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Intussuscepti on: A Guid e to Diagno si s and Intervention i n Children Genevieve Daftary, Harvard Medical School, Year III Gillian Lieberman, MD
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Intussusception: A Guide to Diagnosis

and Intervention in Children

Genevieve Daftary,

Harvard Medical School,

Year III

Gillian Lieberman, MD

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

2

The Anatomy of Intussusception

 

Intussusception occurs when

a segment of bowel, the

intussusceptum, telescopes

into a more distant segment

of bowel, the intussuscipiens

 

The most common type is

ileocolic (pictured here),

followed by ileoileocolic,ileoileas, and colocolic

Radiologic Clinics of North America 1997

www.yoursurgery/Intussusception.jpg

Intussuscipiens

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Radiologic Clinics of North America 1997; Pediatrics 20003

Demographics

 

Most common acute abdominal disorder of earlychildhood (56 children/ 100,000/ year in US)

 

Boys 4x’s more frequently than girls

 

Majority of patients between 3 mon and 3 yr  – Peak incidence between 5 and 9 months

 – 75% under 2 years

 

Seasonal peaks in spring and autumn

 

95% no pathologic lead point

 

5-10% recognizable lead point

 

Some evidence of significant attributable risk with

rotavirus vaccine administration

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Radiologic Clinics of North America 1996,19974

Etiologies of Intussusception

 

Idiopathic: no defined lead point –  Association with viral illness (adenovirus)

 – Hypertrophy of lymphoid tissue

 

Recognizable cause for lead point – Meckel’s diverticulum

 – Intestinal polyp

 – Enteric duplication

 – Lymphoma – Intramural hematoma

 –  Ameboma

 – Henoch-Schönlein purpura

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Radiologic Clinics of North America 1996, 19975

Clinical Presentation: VARIABLE

 

Intermittent, colicky cramping, pain

 

Later development of lethargy and somnolence

 

Vomiting (may be bile-stained)

 

Current jelly stool (blood and mucus)

 

Sausage shaped mass

 

Distention and tenderness

Classic Triad: abdominal pain, currant jelly stool,

palpable abdominal mass (<50%)

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Radiologic Clinics of North America 19976

Complications

Typically do not occur within the first 24 hrs…

 

Bowel obstruction

 

Intestinal ischemia

 

Perforation

 

Shock

 

Sepsis

 

Dehydration

…thus we have a window of opportunity in which

to treat and avoid surgery.

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

 AJR 2005; Rad Clinics of N Amer 19967

Overview of Screening Tools

 

 Abdominal Radiograph – Screen for other Dx’s and free air 

 – Can be safely omitted in the presence of US

 – 45% sensitivity

 

 Abdominal Sonography

 – Diagnostic accuracy near 100%, eval of reducibility, +/- lead

point, post reduction, ischemia

 

 Abdominal CT scan

 –  Accuracy approaching 100%; especially good for lead points

 – High cost, risk of radiation, and risk of sedation in children

make it unpractical

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston8

Patient One: Presentation

 

6 year old female

 

3 weeks ago: URI w/ fever, vomiting, diarrhea

(greenish, non-bloody), abdominal pain;

seemed to resolve after 3 days

 

1 week ago: increasingly lethargic and irritable,

w/vomiting and fever 

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston9

Patient One: Supine KUB

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston10

Patient One: Supine KUB

Paucity of Gason Right Side of

Abdomen

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Radilogic Clinics of North America 1996; Amer J Rad 200511

 Abdominal Radiograph

 

Signs of Intussusception – Soft tissue mass

 – Target sign: created by mesenteric fat

 –  Absence of cecal gas and stool

 – Meniscus sign: crescent of gas outlining intussusceptum – Loss of visualization of the tip of the liver 

 – Paucity of bowel gas

 

Poor sensitivity for dx of intussusception: 45%

 

May be useful to exclude other Dx

 

Determine presence of free air (contraindication to non-surgical reduction with contrast)

 

May be safely omitted if ultrasound is available

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

RadioGraphics 199912

Target & Meniscus Signs

i f

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

RadioGraphics 199913

Target & Meniscus Signs

G i D f MS3 N b 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston14

Patient One: Longitudinal Ultrasound

G i D ft MS3 N b 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston15

Patient One: Longitudinal Ultrasound

•TelescopingBowel

•Sandwich Sign/

Pseudokidney

G i D ft MS3 N b 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston16

Patient One: Axial Ultrasound

Gene ie e Daftar MS3 N b 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston17

Patient One: Axial Ultrasound

Doughnut/

Target Sign

Genevieve Daftary MS3 November 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston18

Patient One: Doppler Ultrasound

Genevieve Daftary MS3 November 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston19

Patient One: Doppler Ultrasound

•Blood flow

maintained 

•Rule out

ischemia ofinvolved bowel

Genevieve Daftary MS3 November 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Rad Clinics of N Amer 199720

 Abdominal Ultrasound

 

Replaced abdominal radiograph as primaryscreening modality

 

