Intussusception medical therapy: Difference between revisions
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* It is essential that nonoperative reduction be done at an institution with an experienced physician. | * It is essential that nonoperative reduction be done at an institution with an experienced physician. | ||
* A major complication of non-operative reduction is "'''Tension Pneumoperitoneum'''."<ref name="pmid23283408">{{cite journal |vauthors=Fallon SC, Kim ES, Naik-Mathuria BJ, Nuchtern JG, Cassady CI, Rodriguez JR |title=Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception |journal=Pediatr Radiol |volume=43 |issue=6 |pages=662–7 |year=2013 |pmid=23283408 |doi=10.1007/s00247-012-2604-y |url=}}</ref> | * A major complication of non-operative reduction is "'''Tension Pneumoperitoneum'''."<ref name="pmid23283408">{{cite journal |vauthors=Fallon SC, Kim ES, Naik-Mathuria BJ, Nuchtern JG, Cassady CI, Rodriguez JR |title=Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception |journal=Pediatr Radiol |volume=43 |issue=6 |pages=662–7 |year=2013 |pmid=23283408 |doi=10.1007/s00247-012-2604-y |url=}}</ref> | ||
'''Fluoroscopic or sonographic guidance''' | |||
* Performed using either :- | |||
** Hydrostatic (saline or contrast) | |||
** pneumatic (air) enema | |||
* Ultrasound is used more and more these days<ref name="pmid19308373">{{cite journal |vauthors=Applegate KE |title=Intussusception in children: evidence-based diagnosis and treatment |journal=Pediatr Radiol |volume=39 Suppl 2 |issue= |pages=S140–3 |year=2009 |pmid=19308373 |doi=10.1007/s00247-009-1178-9 |url=}}</ref> | |||
** It avoids exposure to ionizing radiation. | |||
** It has better detection of pathological lead points. | |||
** A disadvantage of using ultrasound technique is that it can only be used using hydrostatic reduction. | |||
* Fluoroscopy and ultrasound guided techniques have similar success rates of 80-95%.<ref name="pmid17308922">{{cite journal |vauthors=Ko HS, Schenk JP, Tröger J, Rohrschneider WK |title=Current radiological management of intussusception in children |journal=Eur Radiol |volume=17 |issue=9 |pages=2411–21 |year=2007 |pmid=17308922 |doi=10.1007/s00330-007-0589-y |url=}}</ref> | |||
'''Hydrostatic or pneumatic pressure enema''' | '''Hydrostatic or pneumatic pressure enema''' | ||
* This is treatment of choice in infants with ileocolic intussusception. | * This is treatment of choice in infants with ileocolic intussusception. | ||
| Line 18: | Line 28: | ||
** Risk of perforation - 1%. | ** Risk of perforation - 1%. | ||
** Bacteremia<ref name="pmid22929138">{{cite journal |vauthors=Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B |title=Intussusception: clinical presentations and imaging characteristics |journal=Pediatr Emerg Care |volume=28 |issue=9 |pages=842–4 |year=2012 |pmid=22929138 |doi=10.1097/PEC.0b013e318267a75e |url=}}</ref> | ** Bacteremia<ref name="pmid22929138">{{cite journal |vauthors=Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B |title=Intussusception: clinical presentations and imaging characteristics |journal=Pediatr Emerg Care |volume=28 |issue=9 |pages=842–4 |year=2012 |pmid=22929138 |doi=10.1097/PEC.0b013e318267a75e |url=}}</ref> | ||
* Pneumatic reduction | * '''Hydrostatic Reduction''' | ||
