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   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 2 www.yoursurgery/Intussusception.jpg Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Demographics    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 – –     3 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  Idiopathic: no defined lead point – –  Recognizable cause for lead point – – – – – – – 4 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%)  5 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. 6 Radiologic Clinics of North America 1997 Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Overview of Screening Tools  Abdominal Radiograph – – –  Abdominal Sonography –  Diagnostic accuracy near 100%, eval of reducibility, +/- lead point, post reduction, ischemia Abdominal CT scan – – 7 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    8 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 9 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Patient One: Supine KUB Paucity of Gas on Right Side of Abdomen 10 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Abdominal Radiograph  Signs of Intussusception – – – – – –     11 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 12 RadioGraphics 1999 Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Target & Meniscus Signs 13 RadioGraphics 1999 Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Patient One: Longitudinal Ultrasound 14 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Patient One: Longitudinal Ultrasound •Telescoping Bowel •Sandwich Sign/ Pseudokidney 15 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Patient One: Axial Ultrasound 16 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Patient One: Axial Ultrasound Doughnut/ Target Sign 17 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Patient One: Doppler Ultrasound 18 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 19 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Abdominal Ultrasound      20 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 21 RadioGraphics 1999 Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Patient One: Air Enema Normal bowel gas pattern: Spontaneous Reduction 22 Children's Hospital Boston Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Enemas   Air, Liquid (saline, soluble contrast), Barium At one time used for Dx – –  Now used mainly for Treatment/Reduction – – 23 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 24 RadioGraphics 1999 Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Reduction Procedures  Barium enema: previous standard for Dx and reduction – – –  US-guided Hydrostatic reduction – – 25 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.  Pneumatic reduction with fluoroscopic guidance – –  US-guided Pneumatic reduction – –  26 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  27 Rad Clinics of N Amer 1996 Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Complications of Reduction  Perforation – – –  Recurrence – – – – 28 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  Liquid Enema Rule of Three’s for Barium – – –  Air Enema – 29 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…         30 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        31 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  34 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 36 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     41 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?    42 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 43 BIDMC PACS Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Intussusception on CT 44 BIDMC PACS Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Intussusception on CT 45 BIDMC PACS Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Intussusception on CT 46 BIDMC PACS Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Intussusception on CT 47 BIDMC PACS Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 Intussusception on CT 48 BIDMC PACS Genevieve Daftary, MS3 Gillian Lieberman, MD November 2005 References          49 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  Special Thanks To… – – – – – 50 Melissa Gerlach, MD Anne-Catherine Kim, MD Larry Barbaras, Webmaster Pamela Lepkowski Gillian Lieberman, MD November 2005