Intussusception: A Guide to Diagnosis and Intervention in Children

Intussusception: A Guide to Diagnosis
and Intervention in Children
Genevieve Daftary,
Harvard Medical School,
Year III
Gillian Lieberman, MD
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
The Anatomy of Intussusception
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Intussusception occurs when
a segment of bowel, the
intussusceptum, telescopes
into a more distant segment
of bowel, the intussuscipiens
Intussuscipiens
The most common type is
ileocolic (pictured here),
followed by ileoileocolic,
ileoileas, and colocolic
Radiologic Clinics of North America 1997
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www.yoursurgery/Intussusception.jpg
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Demographics
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Most common acute abdominal disorder of early
childhood (56 children/ 100,000/ year in US)
Boys 4x’s more frequently than girls
Majority of patients between 3 mon and 3 yr
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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
Radiologic Clinics of North America 1997; Pediatrics 2000
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Etiologies of Intussusception
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Idiopathic: no defined lead point
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Recognizable cause for lead point
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Association with viral illness (adenovirus)
Hypertrophy of lymphoid tissue
Meckel’s diverticulum
Intestinal polyp
Enteric duplication
Lymphoma
Intramural hematoma
Ameboma
Henoch-Schönlein purpura
Radiologic Clinics of North America 1996,1997
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
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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Radiologic Clinics of North America 1996, 1997
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
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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Radiologic Clinics of North America 1997
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Overview of Screening Tools
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Abdominal Radiograph
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Abdominal Sonography
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Diagnostic accuracy near 100%, eval of reducibility, +/- lead
point, post reduction, ischemia
Abdominal CT scan
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Screen for other Dx’s and free air
Can be safely omitted in the presence of US
45% sensitivity
Accuracy approaching 100%; especially good for lead points
High cost, risk of radiation, and risk of sedation in children
make it unpractical
AJR 2005; Rad Clinics of N Amer 1996
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Presentation
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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
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Supine KUB
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Supine KUB
Paucity of Gas
on Right Side of
Abdomen
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Abdominal Radiograph
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Signs of Intussusception
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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 nonsurgical reduction with contrast)
May be safely omitted if ultrasound is available
Radilogic Clinics of North America 1996; Amer J Rad 2005
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Target & Meniscus Signs
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RadioGraphics 1999
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Target & Meniscus Signs
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RadioGraphics 1999
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Longitudinal Ultrasound
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Longitudinal Ultrasound
•Telescoping
Bowel
•Sandwich Sign/
Pseudokidney
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Axial Ultrasound
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Axial Ultrasound
Doughnut/
Target Sign
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Doppler Ultrasound
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Doppler Ultrasound
•Blood flow
maintained
•Rule out
ischemia of
involved bowel
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Abdominal Ultrasound
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Replaced abdominal radiograph as primary
screening modality
Sensitivity 98 -100%; specificity 88 -100%
Appearance: outer hypoechoic region
surrounding an echogenic center or multiple
concentric rings
Use Doppler to determine bowel ischemia;
guides reduction decisions
Guide hydrostatic and pneumatic reduction
Rad Clinics of N Amer 1997
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Ultrasound Cross-Sections
• A = intussuscipiens
• B = everted intussusceptum
• C = central intussusceptum
• M = mesentery
• L = lymph nodes
• MS = contacting mucosal
surfaces
• S = contacting serosal
surfaces
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RadioGraphics 1999
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient One: Air Enema
Normal bowel gas pattern: Spontaneous Reduction
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Enemas
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Air, Liquid (saline, soluble contrast), Barium
At one time used for Dx
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Now used mainly for Treatment/Reduction
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Coiled spring: edematous mucosal folds of returning
intussusceptum outlined by contrast in colon
Meniscus sign
Avoid patient discomfort and risk of perforation
US better diagnostic tool & rule out tool
RadioGraphics 1999
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Meniscus & Coiled Spring Signs
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RadioGraphics 1999
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Reduction Procedures
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Barium enema: previous standard for Dx and
reduction
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US-guided Hydrostatic reduction
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Risk of barium peritonitis, infection, adhesions,
radiation exposure with fluoroscopy, only see lumen
55-95% accuracy
Iodinated contrast safer but causes fluid shifts
No radiation, good visualization of intussusception &
lead points
Need sonographer
Radiology 2001; AJR 2004 & 2005; Rad Clinics of N Amer 1996
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Reduction Procedures cont.
