Pediatr Radiol (1992) 22:323-325

Pediatric Radiology 9 Springer-Verlag 1992

The current radiologic management of intussusception: a survey and review J. S. M e y e r Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, USA Received: 23 December 1991; accepted: 4 February 1992

Abstract. To determine what practices are being utilized in the m a n a g e m e n t of intussusception, a survey was sent to chairpersons of 64 Pediatric Radiology departments in the United States and Canada. T h e r e was a 92 % response rate. Barium is used in 97 % of departments andis the most commonly used contrast-agent in 64 %. Water-soluble contrast is used in 83 % of departments and air in 50 %. In high-risk patients, water soluble contrast is used in 7 1 % of departments, air in 28 % and barium in 24 %. Glucagon, pre-exam antibiotics, and pre -exam sedation are not use d regularly in a majority of departments. The radiologic m a n a g e m e n t of intussusception is m o r e varied than only a few years ago. Use of water-soluble contrast and air have increased, while barium use is less routine.

The radiologist plays a crucial role in the evaluation and treatment of intussusception. Having determined that a contrast e n e m a is necessary, selection of contrast-agent [1, 2] and administration of antibiotics [3], sedation [4], and glucagon [5, 6, 7] must be considered. Recently, contrastagent selection has been a major issue [8]. Air, which has been used in China [9, 10] and Argentina [11] for m a n y years, has b e e n added to t h e mix of contrast-agents employed in the United States and Canada [12-15]. In addition, reports in the literature have described using water [16] and air [17], in conjunction with ultrasound, to reduce intussusceptions. To determine what practices are presently being utilized in the United States and Canada, a survey was developed and sent to the Chairpersons of Pediatric Radiology departments. This article summarizes the results of that survey.

vey requested that answers be based on practices used by any and all members of the respondents' Radiology departments. Questions regarding contrast use in general (Table 1) and high risk cases (Table 2) were phrased so that the answers would include all contrast agents used for those purposes. High risk cases were defined as "cases in which the risk of perforation is felt to be increased". 59 responses (92% response rate) were received. 1 of the respondents did not work in a hospital where children are evaluated for intussusception. The results are based on the remaining 58 responses.

Results Tables 1 through 6 review the results. The table headings provide the exact phrasing of the individual questions. In 52 of 58 departments (90 %), m o r e than one contrastagent is used. In 23 of the 58 departments (40 %), barium, water soluble contrast and air are used. The contrast-agent used most often is air in 12, barium in 8 and water-soluble in 3. In high risk cases, 10 departments use only water-soluble contrast, 6 use only air, 6 use either air or water-soluble contrast, and 1 uses either barium or water-soluble contrast. In 23 of 58 departments (40 %), barium and water soluble contrast are used. The contrast-agent used most often is barium in 21 and water-soluble in 2. In high-risk cases, 18 departments use only water-soluble contrast, 4 use

Table 1. All types of contrast used (even if only rarely) Barium Water soluble Air Water

97% 83 % 50% 0%

(56) (48) (29) (0)

Methods

Table 2, Types of contrast used in high risk cases (i. e., cases in which the risk of perforation is felt to be increased)

In August 1991, a survey regarding the radiologic approach to the evaluation and treatment of intussusception was sent to sixty-four Pediatric Radiology chairpersons, based on the Society of Chairmen of Radiology in Children's Hospital (SCORCH) mailing list. The sur-

Water soluble Air Barium Water

71% 28% 24% 0%

(41) (16) (14) (0)

324 Table 3. Typeof contrast used most often

Barium Air Water soluble Water

64% (37) 24 % (14) 12 % (7) 0 % (0)

Table 4. Do your patients receive pre-exam sedation? Always 3 % (2) Almost always 7 % (4) Sometimes 45 % (26~) Never 45 % (26) aincludes three respondents who use sedation rarely or almost never and two who use sedation after initial attempts at reduction are unsuccessful Table 5. Do your patients receive pre-exam antibiotics?

