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AJR 2005; 185:S175-S183
© American Roentgen Ray Society

Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module

Kimberly E. Applegate1

1 Indiana University Department of Radiology, Riley Hospital for Children, 702 Barnhill Dr., Room 1053, Indianapolis, IN 46202.

Received June 15, 2005; accepted after revision July 13, 2005.

 
Address correspondence to K. E. Applegate (kiappleg{at}iupui.edu).


Abstract
Top
 Abstract
Background
 Educational Objective
 Scenario 1
 Scenario 2
 Scenario 3
 Scenario 4
 Scenario 5
 References
 
Objective

This article uses case examples to review the current evidence for the management of children with clinically suspected intussusception.

Conclusion

In this educational module, we review the evidence for diagnostic and management strategies in children with clinically suspected intussusception.


Background
Top
 Abstract
 Background
Educational Objective
 Scenario 1
 Scenario 2
 Scenario 3
 Scenario 4
 Scenario 5
 References
 
Intussusception is an acquired invagination of the bowel into itself, usually involving both small and large bowel. Ileocolic intussusception is the most common cause of small-bowel obstruction in children and occurs in at least 56 children per 100,000 per year in the United States [1]. Intussusception is an emergent condition where delay in diagnosis is not rare and may result in bowel obstruction, venous congestion, subsequent bowel necrosis, and perforation. Asymptomatic and transient intussusception involving only the small bowel is seen increasingly on MDCT studies of the abdomen for other indications.


Educational Objective
Top
 Abstract
 Background
 Educational Objective
Scenario 1
 Scenario 2
 Scenario 3
 Scenario 4
 Scenario 5
 References
 
By the end of this activity, the participant will:

  1. Exercise, self-assess, and improve his or her understanding of the appropriate imaging for children with clinically suspected intussusception.
  2. Understand the current evidence regarding the use of sonography and air enema techniques in children with intussusception.
  3. Understand how the air enema technique is performed.


SELF-ASSESSMENT MODULE

This article is qualified by the American Board of Radiology (ABR) in meeting the criteria for self-assessment toward the purpose of fulfilling requirements in the ABR Maintenance of Certification. To obtain SAM credit, visit www.arrs.org and navigate to AJR Integrative Imaging. Log in using your six-digit member number, which is located next to your name on the AJR mailing label.

CONTINUING MEDICAL EDUCATION

This article is available for 1 hour of Category 1 CME credit. It is free to ARRS members and may be purchased by nonmembers for $10.00. Detailed information including objectives, disclosure information, and how to obtain CME credit can be found at www.arrs.org by selecting AJR Integrative Imaging.

 


Scenario 1
Top
 Abstract
 Background
 Educational Objective
 Scenario 1
Scenario 2
 Scenario 3
 Scenario 4
 Scenario 5
 References
 
Clinical History
A 10-month-old boy presents to the emergency department with a 1-day history of irritability, vomiting, and intermittent crying. His parents report that he previously had been well, that he takes no medications, and that they note no fever in their child. Physical examination showed a palpable right abdominal mass. An abdominal radiograph was unremarkable.


QUESTION 1

The pediatrician asks you whether another imaging test would help to sort out the cause of the baby's symptoms. Which of the following would you suggest?

  1. Upright or decubitus abdominal radiograph.
  2. Abdominal sonography.
  3. Barium enema.
  4. Abdominal CT scan.

 

Solution to Question 1
One of the most likely diagnoses in this age group is ileocolic intussusception. The peak age for idiopathic intussusception is 5–10 months and typically ranges up to 3 years [1, 2]. The most common clinical presentation is of an infant with crampy abdominal pain and irritability, vomiting, and bloody stools although signs and symptoms vary considerably and overlap with other abdominal conditions. Intussusception is the most common cause of small-bowel obstruction in children and occurs in at least 56 children per 100,000 per year in the United States [1]. It is an emergent condition where delay in diagnosis is not rare, and leads to an increased risk of bowel obstruction and necrosis [3–5].

The presence of a palpable abdominal mass in this scenario suggests the symptoms are not simply due to the more common pediatric diagnosis of viral gastroenteritis. Some articles have reported associations between intussusception and viral infection, particularly adenovirus, although the lack of seasonality suggests more than one pathogen [1].

