Intervention
Unless perforation, peritonitis, or Henoch-Schönlein purpura is present, radiologic reduction should be attempted. The success rate is 50-85%, depending on factors such as the length of time of the intussusception and degree of edema of the loop and ileocecal valve. Reduction is still possible, although more difficult, in intussusceptions that have been in place for longer than 48 hours. In patients older than 2 years, it should be assumed that intussusception has a lead point etiology; in such cases, further investigation should be undertaken.9,10,11Air reduction
In the current method of air reduction, room air is introduced through a rectal catheter and is taped well in place. A manometer is attached to a Y-connector to monitor pressure in the colon. Pressure should never exceed 110 mm Hg. The air pressure on the intussusception usually forces the inverted bowel back through the ileocecal valve and into its proper position. When reduction occurs, the observed pressure falls precipitously.
Contrast reduction
Contrast reduction was widely used until the current decade. A large rectal tube is taped firmly in place, and dilute water-soluble contrast is introduced slowly by gravity drip into the rectum; hydrostatic pressure is used to reduce the intussusception. The fluid is placed a maximum of 3 feet above the level of the radiography table. No more than 3 attempts at reduction are undertaken, and the column is pressed against the intussusception mass no longer than 3 minutes at each attempt. Visualization of the small bowel usually indicates that intussusception has been reduced. The following rules need to be observed:
- The fluid level should be maintained at no more than 3 feet above the patient.
- Palpation of the abdomen should be avoided during reduction.
- Pressure should be maintained no longer than 3 minutes against a nonmoving intussusception.
Reduction may proceed at an uneven rate, and it may slow at various locations; this is particularly true at the ileocecal valve, which is swollen and often resists passage of the intussusception (see Images below and Images 11-13 in Multimedia). To ensure reduction, contrast should be observed entering the ileum. Once contrast enters the ileum, it often proceeds quickly through the ileum. Vomiting is a frequent side effect of reduction.
Reduction of an intussusceptum through the ileocecal valve is the most difficult part of the reduction. The mass is seen in the cecum (A).
On the second attempt at reduction, the intussusceptum still extends through the ileocecal valve (B). Reduction was unsuccessful.
The ileocecal valve is usually quite edematous after an intussusception has occurred; it may remain large for several days. In this patient, the ileocecal valve was mistaken for an intussusception, although barium had entered the ileum.
The appendix usually fills before the ileum and should not be confused with the ileal reflux of contrast. If there is a problem with reduction across the ileocecal valve, the patient should be allowed to evacuate, and the ileum should then be refilled; this relaxes the valve and allows for better control on refilling. A swollen ileocecal valve may appear unreduced; therefore, identifying air or contrast material in the ileum is important (see Image below and Image 14 in Multimedia).
The appearance of the ileocecal valve at resection is edematous and enlarged (B).
Recurrences
Intussusception recurs in approximately 10% of children. Intussusception can recur at any time and is not a contraindication to repeat reduction. Sedation to assist reduction does not greatly affect the reduction rate. Glucagon has been advocated, but its efficacy has not been established.
Medicolegal Pitfalls
- Failure to make the diagnosis in a timely manner is a pitfall. In subtle or unsuspected occurrences of intussusception, delay in the diagnosis may allow the condition to progress to bowel infarction and bowel perforation. Thus, awareness of the possible diagnosis is important in a young patient with any of the symptoms or signs of intussusception, even when they are not characteristic.
Special Concerns
- One should be aware of conditions that lead to intussusception and that also are predictive of perforation (eg, Henoch-Schönlein purpura). Contrast enema procedures should be avoided in patients with these conditions.
More on Intussusception, Child |
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 Follow-up: Intussusception, Child |
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Keywords
child intussusception, pediatric intussusception, ileocolic intussusception, ileoileal intussusception, colocolic intussusception