Always 5 % (3) Almost always 3 % (2) Sometimes 7 % (4") Never 84 % (49) aincludes one respondent who uses antibiotics rarely Table 6. Do your patients receive pre-exam glucagon? Always 0% (0) Almost always 0% (0) Sometimes 10% (&) Never 90% (52) aincludes two respondents who use glucagon after initial attempts at reduction are unsuccessful

either barium or water-soluble contrast and 1 uses only barium. In 6 of the 58 departments (10 %), barium is used exclusively. In 4 of the 58 departments (7 %),barium and air only are used. The contrast-agent used most often is barium in 2 and air in 2. In high-risk cases, 2 departments use only air, 1 uses only barium, and 1 uses either air or barium. In 2 of the 58 departments (3 %), water soluble contrast and air are used. Both of these use water-soluble contrast most often. In high risk cases, 1 department uses only water-soluble contrast and i uses either air or water soluble contrast. None of the respondents uses either air or water soluble contrast exclusively and none use water as a contrast-agent in evaluating or treating intussusception.

Discussion

Barium continues as the most utilized contrast agent in intussusception management. Barium is used in 97 % of departments and the contrast agent used most often in 64 %. However, barium use is less routine than in 1989, when Campbell found 85 % of departments used barium as the routine contrast medium and 77.5 % used barium in cases with small bowel obstruction [1]. Presently, a high percentage of departments use water-soluble contrast and air

(83 % and50 %, respectively) and only 10 % use barium exclusively. In high risk cases, contrast-agent selection has shifted significantly. Only 24 % of departments presently use barium in a high -risk situation, 76 % of departments use water-soluble and/or air contrast in patients believed to be at an increased risk for perforation. The increased use of water soluble contrast, especially in high risk cases, likely reflects concern regarding barium peritonitis. Studies have demonstrated severe histologic reactions in animals following the injection of barium into their peritoneal cavities [18, 19]. However, these animals did not undergo immediate peritoneal lavage and antibiotic treatment which are implemented in clinical cases of bowel perforation. Clinical reports on barium peritonitis have differed in their recommendations; some authors [20] have supported barium and others [21] water-soluble contrast when performing enemas in high-risk patients. The increasing use of air partially reflects evidence that it is more effective than liquid contrast. Non-randomized studies [9,15,22] have shown reduction rates when using air to be 20 to 32 % higher than when using barium. One nonrandomized study found the effectiveness with barium and air to be 75 % and 76 %, respectively [14]. Nonetheless, these authors recommended the use of air due to evidence that it is cleaner, faster, and safer than liquid contrast [14]. There is at least one ongoing randomized, controlled study to further evaluate these questions (Buonomo C, personal communication). Thirty-two (55 %) of the responding departments use sedation. However, only 6 departments use sedation "always" or "almost always". This low number is surprising, as a study by Touloukian, et al showed a reduction rate 32 % higher in sedated (versus non-sedated) patients undergoing barium enemas for intussusception [4]. Relatedly, Collins, et al performed a non-controlled study in which patients who were not reduced after 3 attempts underwent an additional attempt at hydrostatic reduction under general anesthesia and achieved reduction in 68 % of patients [23]. A recent animal study suggested there may be benefit to not using sedation, at least in those patients undergoing enemas using air (Shiels W E et al., presented at the International Pediatric Radiology meeting, Stockholm, May 1991). A clinical, randomized study might help resolve this question about the effectiveness of sedation. Antibiotics are used in 9 (16 %) of the responding departments. Antibiotics may provide increased protection should bowel perforation occur. In instances of failed radiologic reduction, pre-exam antibiotics can minimize delay in preparing the patient for surgery [3]. However, no studies were found which either supported or disputed the use of antibiotics. It seems their use is dependent on the prevailing attitudes of the radiologist, attending surgeon and/or surgical department. Six (10%) respondents use glucagon "sometimes"; none use it regularly. The use of glucagon was an active topic of discussion and researchin the early 1980's. Two randomized studies [5, 7] did not demonstrate glucagon to be beneficial. However, another randomized study [6] found evidence that suggested, but did not prove a limited benefit to the use of glucagon. This group recommended using glucagon prior to performing a third attempt at hydrostatic re-