Radiographs typically are ordered by the clinician to exclude other diagnoses. Even in experienced hands, abdominal radiographs have poor sensitivity (45%) for the detection of intussusception but may serve to screen for other diagnoses in the differential diagnosis, such as constipation, and for free peritoneal air [6]. The presence of a curvilinear mass within the course of the colon (the crescent sign), particularly in the transverse colon just beyond the hepatic flexure, is a nearly pathognomonic sign of intussusception. The absence of bowel gas in the ascending colon is one of the most specific signs of intussusception on radiographs [7]. However, small-bowel gas located in the right abdomen on radiographs may mimic ascending colon or cecal gas. There was no clinical indication of possible bowel perforation. Option A is not the best response.

Sonography increasingly is used by pediatric radiologists to diagnose either intussusception or alternative causes for a child's abdominal symptoms. Sonography also plays a role in the evaluation of reducibility of intussusception, the presence of a lead point mass, the potential incomplete reduction after enema (vs edema of the ileocecal valve), and of intussusception limited to small bowel [2, 8]. At this point in time, there are no reliable clinical prediction models that accurately can identify all patients with intussusception. The clinical triad of colicky abdominal pain, palpable abdominal mass, and current jelly stools is present in less than 50% of cases [2]. Therefore, option B is the best response.

Barium is no longer the liquid contrast medium of choice for reduction of intussusception due to the risk of barium peritonitis, infection, and adhesions if perforation occurs during the enema [9–12]. While iodinated contrast is considered a safer agent than barium [11, 12], one should be aware that it may produce fluid and electrolyte shifts if perforation occurs because contrast is absorbed from the peritoneum. Option C is not the best response.



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  		Fig. 1 —10-month-old boy with 1-day history of irritability, vomiting, and intermittent crying. Linear sonography of right mid lower abdomen shows target sign of bowel intussusception. There is bowel within bowel and thickened walls of these loops due to edema. No pathologic lead point is identified. [Image courtesy of Dr. Alan Daneman]

 
There is no doubt that a CT scan of the abdomen may diagnose intussusception and increasingly radiologists identify transient small-bowel intussusceptions in asymptomatic children and adults [13, 14]. However, the cost, radiation dose, and risk of sedation in these young children make it far less practical than sonography [3, 10, 15, 16]. Published sonography studies from single institutions suggest high accuracy, approaching 100% in experienced hands, with a sensitivity of 98–100% and specificity of 88–100% [17–20]. The optimal sonographic technique in this population is well described [15, 18, 21–23]. Option D is not the best response.

Conclusion
The patient was referred for sonography. The sonogram was performed with a high-frequency linear transducer for optimal visualization of the bowel. In the right midabdomen, within the peritoneal cavity, there was a complex mass with a target sign or donut appearance (Fig. 1). This appearance represents bowel within bowel, diagnostic of intussusception. The bowel walls were thickened and color Doppler showed flow within the walls. After the radiologists consulted the surgeon, the baby underwent successful iodinated contrast enema reduction of his intussusception (Fig. 2). The appearance of the bowel after reduction was normal, without identifiable lead point. He was then observed overnight in the hospital and discharged home the following morning.



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  		Fig. 2 —10-month-old boy with 1-day history of irritability, vomiting, and intermittent crying. Liquid enema radiograph shows the intussusception mass at mid transverse colon with contrast media distal to it. [Image courtesy of Dr. Alan Daneman]

 


Scenario 2
Top
 Abstract
 Background
 Educational Objective
 Scenario 1
 Scenario 2
Scenario 3
 Scenario 4
 Scenario 5
 References
 
Clinical History
A 14-month-old girl presents to the emergency department of your hospital with poor feeding and intermittent vomiting for 4 days. Her pediatrician had been treating her for presumed viral gastroenteritis. Her parents were worried when she became lethargic today and brought her to the emergency department. An abdominal sonogram shows a target sign of bowel within bowel in the epigastric region, leading to a diagnosis of ileocolic intussusception located at the midtransverse colon (Fig. 3). There was fluid within the lumen between the bowel loops.



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  		Fig. 3 —14-month-old girl with poor feeding and intermittent vomiting. Linear sonography with color Doppler of the right mid lower abdomen intussusception shows little blood flow within bowel wall. This sign is predictive of lower probability of enema reduction and higher risk of bowel necrosis (and bowel resection at surgery). [Image courtesy of Dr. Alan Daneman]

 


QUESTION 2

Which one of the following predicts a decreased probability of successful enema reduction in children with intussusception?

  1. Duration of signs and symptoms greater than 48 hr.
  2. Age of child greater than 6 months.
  3. Location of intussusception in hepatic flexure.
  4. Abdominal distention.