** A reservoir is kept 1 Meter above the patient. | |||
** This is done to maintain hydrostatic pressure. | |||
** The height is changed to manipulate the pressure needed to reduce the intussusception. | |||
** Initially barium contrast medium was used with fluoroscopy in North America and Europe but, it can cause electrolyte imbalance and peritonitis if perforation occurs.<ref name="pmid14634696">{{cite journal |vauthors=Daneman A, Navarro O |title=Intussusception. Part 2: An update on the evolution of management |journal=Pediatr Radiol |volume=34 |issue=2 |pages=97–108; quiz 187 |year=2004 |pmid=14634696 |doi=10.1007/s00247-003-1082-7 |url=}}</ref> | |||
** Water soluble contrast enema is preferred when using fluoroscopy as it reduces the risk of electrolyte imbalance and peritonitis if perforation occurs. | |||
** If ultrasonographic guidance is used with hydrostatic reduction then normal saline is used as enema. | |||
* '''Pneumatic reduction''' | |||
** It has slightly higher success rate with no increased risk of perforation. | ** It has slightly higher success rate with no increased risk of perforation. | ||
** A study showed success rate of 83 % in patients in whom pneumatic reduction was performed, and 70 % in whom hydrostatic reduction was performed.<ref name="pmid26496576">{{cite journal |vauthors=Sadigh G, Zou KH, Razavi SA, Khan R, Applegate KE |title=Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children |journal=AJR Am J Roentgenol |volume=205 |issue=5 |pages=W542–9 |year=2015 |pmid=26496576 |doi=10.2214/AJR.14.14060 |url=}}</ref> | ** A study showed success rate of 83 % in patients in whom pneumatic reduction was performed, and 70 % in whom hydrostatic reduction was performed.<ref name="pmid26496576">{{cite journal |vauthors=Sadigh G, Zou KH, Razavi SA, Khan R, Applegate KE |title=Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children |journal=AJR Am J Roentgenol |volume=205 |issue=5 |pages=W542–9 |year=2015 |pmid=26496576 |doi=10.2214/AJR.14.14060 |url=}}</ref> | ||
| Line 38: | Line 55: | ||
*** Water- soluble contrast is used to confirm.<ref name="pmid2392368">{{cite journal |vauthors=Stringer DA, Ein SH |title=Pneumatic reduction: advantages, risks and indications |journal=Pediatr Radiol |volume=20 |issue=6 |pages=475–7 |year=1990 |pmid=2392368 |doi= |url=}}</ref> | *** Water- soluble contrast is used to confirm.<ref name="pmid2392368">{{cite journal |vauthors=Stringer DA, Ein SH |title=Pneumatic reduction: advantages, risks and indications |journal=Pediatr Radiol |volume=20 |issue=6 |pages=475–7 |year=1990 |pmid=2392368 |doi= |url=}}</ref> | ||
* | ** | ||
* | |||
==References== | ==References== | ||
Revision as of 16:14, 27 December 2017
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American Roentgen Ray Society Images of Intussusception |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
Nonoperative reduction
- Patients with high suspicion of ileocolic intussusception but with normal vital signs and no signs of perforation can be treated non-operative reduction.
- It is essential that nonoperative reduction be done at an institution with an experienced physician.
- A major complication of non-operative reduction is "Tension Pneumoperitoneum."[1]
Fluoroscopic or sonographic guidance
- Performed using either :-
- Hydrostatic (saline or contrast)
- pneumatic (air) enema
- Ultrasound is used more and more these days[2]
- It avoids exposure to ionizing radiation.
- It has better detection of pathological lead points.
- A disadvantage of using ultrasound technique is that it can only be used using hydrostatic reduction.
- Fluoroscopy and ultrasound guided techniques have similar success rates of 80-95%.[3]
Hydrostatic or pneumatic pressure enema
- This is treatment of choice in infants with ileocolic intussusception.
- Done when no signs of perforation are present.
- Success rate is very high in children who have ileocolic intussusception.
- Volume is repleted in volume depleted children before using reduction enema.
- Patient is stabilized using iv fluids.
- Complications
- Risk of perforation - 1%.
- Bacteremia[4]
- Hydrostatic Reduction
- A reservoir is kept 1 Meter above the patient.
