruction,16 we use a barium enema as the first step in the treatment of all patients without signs of preexisting perforation. Using this ap¬ proach, a success rate of 71% has been reported.17 Premedication with meperidine hydrochloride has value,18 but we do not use glucagon during hydrostatic reduction.19 The possibility of an incomplete reduction, even with free flow of contrast medium into the small bowel in the face of a segment of nonviable terminal ileum, has been reported.20 In that reported case, a persistent filling defect in the cecum, residual mechanical small-bowel obstruc¬ tion, and poor evacuation of the colon were present. None of this occurred in our patient. Given the intraoperative findings of a stiff, strictured segment of ileum with mul¬ tiple surrounding adhesions in the area of perforation, in-
re¬
flects the time course of the development of stricture for¬ mation after ischemie insult. Given the perforation found at laparotomy, full-thickness bowel necrosis occurred in at least one area. A successful reduction of irreversibly ischemie ileum occurred in this case. This case demonstrates that ischemie stricture and sub¬ sequent perforation of an easily reduced intussusceptum may occur. The intussusception was met in the proximal sigmoid colon, implying a significant length of intussuscepted mesenteric vessels. The simultaneous obstruction of arterial inflow and venous return might be expected to allow ischemie necrosis at the lead point without extensive venous engorgement and swelling. Whether this rare complication is more likely after intussusceptions of greater than average length is unknown. Delayed recurrence of symptoms and roentgenographic evidence of small-bowel obstruction in patients who have undergone hydrostatic reduction of intussusceptions should prompt careful investigation of the terminal ileum for is¬ chemie changes if recurrent intussusception is not found. References 1. Campbell 19:293-296. 2. Mercer S,
tussuscipiens
JB. Contrast media in
intussusception. Pediatr Radiol. 1989;
Carpenter B. Mechanism of perforation occurring in the induring hydrostatic reduction of intussusception. Can J Surg.
1982;25:481-483. 3. Humphrey A, Ein SH, Mok PM. Perforation of the intussuscepted colon. AJR AmJ Roentgenol. 1981;137:1135-1138. 4. Ein SH, Mercer S, Humphrey A, MacDonald P. Colon perforation during attempted barium enema reduction of intussusception. J Pediatr Surg. 1981;16:313-315. 5. Eklof O, Hald J, Thomasson B. Barium peritonitis, experience of five pediatric cases. Pediatr Radiol. 1983;13:5-9. 6. Armstrong EA, Dunbar JS, Graviss ER, Martin L, Rosenkrantz J. Intussusception complicated by distal perforation of the colon. Radiology. 1980;
136:77-81. 7. Naylor HG. Hydrostatic perforation of intussusception. Br J Surg. 1970; 57:79-80. 8. Bashour SB, Pierce RJ. Perforation of normal colon by barium enema in an infant with gangrenous ileocolic intussusception. Am J Su1966;112: rg. 787-790. 9. Mahboubi S, Sherman NH, Ziegler MM. Barium peritonitis following attempted reduction of intussusception. Clin Pediatr. 1984;23:36-38. 10. Dibbell DG, Cohn R. Perforation of the colon during hydrostatic reduction. Am J Surg. 1966;111:715-717. 11. Bettenay F, Beasley SW, De Campo JF, Auldist AW. Intussusception: clinical prediction of outcome of barium reduction. Aust N Z J Surg. 1988; 58:899-902. 12. Bisset GS, Kirks DR. Intussusception in infants and children: diagnosis and therapy. Radiology. 1988;168:141-145. 13. Wang G, Liu S. Enema reduction of intussusception by hydrostatic pressure under ultrasound guidance: a report of 377 cases. J Pediatr Surg.
1988;23:814-818.
14. Kuta AJ, Benator RM. Intussusception: hydrostatic pressure equivalents for barium and meglumine sodium diatrizoate. Radiology. 1990;175:125-126. 15. Du JNH. Ten years' experience in the management of intussusception in infants and children by hydrostatic reduction. Can Med Assoc J. 1978; 119:1075-1076. 16. Leonidas JC. Treatment of intussusception with small bowel obstruction: application of decision analysis. AJR Am J Roentgenol. 1984;145:665-669. 17. Pues RA, Hyde I, Griffiths DM. The management of intussusception. Br J Radiol. 1988;61:187-189. 18. Touloukian RJ, O'Connell JB, Markowitz RI, Rosenfield N, Seashore JH, Ablow RC. Analgesic premedication in the management of ileocolic intussusception. Pediatrics. 1987;79:432-434. 19. Franken EA, Smith WL, Chernish SM, Campbell, JB, Fletcher BD, Goldman HS. The use of glucagon in hydrostatic reduction of intussusception: a double blind study of 30 patients. Radiology. 1983;146:687-689. 20. Fitch SJ, Magil HL, Benator RM, Parvey LS, Hixson SD. Pseudoreduction of intussusception: is ileal reflux and the end point? Gastrointest Radiol.
1985;10:181-183.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/04/2015