 

Solution to Question 2
The most important factor that decreases the reduction rate of enema is the duration of symptoms. The longer the duration of symptoms beyond 24 hr, the lower the likelihood of successful contrast enema reduction. Most literature suggests a significant delay is typically 48 hr of symptoms but some reports suggest 24 or 72 hr [2, 24]. Option A is the best response.

Age less than 3 months is associated with both a higher perforation rate and a lower rate of successful reduction, as is dehydration and small-bowel obstruction. These situations are less common [2, 6, 24–26]. The lethargy, as seen in this child, is not rare when they become dehydrated. It is important to correct the child's dehydration to improve the enema intussusception reduction rate. Option B is not the best response.


QUESTION 3

In which of the following situations is enema reduction of an intussusception not contraindicated?

  1. Pneumoperitoneum.
  2. Shock.
  3. Peritonitis.
  4. Small-bowel obstruction.

QUESTION 4

What is the perforation rate during enema reduction of intussusception by experienced radiologists?

  1. Less than 1%.
  2. 2%.
  3. 5%.
  4. Greater than 5%.

QUESTION 5

Which of the following enema techniques provides the highest intussusception reduction rate?

  1. Barium enema.
  2. Iodinated contrast enema.
  3. Air enema.
  4. Sonography-guided saline enema.

 

An intussusception encountered in the rectum has only a 25% reduction rate [2, 6, 24–26], but intussusceptions encountered elsewhere in the colon, including the hepatic flexure, can be expected to have a successful reduction rate of approximately 80%. The most common location to encounter idiopathic intussusception is at the hepatic flexure. Option C is not the best response.

Abdominal distention may be seen in many children with intussusception but it is not known to decrease the enema success rate unless there is small-bowel obstruction. Option D is not the best response.

Solution to Question 3
All children should have surgical consultation before enema to assess for signs of peritonitis precluding enema, to identify children who are found to have perforation, and for postreduction management. Before enema reduction, dehydration should be treated with IV fluid resuscitation. If the child is clinically unstable, he or she should not undergo enema. Children with evidence of peritonitis, shock, sepsis, or free air on abdominal radiographs are not candidates for enema. These children should be stabilized and treated surgically. Therefore, options A, B, and C are not the best responses.

The presence of small-bowel obstruction reduces the probability of successful enema reduction but it is not a contraindication to performing the enema. Option D is the best response.

Solution to Question 4
The most important potential complication of enema is bowel perforation. The risk of perforation depends on each radiologist's patient population and technique. Several reports in both pig models and children suggest that there may be preexisting focal perforation in the necrotic intussuscipiens or, less commonly, the intussusceptum, that are rarely radiographically apparent as free air [9, 24, 25, 27–30]. The most common site is at or just proximal to the intussusception in the transverse colon [30]. Perforations with air tend to be smaller than those with liquid enema although the overall perforation rates are similar [9, 28].

In a summary of the literature, there are 66 published studies with an overall mean perforation rate 0.8% (see Table 1) (Applegate KE, unpublished data). Option A is the best response. Options B, C, and D are not the best responses.


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  		TABLE 1 Summary of Published Intussusception Enema Reduction Rates and Perforation Rates

 

Solution to Question 5
The ultimate goal that radiologists should strive for is nonoperative reduction for all children with idiopathic intussusception (approximately 95% of cases) [24]. Yet this goal remains elusive due to delays in presentation. Radiologists should strive for enema reduction rates of at least 80%.

There is only one direct comparison of air and liquid enema reduction rates in children with intussusception. Meyer and colleagues [31] randomized 101 children and reported similar success rates of 76% for air and 63% for barium enema. However, the statistical power may have been inadequate to detect a true difference. In addition, the trial used sedation and had lower reduction rates than those not using sedation so the authors abandoned the use of sedation after this study.

The air enema is considered superior at reduction, cleaner (based on appearance of peritoneal cavity at surgery when perforation occurs), safer, and faster, with less radiation when compared with liquid enema [9, 11, 16, 32–34]. In a summary of the literature, there were 32 studies using air reduction and 39 using liquid (barium, iodinated contrast, saline, or water) reduction techniques (Applegate KE, unpublished data). Air enema studies had significantly higher mean reduction rates as compared with liquid enema studies, 82% versus 68% (p < 0.001) (Table 2). Option C is the best response. Options A, B, and D are not the best responses.