325 duction. It s h o u l d b e n o t e d , t h a t t h e p r e s e n t s u r v e y r e f e r r e d to " p r e - e x a m g l u c a g o n " a n d in the 6 d e p a r t m e n t s which use glucagon, 2 d e s c r i b e d using it a f t e r initial a t t e m p t s at r e d u c t i o n w e r e unsuccessful. M o r e d e p a r t m e n t s m a y use g l u c a g o n in this m a n n e r a n d the s u r v e y d e s i g n m a y h a v e falsely m i n i m i z e d t h e i r n u m b e r s . T h e r a d i o l o g i c m a n a g e m e n t o f i n t u s s u s c e p t i o n is m o r e v a r i e d t h a n o n l y a few y e a r s ago. B a r i u m is n o l o n g e r t h e c l e a r l y d o m i n a n t c o n t r a s t - a g e n t . W a t e r - s o l u b l e contrast a n d air a r e u s e d in a s u b s t a n t i a l n u m b e r o f d e p a r t m e n t s a n d t h e r e has b e e n a d e f i n i t e t r e n d a w a y f r o m t h e use of b a r i u m in h i g h - r i s k cases. G l u c a g o n , p r e - e x a m a n t i b i o tics, a n d s e d a t i o n h a v e t h e i r p r o p o n e n t s , b u t a r e n o t u s e d r e g u l a r l y in a m a j o r i t y of d e p a r t m e n t s .

Acknowledgements.The author thanks Kenneth E. Fellows, Jr., M. D. for his helpful comments and Janet Birkmann, Nisha Merchant and Valerie Tsafos for secretarial assistance.

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9. Sheh YH, Ting WH, Yeh HH (1964) Reduction of intestinal intussusception in infancy by colonic air insufflation. Chin Med J 83: 668~573 10. Zhang J, Wang Y, Wei L (1986) Rectal inflation reduction of intussusception in infants. J Pediatr Surg 21:30-32 11. Fiorito ES, Cuestas LAR (1959) Diagnosis and treatment of acute intestinal intussusception with controlled insufflation of air. Pediatrics 24:241-244 12. Gu L, Alton D J, Daneman A et al (1988) Intussusception reduction in children by rectal insufflation of air. A JR 150:1345-1348 13. Stringer DA, Ein SH (1990) Pneumatic reduction: advantages, risks and indications. Pediatr Radio120:475-477 14. Palder SB, Ein SH, Stringer DA, Alton D (1991) Intussusception: barium or air? J Pediatr Surg 26:271-275 15. Shiels II WE, Maves CK, Hedlund GL, Kirks DR (1991) Air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates. Radiology 181:169-172 16. Wang G, Liu S (1988) Enema reduction of intussusception by hydrostatic pressure under ultrasound guidance: a report of 377 cases. J Pediatr Surg 23:814-818 17. Todani T, Sato Y, Watanabe Y, Toki A, Uemura S, Urushihara N (1990) Air reduction for intussusception in infancy and childh ood: ultrasonographic diagnosis and management without X-ray exposure. Z Kinderchir 45:222-226 18. Cochran DQ, Almond CH, Shucart WA (1963) An experimental study of the effects of barium and intestinal contents on the peritoneal cavity. A JR 89:883-887 19. Ginai A Z (1985) Experimental evaluation of various available contrast agents for use in the gastrointestinal tract in cases of suspected leakage. Effects on peritoneum. Br J Radio158:969-978 20. Humphry A, Ein SH, Mok PM (1981) Perforation of the intussuscepted colon. AJR 137:1135-1138 21. Armstrong EA, Dunbar JS, Graviss ER, Martin L, Rosenkrantz J (1980) Intussusception complicated by distal perforation of the colon. Radiology 136:7%81 22. Phelan E, de Campo JF. Malecky G (1988) Comparison of oxygen and barium reduction of ileocolic intussusception. AJR 150: 1349-1352 23. Collins DL, Pinckney LE, Miller KE et al (1989) Hydrostatic reduction of ileocolic intussusception: a second attempt in the operating room with general anesthesia. J Pediatr 115:204-207 J. S. Meyer, MD Department of Radiology Children's Hospital of Philadelphia 34th Street and Civic Center Blvd. Philadelphia, PA 19104 USA

The current radiologic management of intussusception: a survey and review.

To determine what practices are being utilized in the management of intussusception, a survey was sent to chairpersons of 64 Pediatric Radiology depar...
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