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Pneumatic reduction with fluoroscopic guidance
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US-guided Pneumatic reduction
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Quick, safe, clean (less fecal spillage), cheap
Radiation exposure, cannot depict lead points well, only see
intraluminal content
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 and
residual intussusceptions
Surgical
Radiology 2001; AJR 2004 & 2005; RadioGraphics 1999
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Contraindications to Enema
Dehydration
 Peritonitis
 Shock
 Sepsis
 Free air on radiograph
Stabilize then treat surgically
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Rad Clinics of N Amer 1996
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Complications of Reduction
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Perforation
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Recurrence
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Overall rate of 0.8%
Similar rates for liquid and air enemas
Perforations with air usually smaller
Approximately 10%
Similar rates for liquid and air enemas
50% will occur within 48 hrs
Repeat enemas are safe and effective
AJR 2005
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Reduction Guidelines
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Liquid Enema Rule of Three’s for Barium
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Air Enema
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3 attempts
3 min duration
Liquid enema bag 3 feet above fluoroscopy table (5
feet if using water-soluble contrast)
Ensure maximal pressures <120 mm Hg at rest
AJR 2005
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Success of Reduction Depend On…
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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 the
intussusceptum
Adequate blood flow
Location other than the rectum (rectum only 25%
success)
AJR 2002 & 2005
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Presentation
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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 one
month prior
Abdomen soft, non-distended with active BS, diffusely
tender
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Supine KUB
Patient does not have
classic triad of
intussusception
Use KUB to
consider other
diagnoses
32
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Supine KUB
•Paucity of
Gas on Right
•Dilated
loops of
small bowel
•Looks like
obstruction
33
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
DDx of Intestinal Obstruction in a Child
Adhesions/Congenital peritoneal bands (Ladd’s
bands
 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
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Felson, Gamuts in Radiology
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Longitudinal Ultrasound
Use US to explore
possible causes of
obstruction including
intussusception
Patient is not exposed
to any further radiation
or the discomfort of
enema until further Dx
35
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Sagittal Ultrasound
Dilated loops of bowel
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Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Axial Ultrasound
37
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Axial Ultrasound
•Doughnut/Target
Sign
•Patient’s obstruction
is due to
intussusception
38
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Doppler Ultrasound
39
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Patient Two: Doppler Ultrasound
•Blood flow
maintained
•Rule out bowel
ischemia
•Patient is safe to
receive an US
guided air enema
with likelihood of
resolution
40
Children's Hospital Boston
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Review
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Intussusception is COMMON in young children
Clinical presentation is variable underscoring the need
for a safe, quick, inexpensive screening tool such as
ultrasound
Ultrasound is extremely accurate in diagnosing
obstruction; CT is more accurate in defining a lead
point; abdominal radiographs can be helpful in
considering other diagnoses
Ultrasound guided air enema combines the safety of
ultrasound (lack of radiation) with the effectiveness,
ease, cleanliness, and safety of air enema in reducing
intussusception
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
What does intussusception look like on CT?
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Since lead points are more likely in the adult
population, CT is done more frequently in this
population with suspected intussusception
Scroll through the following images to get a
sense of what intussusception looks like on CT
Notice the familiar target sign, also useful in
diagnosis using plain film and ultrasound!
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Intussusception on CT
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BIDMC PACS
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Intussusception on CT
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BIDMC PACS
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Intussusception on CT
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BIDMC PACS
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Intussusception on CT
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BIDMC PACS
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Intussusception on CT
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BIDMC PACS
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Intussusception on CT
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BIDMC PACS
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
References
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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 to
Diagnosis and Reduction. Radiologic Clinics of North America 1996; 34: 743-756.
Del-Pozo G et al. Intussusception in Children: Current Concepts in Diagnosis and
Enema Reduction. RadioGraphics 1999; 19: 299-319.
Felson. Gamuts in Radiology.
Koumanicou C et al. Sonographic Detection of Lymph Nodes in the
Intussusception of Infants and Young Children. AJR 2002; 178: 445-450.
Navarro O, 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. AJR 2004; 182: 1169-1176.
Parashar UD et al. Trends in Intussusception-Associated Hospitalizations and
deaths Among US Infants. Pediatrics 2000; 106: 1413-1421.
Sivit CJ. Gastrointestinal Emergencies in Older Infants and Children. Radiologic
Clinics of North America 1997; 35: 865-877.
Yoon CH, Kim HJ, Goo HW. Intussusception in Children: US-guided Pneumatic
Reduction—Initial Experience. Radiology 2001; 218: 85-88.
Genevieve Daftary, MS3
Gillian Lieberman, MD
Acknowledgements
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Special Thanks To…
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Melissa Gerlach, MD
Anne-Catherine Kim, MD
Larry Barbaras, Webmaster
Pamela Lepkowski
Gillian Lieberman, MD
November 2005