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  		TABLE 2 Summary Comparison of Air Versus Liquid Contrast Enema Reduction and Perforation Rates

 

The air enema technique is well described in the literature [16, 33, 35]. Briefly, the enema tip should be placed within the child's rectum and taped in place with abundant tape. The child is placed in a prone position to allow the radiologist or assistant to squeeze the buttocks closed and prevent air from leaking. Air is rapidly insufflated into the colon under fluoroscopic observation. Once the intussusception is encountered (Fig. 4), its reduction is followed fluoroscopically until it is completely reduced. Air should flow freely from the cecum into the distal small bowel loops to signify complete reduction. One critical safety issue is to keep air pressure below a maximum limit of 120 mm Hg to avoid the risk of perforation [9, 10, 16].



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  		Fig. 4 —14-month-old girl with poor feeding and intermittent vomiting. Appearance of intussusception at air enema reduction. Intussusception is encountered at mid transverse colon, with baby in supine position (arrow). The more proximal bowel that herniates into more distal bowel is called intussusceptum and the bowel that contains it is called intussuscipiens. Goal of enema should be successful reduction in approximately 80% of such cases.

 

There is no direct evidence supporting the commonly taught "Rule of Threes" regarding the liquid enema technique, particularly the appropriate height of the enema bag [24, 36]. This general guideline for the liquid enema technique, often taught to radiology residents, is 3 attempts of 3 min duration, with the liquid enema bag at 3 feet above the fluoroscopy table.



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  		Fig. 5 —14-month-old girl with poor feeding and intermittent vomiting. Trapped intraperitoneal fluid on sonography. Image shows anechoic fluid (curved arrow) between the two bowel walls of the intussusception. This sign is associated with lower probability of successful enema reduction and higher probability of bowel resection at surgery due to necrosis.

 
The superior air enema reduction rate may be due to the presence of higher intraluminal pressure for air as compared with standard hydrostatic reduction [37, 38]. The recurrence rates for air versus liquid enema reductions do not differ (both are approximately 10%). Neither sedation nor medications (glucagon) increase the enema success rate.

Conclusion
This girl had a long duration of symptoms (> 4 days), making it less likely that the enema will successfully reduce her intussusception. Her sonogram made the correct diagnosis, did not identify a pathologic lead point, and in addition provided further information about the probability of enema reduction. The probability of bowel necrosis and enema failure is suggested when color Doppler images show no flow within the intussusception bowel wall or when there is trapped intraperitoneal fluid. The sonogram showed the presence of trapped intraperitoneal fluid within the intussuscipiens. The girl in our case had an unsuccessful enema and underwent surgical reduction with bowel resection.

Del-Pozo and colleagues [8] reported sonography in 145 children with intussusception and found that fluid seen inside the intussusception represented trapped peritoneal fluid and was associated with significantly fewer reductions on enema, and bowel ischemia at surgery (Fig. 5) [39].

Lack of color Doppler signal in the intussuscepted bowel wall has suggested bowel ischemia in several small series [40–42]. The presence of free intraperitoneal fluid in small or moderate amounts is present in approximately half of children with intussusception and does not predict a lower enema success rate [22].


Scenario 3
Top
 Abstract
 Background
 Educational Objective
 Scenario 1
 Scenario 2
 Scenario 3
Scenario 4
 Scenario 5
 References
 
Clinical History
The 10-month-old boy presented in Scenario 1 returns to your hospital's emergency department the day after successful enema reduction of his intussusception. His parents note similar symptoms to his prior presentation, including intermittent crying, vomiting, and irritability.


QUESTION 6

Which of the following is the most appropriate management for this boy?

  1. Abdominal radiographs.
  2. CT.
  3. Enema.
  4. Surgical reduction of recurrent intussusception.

QUESTION 7

What percentage of intussusceptions recurs following reduction by enema?

  1. ≤ 1%.
  2. 10%.
  3. 5%.
  4. ≥ 15%.

 

Solution to Question 6
This baby boy had a recent intussusception and now has symptoms suggesting a recurrence. Fifty percent of children who develop recurrent intussusception will present within 48 hr, although recurrences have been reported up to 18 months later [11].

If the clinical concern is for recurrent intussusception, there is little added information gained by abdominal radiography. Radiographs may show alternative diagnoses or obstruction but if the clinical concern is for recurrent intussusception, sonography is the most reliable test. Option A is not the best response.

CT to detect intussusception is not currently recommended unless there is concern for a pathologic lead point that could not be identified on sonography. Option B is not the best response.

There is no question that sonography to screen for intussusception is a valid imaging test. However, in this situation, the pretest probability is high for the diagnosis of intussusception and, therefore, enema would be the reasonable next step. Repeat enema is both safe and effective in recurrent intussusception [2, 10, 43, 44] as long as the child remains clinically stable. Option C is the best response.

