Ileocolic and Ileo Ileocolic Intussusception

A review of the history of the management of intussusception shows that there has been a continuing evolution of management techniques [4]. Changes in management of this condition over the last 20 years have evolved despite the lack of large, controlled, prospective, comparative studies. This has caused some controversy and some criticism in the literature [1-3, 5]. Indeed, successful management can be achieved in one of a number of different ways [1-3, 5-15]. In future years, the management of intussusception will probably continue to evolve.

Diagnosis

Children presenting with ileocolic or ileo-ileocolic intussusception commonly do not present with the classical clinical triad of abdominal pain, red currant jelly stool and a palpable abdominal mass. Presentation may, therefore, be nonspecific. For this reason, the clinician often has to rely on imaging procedures to promptly and accurately diagnose or exclude intussusception. The diagnosis can be made by either sonography, plain abdominal radiographs or by contrast studies of the colon [7-11].

Sonography

It has been shown in many series that sonography is 100% accurate in depicting the presence or absence of the common type of ileocolic or ileo-ileocolic intussusceptions in children [1, 7-9]. These lesions have a characteristic sonographic appearance and are usually found just under the abdominal wall, most commonly on the right side of the abdomen (Fig. 1, 2). Sonography is the modality of choice for the evaluation of patients suspected of having an intussus-

Fig. 1. Sonograms of a child with ileocolic intussusception. a Transverse scan through the intussusception shows the typical target sign that can be easily detected just below the abdominal wall anteriorly. The characteristic of this target sign that enables the diagnosis of intussusception to be made is the crescent of echogenicity (white arrow), which represents the fat in the mesentery that has been drawn into the intussusception between the layers of the intus-susceptum. The black arrow indicates a hy-poechoic area representing an enlarged lymph node within the mesentery. b Sono-gram of the adjacent mesentery shows multiple nodes which have a normal echogenicity. The presence of the nodes in the mesentery reflects the lym-phoid hyperplasia that is commonly found in these patients

Fig. 2. Sonograms of child with ileocolic intussusception. a This intussusception shows a more complex target sign than shown in Figure 1. The echogenic fat in the mesentery is again noted (black arrow) between the layers of the intussusceptum. There is also fluid (F) trapped between the layers of the intussusceptum as a result of increased pressure and transudation of this fluid. The intussuscipiens is quite thinned (white arrows) and can be seen along the periphery of the intussusception also, separated from the outer layer of the intussusceptum by some fluid, b The color Doppler evaluation of the intussusception shows good flow to both the intussusceptum and the intussuscipiens along the periphery. It is difficult to predict whether an intussusception will reduce based on the ultrasound findings. The presence of fluid within the intussusception as shown in this patient suggests the intussusception may not reduce, whereas good blood flow to the intussusception suggests it will reduce easily. This intussusception was successfully reduced by pneumatic reduction

ception because it is a noninvasive, accurate procedure. An excellent review of the sonographic appearance of intussusception is provided in the article by del Pozo et al. [9].

Plain Abdominal Radiographs

There are some characteristic signs of an intussusception on a plain radiograph, including the meniscus sign, the target sign and, less commonly, a soft tissue mass [10, 11]

(Fig. 3, 4). Some institutions still rely on the plain radiograph for the diagnosis or exclusion of intussusception, but there is no study that has proven it to be as accurate as sonography [1, 10, 11]. In our institution we have relied on the plain radiograph only in those instances where there is a clinical consideration of peritonitis. In this clinical setting the plain radiograph is essential to exclude perforation, which is the major contraindication for attempted enema reduction.

Fig. 3. Child with ileocolic intussusception, which extended into the transverse colon. a Abdominal radiograph shows a gasless right hemi-abdomen due to the presence of the intussusception on the right. The black arrow indicates a soft tissue meniscus sign that represents the leading end of the intussusceptum in the transverse colon. b A hydrostatic contrast enema confirms the presence of the leading edge of the intussusceptum (arrow) in the transverse colon

Fig. 3. Child with ileocolic intussusception, which extended into the transverse colon. a Abdominal radiograph shows a gasless right hemi-abdomen due to the presence of the intussusception on the right. The black arrow indicates a soft tissue meniscus sign that represents the leading end of the intussusceptum in the transverse colon. b A hydrostatic contrast enema confirms the presence of the leading edge of the intussusceptum (arrow) in the transverse colon

Fig. 4. Child with ileocolic intussusception causing marked small bowel obstruction. Supine (a) and upright (b) abdominal radiographs show marked distention of the small bowel with gas and air fluid levels indicating obstruction. The appearance is nonspecific. When this degree of small bowel distention occurs the other plain radiographic signs such as the gasless right hemi-abdomen, meniscus sign and target sign are usually not visible. Diagnosis of the exact etiology of the obstruction will then depend more on detailed clinical information

Contrast Enema

Despite the proven value of sonography, some institutions still consider the contrast enema as the quickest and most cost-effective method of excluding or confirming the presence of intussusception [1]. This, however, represents a more invasive diagnostic procedure and requires radiation. In some series using the contrast enema for diagnosis, 50% of the enemas may be negative for intussusception [1]. Using sonography as the diagnostic modality enables one to avoid performing unnecessary contrast enemas in those patients without intussusception [1, 6].

Reduction

There are many series in the recent literature that have shown a reduction rate of intussusception varying from 80% to as high as 95% [2, 12-15]. These series have used either fluoroscopic or sonographic guidance for reducing the intussusception and the series have used either hydrostatic [barium, water soluble contrast, saline] or pneumatic reduction (Fig. 5, 6). The fact that different techniques have been used with similar success rates suggests that it is not important which technique is used. There has been much controversy in the last 20 years regarding which technique is the best, but because the various techniques are probably equal in terms of success rates, the most important factors are to keep the safety of the child in mind and that individual radiologists use the technique with which they are most comfortable and experienced.

