Intussusception medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sargun Singh Walia M.B.B.S.[2]
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]
- Ultrasonographic Guidance
- In Ultrasonographic Guidance a saline enema is used to provide retrograde pressure.
- Pnematic enema(air) cannot be used as it interferes with ultrasound visualization.
- Sonographic signs of successful reduction
- Dissappearance of intussusception
- Appearance of water and bubbles in terminal ileum
- Fluoroscopic Guidance
- In a patient with ileocolic intussusception a filling defect is seen within the bowel lumen.
- When hydrostatic reduction is used, a low density filling defect is seen .
- When pneumatic reduction techniques are used, a higher density filling defect is visualized.
- A coiled spring pattern can be visualized when the contrast coats the outer surface of intussuscipien.
- Successful Reduction
- Indicated by free flowing contrast or air into the small bowel.
- Relief of symptoms occurs.
- Abdominal mass disappears.
- Lack of a filling defect in the cecum even without the reflux of contrast material denotes a complete reduction.[4]
- A repeat study is done if a post reduction filling defect is seen; it might be due to a residual edema around the ileocecal valve.[5]
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[6]
- 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.[7]
- 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.[8]
- Radiation exposure is lesser with pneumatic reduction when compared with hydrostatic enema.[9]
- 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.[10]
- Delayed Repeat Enema
- It refers to the second attempt of reduction in partly successful first attemp if the patient is stable.
- The time between attempts varies from 30 mins to a few hours.
- Some studies suggest that this approach can avoid surgical intervention.[11]
- This should not be attempted if the first attempt was completely unsuccessful.
- If first attempt was completely unsuccessful then surgical intervention should be done promptly.
Complications of Nonoperative Reduction
- Perforation of bowel (1% risk). [12]
- Mostly occurs in the distil part of intussusception.
- Often in the transverse colon.[13]
- Risk Factors
- Age: Less than 6 months.
- Long duration of symptoms.
- Small bowel obstruction
- Use of high pressures during reduction of intussusception. [14]
- Peritoneal irritation/free peritoneal air.
- Perforation caused by pneumatic reduction are less harmful than those caused by hydrostatic contrast materials.
- Excess air in the peritoneal cavity may cause respiratory compromise and may need needle decompression.[15]
Recurrence
- Recurrence of intussusception can occur in about 10% children after successful reduction.[16]
- 50% cases occur in the first 72 hours.
- Residual bowel edema and inflammation are a major cause of recurrence.
- Each recurrence should be considered as the first episode.
- Surgical management can be considered even if the patient is unstable.
- Glucocorticoids can be used to prevent recurrence of intussusception caused by lymphoid hyperplasia.
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.
- ↑ Shekherdimian S, Lee SL, Sydorak RM, Applebaum H (2009). "Contrast enema for pediatric intussusception: is reflux into the terminal ileum necessary for complete reduction?". J. Pediatr. Surg. 44 (1): 247–9, discussion 249–50. doi:10.1016/j.jpedsurg.2008.10.051. PMID 19159751.
- ↑ Ein SH, Shandling B, Reilly BJ, Stringer DA (1986). "Hydrostatic reduction of intussusceptions caused by lead points". J. Pediatr. Surg. 21 (10): 883–6. PMID 3783374.
- ↑ 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.
- ↑ Gorenstein A, Raucher A, Serour F, Witzling M, Katz R (1998). "Intussusception in children: reduction with repeated, delayed air enema". Radiology. 206 (3): 721–4. doi:10.1148/radiology.206.3.9494491. PMID 9494491.
- ↑ Sohoni A, Wang NE, Dannenberg B (2007). "Tension pneumoperitoneum after intussusception pneumoreduction". Pediatr Emerg Care. 23 (8): 563–4. doi:10.1097/PEC.0b013e31812eef31. PMID 17726417.
- ↑ Armstrong EA, Dunbar JS, Graviss ER, Martin L, Rosenkrantz J (1980). "Intussusception complicated by distal perforation of the colon". Radiology. 136 (1): 77–81. doi:10.1148/radiology.136.1.7384527. PMID 7384527.
- ↑ Daneman A, Alton DJ, Ein S, Wesson D, Superina R, Thorner P (1995). "Perforation during attempted intussusception reduction in children--a comparison of perforation with barium and air". Pediatr Radiol. 25 (2): 81–8. PMID 7596670.
- ↑ 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.
- ↑ Whitehouse JS, Gourlay DM, Winthrop AL, Cassidy LD, Arca MJ (2010). "Is it safe to discharge intussusception patients after successful hydrostatic reduction?". J. Pediatr. Surg. 45 (6): 1182–6. doi:10.1016/j.jpedsurg.2010.02.085. PMID 20620317.