If the patient is not clinically stable or has signs of peritonitis, then the patient should undergo surgical reduction. Since our patient presents without concerns for perforation or peritonitis, he can undergo enema reduction of a recurrent intussusception. Option D is not the best response.

Solution to Question 7
Intussusception recurrence rates average 10% in large series, with a range of 5.4% to 15.4%, [2, 45], regardless of air versus liquid enema technique. The recurrence rates are less than or equal to 5% when surgical reduction is performed, presumably due to the development of adhesions [43]. Option B is the best response. Options A, C, and D are not the best responses.


QUESTION 8

Which statement is TRUE regarding recurrent intussusception?

  1. The majority of cases will have a pathologic lead point.
  2. The rate of successful image-guided reduction is less than 50%.
  3. Attempts at reduction are more likely to result in perforation than in nonrecurring cases.
  4. In the absence of specific contraindications, image-guided reduction should be attempted.

 

Solution to Question 8
The risk of a pathologic lead point in children with recurrent intussusception is low. In one large series of 763 children with intussusception, 8% of those with recurrent intussusception had a pathologic lead point (5/69) [11]. This risk is only slightly higher than the reported 5–6% incidence of pathologic lead points at first presentation of intussusception [2]. No predictive clinical factors have been identified for pathologic lead point in these children with recurrent intussusception. No clear risk factors are known for why some children have recurrences although some do have a focal pathologic lead point. Those with diffuse bowel abnormalities (diffuse pathologic lead points) and ileocolic intussusception, such as children with cystic fibrosis, Henoch-Schönlein purpura, or celiac disease, may be treated with enema reduction more aggressively than those with focal pathologic lead points to avoid surgery. Option A is not the best response.

Reduction with air enema was possible in up to 95% of recurrences in the largest reported experience and did not have a higher perforation rate than that reported for nonrecurring intussusception [2, 11]. Options B and C are not the best responses.

Repeat enema is both safe and effective in recurrent intussusception [2, 10, 43, 44] as long as the child remains clinically stable. Option D is the best response.

Conclusion
The baby had recurrent ileocolic intussusception that was encountered in the hepatic flexure region at enema. This is the most common location to encounter the idiopathic intussusception. It was successfully reduced with fluoroscopic-guided enema. Again, the baby was observed in the hospital for the day and when he showed that he could feed well without vomiting, he was discharged home.


Scenario 4
Top
 Abstract
 Background
 Educational Objective
 Scenario 1
 Scenario 2
 Scenario 3
 Scenario 4
Scenario 5
 References
 
Clinical History
A 2-year-old girl has a 1-week history of dark-colored (tarry) stools and abdominal pain. Her parents take her to the emergency department when she develops vomiting and worsening abdominal pain. She is mildly anemic and her abdominal radiographs are normal. An abdominal sonogram shows a target sign within the peritoneal cavity diagnostic of an intussusception in the right lower quadrant. This girl undergoes an air enema with successful reduction of the intussusception.


QUESTION 9

The pediatrician is concerned that she might have a Meckel's diverticulum because of her unexplained anemia. Which of the following is the best imaging test to recommend for her?

  1. 99mTc pertechnetate study.
  2. CT scan.
  3. Repeat sonogram.
  4. Small-bowel follow through.

 

Solution to Question 9
Approximately 5–6% of intussusceptions in children are caused by pathologic lead points that are due to either focal masses or diffuse bowel wall abnormality. The most common focal pathologic lead points are (in decreasing order of incidence) Meckel's diverticulum, duplication cyst, polyp, and lymphoma [2, 3, 46]. The relative prevalence of pathologic lead points with intussusception is higher in children over the age of 3 years, particularly for lymphoma [2].

Most symptomatic Meckel's diverticula, particularly those that are associated with intestinal bleeding, will have ectopic gastric mucosa. The imaging test with the highest overall accuracy in the detection of Meckel's diverticulum is the nuclear medicine pertechnetate study. It has a reported 85% sensitivity, 95% specificity, and accuracy of 90% [47]. Option A is the best response.