Sensitivity 98 -100%; specificity 88 -100%

 

 Appearance: outer hypoechoic regionsurrounding an echogenic center or multipleconcentric rings

 

Use Doppler to determine bowel ischemia;guides reduction decisions

 

Guide hydrostatic and pneumatic reduction

Genevieve Daftary MS3 November 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

RadioGraphics 199921

Ultrasound Cross-Sections

• A = intussuscipiens• B = everted intussusceptum

• C = central intussusceptum

• M = mesentery

• L = lymph nodes

• MS = contacting mucosal

surfaces

• S = contacting serosal

surfaces

Genevieve Daftary MS3 November 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

Children's Hospital Boston22

Patient One: Air Enema

 Normal bowel gas pattern: Spontaneous Reduction

Genevieve Daftary MS3 November 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

RadioGraphics 199923

Enemas

 

 Air, Liquid (saline, soluble contrast), Barium

 

 At one time used for Dx

 – Coiled spring: edematous mucosal folds of returning

intussusceptum outlined by contrast in colon – Meniscus sign

 

Now used mainly for Treatment/Reduction

 –  Avoid patient discomfort and risk of perforation

 – US better diagnostic tool & rule out tool

Genevieve Daftary, MS3 November 2005

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Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

RadioGraphics 199924

Meniscus & Coiled Spring Signs

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Genevieve Daftary, MS3 November 2005

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y,

Gillian Lieberman, MDNovember 2005

Radiology 2001; AJR 2004 & 2005; RadioGraphics 199926

Reduction Procedures cont.

 

Pneumatic reduction with fluoroscopic guidance – Quick, safe, clean (less fecal spillage), cheap

 – Radiation exposure, cannot depict lead points well, only see

intraluminal content

 

US-guided Pneumatic reduction

 – No radiation, confirm dx, highest successful reduction rate

(92%), quick and clean, can see lead points well (but not all)

 –  Air blocks US beam; difficult to see ileocecal valve andresidual intussusceptions

 

Surgical

Genevieve Daftary, MS3 November 2005

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y,

Gillian Lieberman, MDNovember 2005

Rad Clinics of N Amer 199627

Contraindications to Enema

 

Dehydration

 

Peritonitis

 

Shock

 

Sepsis

 

Free air on radiograph

Stabilize then treat surgically

Genevieve Daftary, MS3 November 2005

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y

Gillian Lieberman, MDNovember 2005

 AJR 200528

Complications of Reduction

 

Perforation – Overall rate of 0.8%

 – Similar rates for liquid and air enemas

 – Perforations with air usually smaller 

 

Recurrence

 –  Approximately 10%

 – Similar rates for liquid and air enemas

 – 50% will occur within 48 hrs

 – Repeat enemas are safe and effective

Genevieve Daftary, MS3 November 2005

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Gillian Lieberman, MD

 AJR 200529

Reduction Guidelines

 

Liquid Enema Rule of Three’s for Barium – 3 attempts

 – 3 min duration

 – Liquid enema bag 3 feet above fluoroscopy table (5feet if using water-soluble contrast)

 

 Air Enema

 – Ensure maximal pressures <120 mm Hg at rest

Genevieve Daftary, MS3 November 2005

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Gillian Lieberman, MD

 AJR 2002 & 200530

Success of Reduction Depend On…

 

Short duration of symptoms (<24-48 hrs)

 

 Adequate hydration

 

 Age (older than 3 months)

 

 Absence of small-bowel obstruction

 

 Absence of trapped intraperitoneal fluid

 

 Absence of enlarged lymph nodes in theintussusceptum

 

 Adequate blood flow

 

Location other than the rectum (rectum only 25%success)

Genevieve Daftary, MS3 November 2005

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Gillian Lieberman, MD

Children's Hospital Boston31

Patient Two: Presentation

 

2 year old male

 

Worsening vomiting and abdominal pain since the

morning of admission

 

Vomited 8x’s since morning, no bile, blood or stool

 

No fevers; no current or recent illness

 

No new foods, travel or trauma

 

Prior incident of vomiting which he recovered from onemonth prior 

 

 Abdomen soft, non-distended with active BS, diffusely

tender 

Genevieve Daftary, MS3 November 2005

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Gillian Lieberman, MD

Children's Hospital Boston32

Patient Two: Supine KUB

Patient does not have

classic triad of

intussusception

Use KUB to

consider other

diagnoses

Genevieve Daftary, MS3 November 2005

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Gillian Lieberman, MD

Children's Hospital Boston33

Patient Two: Supine KUB

•Paucity ofGas on Right

•Dilated

loops of

small bowel

•Looks likeobstruction

Genevieve Daftary, MS3

illi i bNovember 2005

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Gillian Lieberman, MD

Felson, Gamuts in Radiology34

DDx of Intestinal Obstruction in a Child

 

 Adhesions/Congenital peritoneal bands (Ladd’sbands

 

 Appendicitis

 

Hernia, incarcerated (internal or external)

 