- This is done to maintain hydrostatic pressure.
- The height is changed to manipulate the pressure needed to reduce the intussusception.
- Initially barium contrast medium was used with fluoroscopy in North America and Europe but, it can cause electrolyte imbalance and peritonitis if perforation occurs.[5]
- Water soluble contrast enema is preferred when using fluoroscopy as it reduces the risk of electrolyte imbalance and peritonitis if perforation occurs.
- If ultrasonographic guidance is used with hydrostatic reduction then normal saline is used as enema.
- Pneumatic reduction
- It has slightly higher success rate with no increased risk of perforation.
- A study showed success rate of 83 % in patients in whom pneumatic reduction was performed, and 70 % in whom hydrostatic reduction was performed.[6]
- Radiation exposure is lesser with pneumatic reduction when compared with hydrostatic enema.[7]
- Air has lower density than thhe contrast media used in hydrostatic enema.
- Thus, it needs lesser exposure to generate an image with fluoroscopy.
- If fluoroscopy is used then pneumatic reduction is the preferred technique.
- If ultrasonography is used then pneumatic reduction cannot be used.
- Technique:-
- Foley catheter or rectal tube is inserted into rectum.
- A tight seal is formed using a tape around the tube or catheter.
- This is critical to prevent any leaks and maintain the pressure necessary for reduction.
- Fluoroscopy is used for monitoring the procedure.
- Excessive pressure is avoided and intussusceptum is gently pushed using air pressure.
- Colonic intraluminal pressure is maintained using a sphygmomanometer.
- Pressure should not exceed 120mm Hg.
- Carbon dioxide can be used instead of air as it is absorbed more rapidly from the gut and causes lesser discomfort.
- Successful reduction - A sudden rush of air occurs into terminal air with a sudden drop in intraluminal pressure and disappearance of intestinal mass.
- Water- soluble contrast is used to confirm.[8]
References
- ↑ Fallon SC, Kim ES, Naik-Mathuria BJ, Nuchtern JG, Cassady CI, Rodriguez JR (2013). "Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception". Pediatr Radiol. 43 (6): 662–7. doi:10.1007/s00247-012-2604-y. PMID 23283408.
- ↑ Applegate KE (2009). "Intussusception in children: evidence-based diagnosis and treatment". Pediatr Radiol. 39 Suppl 2: S140–3. doi:10.1007/s00247-009-1178-9. PMID 19308373.
- ↑ Ko HS, Schenk JP, Tröger J, Rohrschneider WK (2007). "Current radiological management of intussusception in children". Eur Radiol. 17 (9): 2411–21. doi:10.1007/s00330-007-0589-y. PMID 17308922.
- ↑ Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B (2012). "Intussusception: clinical presentations and imaging characteristics". Pediatr Emerg Care. 28 (9): 842–4. doi:10.1097/PEC.0b013e318267a75e. PMID 22929138.
- ↑ Daneman A, Navarro O (2004). "Intussusception. Part 2: An update on the evolution of management". Pediatr Radiol. 34 (2): 97–108, quiz 187. doi:10.1007/s00247-003-1082-7. PMID 14634696.
- ↑ Sadigh G, Zou KH, Razavi SA, Khan R, Applegate KE (2015). "Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children". AJR Am J Roentgenol. 205 (5): W542–9. doi:10.2214/AJR.14.14060. PMID 26496576.
- ↑ Kaplan SL, Magill D, Felice MA, Edgar JC, Anupindi SA, Zhu X (2017). "Intussusception reduction: Effect of air vs. liquid enema on radiation dose". Pediatr Radiol. 47 (11): 1471–1476. doi:10.1007/s00247-017-3902-1. PMID 28578475.
- ↑ Stringer DA, Ein SH (1990). "Pneumatic reduction: advantages, risks and indications". Pediatr Radiol. 20 (6): 475–7. PMID 2392368.