The detection of lead points by imaging remains problematic, and there are no studies that report the accuracy of CT scan to diagnose Meckel's diverticulum. Since children with Meckel's diverticulum are often young enough to require sedation for the CT scan, it carries more risk, cost, and radiation exposure. Option B is not the best response. Sonography is the noninvasive standard of reference. Sixty-six percent of pathologic lead points may be identified at sonography and 40% of pathologic lead points may be diagnosed on liquid enema [3, 48]. Air enema has a lower rate of detection of pathologic lead points of 11% [49]. However, sonography is not the preferred test for diagnosing a Meckel's diverticulum. Option C is not the best response.

While the small-bowel follow through may detect a Meckel's diverticulum, it is well known for missing this diagnosis. Option D is not the best response.



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  		Fig. 6A —2-year-old girl with Meckel's diverticulum. Shows nuclear medicine 99mTc pertechnetate scan of child with abnormal tracer uptake in midabdomen, just to right of midline (arrow), that was later shown at surgery to be hemorrhagic Meckel's diverticulum.

 



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  		Fig. 6B —2-year-old girl with Meckel's diverticulum. Intraoperative image shows surgical specimen of the hemorrhagic Meckel's diverticulum (arrow). [Image 6B courtesy of Dr. Alan Daneman]

 
Conclusion
In our case scenario, the girl had a successful enema reduction of her intussusception. Later, the girl underwent a technetium pertechnetate study that showed tracer uptake in the right lower abdomen (Fig. 6A). At surgery, she had resection of an inflamed Meckel's diverticulum (Fig. 6B).

Some surgeons may request enema reduction in children with known pathologic lead points; even if it only partially reduces, it may decrease the laparotomy incision size [24, 44, 50, 51].


Scenario 5
Top
 Abstract
 Background
 Educational Objective
 Scenario 1
 Scenario 2
 Scenario 3
 Scenario 4
 Scenario 5
References
 
Clinical History
A 12-year-old boy presents to the emergency department with a 2-week history of increasing abdominal pain, fatigue, weight loss, and new vomiting. His abdominal radiograph shows no obstruction or free peritoneal air, but suggests a small-bowel ileus. After his blood tests reveal anemia, he undergoes an abdominal sonogram and then CT (Fig. 7). Both revealed a small-bowel intussusception in the pelvis with free peritoneal fluid and a separate large retroperitoneal mass in the left upper quadrant.



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  		Fig. 7 —12-year-old boy with Burkitt's lymphoma. CT scan of pelvis shows small-bowel intussusception in right pelvis (curved arrow) within ileum. In separate ileal loop, there is tumor caking of wall of bowel (straight arrow) and some ascites.

 
Conclusion
While sonography will not detect all pathologic lead points, the risk of missing a pathologic lead point without other signs or symptoms to guide management is unlikely. Ein [46] reviewed 1,200 intussusception cases covering 40 years' experience at one institution to analyze this risk. When the enema failed to detect lymphoma as a pathologic lead point, Ein noted the presence of clinical signs of illness of greater than 1 week, patient age greater than 3 years, weight loss, and palpable mass in all of these children. In our scenario, the boy was older than typically seen with idiopathic intussusception and he had symptoms and signs that suggested a more serious diagnosis.

The CT scan showed a large mass in the retroperitoneum of the left upper quadrant, tumor caking of the bowel wall of the distal ileum, and two small-bowel intussusceptions (Fig. 7). A biopsy of the large mass revealed Burkitt's lymphoma. A few days after chemotherapy, this tumor had markedly reduced in size and the intussusceptions resolved.


References
Top
 Abstract
 Background
 Educational Objective
 Scenario 1
 Scenario 2
 Scenario 3
 Scenario 4
 Scenario 5
 References
 