Hirschsprung disease

 

Intussusception

Uncommonly: Crohn’s, fecal impaction, bezoar,Kawasaki , neoplasm, congenital stenosis, TB,volvulus, CF, Chronic granulomatous disease

Genevieve Daftary, MS3

Gilli Li b MDNovember 2005

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Gillian Lieberman, MD

Children's Hospital Boston35

Patient Two: Longitudinal Ultrasound

Use US to explore

 possible causes of

obstruction including

intussusception

Patient is not exposed

to any further radiationor the discomfort of

enema until further Dx

Genevieve Daftary, MS3

Gilli Li b MDNovember 2005

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Gillian Lieberman, MD

Children's Hospital Boston36

Patient Two: Sagittal Ultrasound

Dilated loops of bowel

Genevieve Daftary, MS3

Gilli Li b MDNovember 2005

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Gillian Lieberman, MD

Children's Hospital Boston37

Patient Two: Axial Ultrasound

Genevieve Daftary, MS3

Gillian Lieberman MDNovember 2005

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Gillian Lieberman, MD

Children's Hospital Boston38

Patient Two: Axial Ultrasound

•Doughnut/Target

Sign

•Patient’s obstructionis due to

intussusception

Genevieve Daftary, MS3

Gillian Lieberman MDNovember 2005

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Gillian Lieberman, MD

Children's Hospital Boston39

Patient Two: Doppler Ultrasound

Genevieve Daftary, MS3

Gillian Lieberman MDNovember 2005

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Gillian Lieberman, MD

Children's Hospital Boston40

Patient Two: Doppler Ultrasound

•Blood flow

maintained 

•Rule out bowelischemia

•Patient is safe to

receive an USguided air enema

with likelihood of

resolution

Genevieve Daftary, MS3

Gillian Lieberman MDNovember 2005

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Gillian Lieberman, MD

41

Review

 

Intussusception is COMMON in young children

 

Clinical presentation is variable underscoring the needfor a safe, quick, inexpensive screening tool such asultrasound

 

Ultrasound is extremely accurate in diagnosingobstruction; CT is more accurate in defining a leadpoint; abdominal radiographs can be helpful in

considering other diagnoses

 

Ultrasound guided air enema combines the safety ofultrasound (lack of radiation) with the effectiveness,ease, cleanliness, and safety of air enema in reducing

intussusception

Genevieve Daftary, MS3

Gillian Lieberman MDNovember 2005

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Gillian Lieberman, MD

42

What does intussusception look like on CT?

 

Since lead points are more likely in the adultpopulation, CT is done more frequently in this

population with suspected intussusception

 

Scroll through the following images to get asense of what intussusception looks like on CT

 

Notice the familiar target sign, also useful in

diagnosis using plain film and ultrasound!

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Genevieve Daftary, MS3

Gillian Lieberman MDNovember 2005

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Gillian Lieberman, MD

BIDMC PACS44

Intussusception on CT

Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

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Gillian Lieberman, MD

BIDMC PACS45

Intussusception on CT

Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

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Gillian Lieberman, MD

BIDMC PACS46

Intussusception on CT

Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

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,

BIDMC PACS47

Intussusception on CT

Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

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,

BIDMC PACS48

Intussusception on CT

Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

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,

49

References

 

 Applegate KE. Clinically Suspected Intussusception in Children: Evidence-Based

Review and Self-Assessment Module.  AJR 2005; 185: S175-S183.

 

Daneman A and Alton J. Intussusception: Issues and Controversies Related toDiagnosis and Reduction. Radiologic Clinics of North America 1996; 34: 743-756.

 

Del-Pozo G et al. Intussusception in Children: Current Concepts in Diagnosis andEnema Reduction. RadioGraphics 1999; 19: 299-319.

 

Felson. Gamuts in Radiology.

 

Koumanicou C et al. Sonographic Detection of Lymph Nodes in theIntussusception of Infants and Young Children.  AJR 2002; 178: 445-450.

 

Navarro O, Daneman A, Chae A. Intussusception: The Use of Delayed RepeatedReduction Attempts and the Management of Intussusceptions Due to Pathologic

Lead Points in Pediatric Patients.  AJR 2004; 182: 1169-1176.

 

Parashar UD et al. Trends in Intussusception-Associated Hospitalizations anddeaths Among US Infants. Pediatrics 2000; 106: 1413-1421.

 

Sivit CJ. Gastrointestinal Emergencies in Older Infants and Children. RadiologicClinics of North America 1997; 35: 865-877.

 

Yoon CH, Kim HJ, Goo HW. Intussusception in Children: US-guided PneumaticReduction—Initial Experience. Radiology 2001; 218: 85-88.

Genevieve Daftary, MS3

Gillian Lieberman, MDNovember 2005

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 Acknowledgements

 

Special Thanks To… – Melissa Gerlach, MD

 –  Anne-Catherine Kim, MD

 – Larry Barbaras, Webmaster 

 – Pamela Lepkowski

 – Gillian Lieberman, MD