Nonoperative reduction of an intussusception should only be attempted after the surgical team has evaluated the patient and the patient is clinically stable, well hydrated, has no evidence of peritonitis and has an intravenous line in place [2]. The major contraindications to performing the enema are the clinical findings of peri tonitis or shock or the signs of perforation on an abdominal radiograph [2].

We use pneumatic reduction because it is a simple, quick and clean technique [2]. The technique is also easy to learn. Furthermore, it has been shown clinically and experimentally that air enema is usually associated with smaller perforations and less fecal contamination of the peritoneum than hydrostatic enema [2, 16]. The advan-

Fig. 5. Air enema in child with ileocolic intussusception that has reached the splenic flexure. The air enema easily outlines the leading edge of the intussusceptum (I) in the region of the splenic flexure

Fig. 6. Air enema reduction of ileocolic intussusception. a Initial image from air enema shows the leading edge of the intussusceptum (arrow) in the rectosigmoid region. b Later during the enema, the intussusceptum has been reduced into the transverse colon (arrow). Note the distended distal colon with air. c This shows the intussusceptum (arrow) reduced into the mid ascending colon. Note the air-distended sigmoid colon. d Complete reduction of the ileocolic intussusceptum is achieved and air fills not only the colon but multiple loops of small bowel, confirming complete reduction, as no residual intussusceptum can be identified

Fig. 6. Air enema reduction of ileocolic intussusception. a Initial image from air enema shows the leading edge of the intussusceptum (arrow) in the rectosigmoid region. b Later during the enema, the intussusceptum has been reduced into the transverse colon (arrow). Note the distended distal colon with air. c This shows the intussusceptum (arrow) reduced into the mid ascending colon. Note the air-distended sigmoid colon. d Complete reduction of the ileocolic intussusceptum is achieved and air fills not only the colon but multiple loops of small bowel, confirming complete reduction, as no residual intussusceptum can be identified tage of sonography, however, is that it does not involve radiation. However, there is little information in the literature regarding the ease of recognition of perforation when using sonographic guidance. Even if one uses an air enema, sonography is an excellent modality to use for confirming reduction in those patients in whom it is difficult to determine whether reduction is complete on an air enema [2, 17]. Perforation rates should be under 1% [2, 16]. The surgical team must be available to intervene if complications occur during the enema.

In order to improve reduction rates, delayed, repeated reduction attempts can be used as long as the intussusception does move on the initial attempted reduction, and the child becomes asymptomatic and maintains stable vital signs [18]. It has been shown that this approach is a safe and effective technique with a good success rate [3, 18]. We have used this approach in approximately 15% of our patients with intussusception, achieving successful reduction in 50% of those intussusceptions not reduced on the first attempt [2, 18]. There does not appear to be a fixed optimal timing between attempts, and the delayed second or third attempts can be made several hours after the first attempt [18]. However, it is essential to maintain strict clinical observation of the child between attempts. We have not experienced any perforations using this approach. There is not enough data in the literature to determine the optimal number of attempts that may be tried and this should be weighed against the risk of unnecessary added radiation in each patient if fluoroscopic guidance is used.

Recurrent intussusception occurs in approximately 10% of all children who have successful initial reduction [2, 19]. Two thirds of children having a recurrence will only have one recurrence and most will occur within the first few days (or even hours) after the initial reduction. The remaining third might have multiple (even ten or more) recurrences and these may occur as isolated episodes or randomly in clusters, sometimes over several years [2, 19]. Children who have recurrent intussusceptions usually have easy reductions. It has been suggested that intramuscular injection of steroids may de crease early recurrence by ameliorating the lymphoid hyperplasia [2].

Spontaneous reduction of ileocolic and ileo-ileocolic intussusceptions may occur. However, in recent years spontaneous reduction of intussusception has been documented more frequently in some small bowel intussusceptions depicted incidentally by sonography or CT [3, 20] (Fig. 7). These are usually small bowel intussusceptions with no recognizable pathologic lead point and may be seen in symptomatic or asymptomatic patients.

Fig. 7. Sonogram in a child with malabsorption shows three incidental small bowel intussusceptions (1, 2, 3). In this image, the sonogram depicts intussusception number two to best advantage. Note the crescent of mesentery between the layers of the intussus-ceptum. Also note more anteriorly the punctate areas of increased echogenicity that represent air trapped between the outer layer of the intussusceptum and the thinned intussuscipiens along the periphery. b Longitudinal scan through the intussusception number two (arrows) shows the so-called sandwich sign with some echogenic mesentery noted centrally. The intussusceptum enters the intussuscipiens from the region of the white arrow. At the time of evaluation this patient had a small amount of ascites

Fig. 7. Sonogram in a child with malabsorption shows three incidental small bowel intussusceptions (1, 2, 3). In this image, the sonogram depicts intussusception number two to best advantage. Note the crescent of mesentery between the layers of the intussus-ceptum. Also note more anteriorly the punctate areas of increased echogenicity that represent air trapped between the outer layer of the intussusceptum and the thinned intussuscipiens along the periphery. b Longitudinal scan through the intussusception number two (arrows) shows the so-called sandwich sign with some echogenic mesentery noted centrally. The intussusceptum enters the intussuscipiens from the region of the white arrow. At the time of evaluation this patient had a small amount of ascites

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