  1. Parashar UD, Holman RC, Cummings KC, et al. Trends in intussusception-associated hospitalizations and deaths among US infants. Pediatrics 2000;106 : 1413-1421[Abstract/Free Full Text]
  2. Navarro O, Daneman A. Intussusception part 3: diagnosis and management of those with an identifiable or predisposing cause and those that reduce spontaneously. Pediatr Radiol2004; 34:305 -312[CrossRef][Medline]
  3. Daneman A, Navarro O. Intussusception part 1: a review of diagnostic approaches. Pediatr Radiol2003; 33:79 -85[Medline]
  4. Berlin L. Reducing the intussuscepted colon. AJR 1998; 170:1161 -1163[Free Full Text]
  5. Meier DE, Coln CD, Rescorla FJ, OlaOlorun A, Tarpley JL. Intussusception in children: international perspective. World J Surgery 1996; 20:1035 -1039;discussion 1040
  6. Sargent MA, Babyn P, Alton DJ. Plain abdominal radiography in suspected intussusception: a reassessment. Pediatr Radiol 1994; 24:17 -20[CrossRef][Medline]
  7. West KW, Stephens B, Vane DW, Grosfeld JL. Intussusception: current management in infants and children. Surgery1987; 102:704 -710[Medline]
  8. Del-Pozo G, Gonzalez-Spinola J, Gomez-Anson B, et al. Intussusception: trapped peritoneal fluid detected with US: relationship to reducibility and ischemia. Radiology1996; 201:379 -383[Abstract/Free Full Text]
  9. Shiels WE II, Kirks DR, Keller GL, et al. John Caffey award. Colonic perforation by air and liquid enemas: comparison study in young pigs. AJR 1993; 160:931 -935[Abstract/Free Full Text]
  10. Kirks DR. Diagnosis and treatment of pediatric intussusception: how far should we push our radiologic techniques? Radiology 1994;191 : 622-623[Free Full Text]
  11. Daneman A, Alton DJ, Ein S, Wesson D, Superina R, Thorner P. Perforation during attempted intussusception reduction in children: a comparison of perforation with barium and air. Pediatr Radiol 1995; 25:81 -88[CrossRef][Medline]
  12. Hernanz-Schulman M, Foster C, Maxa R, et al. Experimental study of mortality and morbidity of contrast media and standardized fecal dose in the peritoneal cavity. Pediatr Radiol 2000;30 : 369-378[CrossRef][Medline]
  13. Strouse PJ, DiPietro MA, Saez F. Transient small-bowel intussusception in children on CT. Pediatr Radiol2003; 33:316 -320. Epub 2003 Feb 26[Medline]
  14. Sandrasegaran K, Kopecky KK, Rajesh A, Lappas J. Proximal small bowel intussusception in adults: CT appearance and clinical significance. Abdom Imaging 2004;29 : 653-657[CrossRef][Medline]
  15. Henrikson S, Blane CE, Koujok K, Strouse PJ, DiPietro MA, Goodsitt MM. The effect of screening sonography on the positive rate of enemas for intussusception. Pediatr Radiol 2003;33 : 190-193[Medline]
  16. Shiels WE II, Maves CK, Hedlund GL, Kirks DR. Air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates. Radiology 1991;181 : 169-172[Abstract/Free Full Text]
  17. Harrington L, Connolly B, Hu X, Wesson DE, Babyn P, Schuh S. Ultrasonographic and clinical predictors of intussusception. J Pediatr 1998; 132:836 -839[CrossRef][Medline]
  18. Pracros JP, Tran-Minh VA, Morin de Finfe CH, Deffrenne-Pracros P, Louis D, Basset T. Acute intestinal intussusception in children: contribution of ultrasonography (145 cases). Ann Radiol (Paris)1987; 30:525 -530[Medline]
  19. Shanbhogue RLK, Hussain SM, Meradji M, Robben SGF, Vernooij JEM, Molenaar JC. Ultrasonography is accurate enough for the diagnosis of intussusception. J Pediatr Surgery 1994;29 : 324-328[CrossRef][Medline]
  20. Verschelden P, Filiatrault D, Garel L, et al. Intussusception in children: reliability of US in diagnosis—a prospective study. Radiology 1992;184 : 741-744[Abstract/Free Full Text]
  21. Lee HC, Yeh HJ, Leu YJ. Intussusception: the sonographic diagnosis and its clinical value. J Pediatr Gastroenterol Nutr1989; 8:343 -347[Medline]
  22. Swischuk LE, Hayden CK, Boulden T. Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney signs. Pediatr Radiol 1985;15 : 388-391[CrossRef][Medline]
  23. Del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in diagnosis and enema reduction. RadioGraphics 1999;19 : 299-319[Abstract/Free Full Text]
  24. Daneman A, Navarro O. Intussusception part 2: an update on the evolution of management. Pediatr Radiol2004; 34:97 -108[CrossRef][Medline]
  25. Beasley S. Intussusception. Pediatr Radiol2004; 34:302 -304[CrossRef][Medline]
  26. Sargent MA, Babyn P, Alton DJ. Plain abdominal radiography in suspected intussusception: a reassessment. Pediatr Radiol 1994; 24:17 -20
  27. Armstrong EA, Dunbar JS, Graviss ER, Martin L, Rosenkrantz J. Intussusception complicated by distal perforation of the colon. Radiology 1980;136 : 77-81[Abstract/Free Full Text]
  28. Blane CE, DiPietro MA, White SJ, Klein ME, Coran AG; Wesley JR. An analysis of bowel perforation in patients with intussusception. J Can Assoc Radiol 1984; 35:113 -115[Medline]
  29. Daneman A, Alton DJ, Lobo E, Gravett J, Kim P, Ein SH. Patterns of recurrence of intussusception in children: a 17-year review. Pediatr Radiol 1998;28 : 913-919[CrossRef][Medline]
  30. Mercer S, Carpenter B. Mechanism of perforation occurring in the intussuscipiens during hydrostatic reduction of intussusception. Can J Surgery 1982;25 : 481-483
  31. Meyer JS, Dangman BC, Buonomo C, Berlin JA. Air and liquid contrast agents in the management of intussusception: a controlled, randomized trial. Radiology 1993;188 : 507-511[Abstract/Free Full Text]
  32. Beasley SW, Glover J. Intussusception: prediction of outcome of gas enema. J Pediatr Surgery 1992;27 : 474-475[CrossRef][Medline]
  33. Gu L, Alton D, Daneman A, et al. John Caffey award. Intussusception reduction in children by rectal insufflation of air. AJR 1988; 150:1345 -1348[Abstract/Free Full Text]
  34. Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6396 cases in 13 years. J Pediatr Surgery 1986; 21:1201 -1203[CrossRef][Medline]
  35. Stringer MD, Pablot SM, Brereton RJ. Paediatric intussusception. BR J Surg 1992;79 : 867-876[Medline]
  36. McAlister WH. Intussusception: even Hippocrates did not standardize his technique of enema reduction. Radiology1998; 206:595 -598[Free Full Text]
  37. Bratton SL, Haberkern CM, Waldhausen JH, Sawin RS, Allison JW. Intussusception: hospital size and risk of surgery. Pediatrics 2001;107 : 299-303[Abstract/Free Full Text]
  38. Leonidas JC. Treatment of intussusception with small bowel obstruction: application of decision analysis. AJR1985; 145:665 -669[Abstract/Free Full Text]
  39. Britton I, Wilkinson AG. Ultrasound features of intussusception predicting outcome of air enema. Pediatr Radiol1999; 29:705 -710[CrossRef][Medline]
  40. Lagalla R, Caruso G, Novara V, Derchi LE, Cardinale AE. Color Doppler ultrasonography in pediatric intussusception. J Ultrasound Med 1994; 13:171 -174[Abstract]
  41. Lam AH, Firman K. Value of sonography including color Doppler in the diagnosis and management of long standing intussusception. Pediatr Radiol 1992;22 : 112-114[CrossRef][Medline]
  42. Lim HK, Bae SH, Lee KH, Seo GS, Yoon GS. Assessment of reducibility of ileocolic intussusception in children: usefulness of color Doppler sonography. Radiology 1994;191 : 781-785[Abstract/Free Full Text]
  43. Ein SH. Recurrent intussusception in children. J Pediatr Surgery 1975; 10:751 -755[CrossRef][Medline]
  44. Katz M, Phelan E, Carlin JB, Beasley SW. Gas enema for the reduction of intussusception: relationship between clinical signs and symptoms and outcome. AJR 1993;160 : 363-366[Abstract/Free Full Text]
  45. Champoux AN, Del Beccaro MA; Nazar-Stewart V. Recurrent intussusception. Arch Pediatr Adolesc Med1994; 148:474 -478[Abstract]
  46. Ein SH. Leading points in childhood intussusception. J Pediatr Surgery 1976; 11:209 -211[CrossRef][Medline]
  47. Sfakianakis GN, Conway JJ. Detection of ectopic gastric mucosa in Meckel's diverticulum and in other aberrations by scintigraphy. J Nucl Med 1981; 22:647 -654[Abstract/Free Full Text]
  48. Navarro O, Dugougeat F, Kornecki A, Shuckett B, Alton DJ, Daneman A. The impact of imaging in the management of intussusception owing to pathologic lead points in children: a review of 43 cases. Pediatr Radiol 2000; 30:594 -603[CrossRef][Medline]
  49. Miller SF, Landes AB, Dautenhahn LW, et al. Intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities. Radiology1995; 197:493 -496[Abstract/Free Full Text]
  50. Navarro OM, Daneman A, Chae A. Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathologic lead points in pediatric patients. AJR2004; 182:1169 -1176[Abstract/Free Full Text]
  51. Katz ME, Kolm P. Intussusception reduction 1991: an international survey of pediatric radiologists. Pediatr Radiol1992; 22:318 -322[CrossRef][Medline]

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Imaging and intussusception
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