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

Non-operative treatment of intussusception is done in patients who are stable and have normal vital signs with no signs of intestinal perforation. It is done in a clinical setting with an experienced physician. This is done to prevent a major complication called tension pneumoperitoneum. Methods include fluoroscopic and ultrasonographic guided hydrostatic or pneumatic enema. Ultrasound is preferred as it avoids exposure to ionizing radiation and has better detection of pathological lead points. Ultrasonographic reduction uses a saline enema as pneumatic enema cannot be used in this. If reduction is successful then the intussusception disappears and wate /air bubbles are seen in the terminal ileum. Fluoroscopic guidance is used if there is a filling defect within bowel enema. Both hydrostatic and pneumatic enema can be used under this method. If reduction is successful then free flowing contrast or air into the small bowel is seen and there is relief of symptoms. Complications of non-operative reduction include perforation of bowel.It mostly occurs in the distal part of intussusception in the transverse colon. Recurrence of intussusception can occur in about 10% children after successful reduction. 50% cases occur in the first 72 hours and all episodes of recurrence should be considered as the first episode.

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:
  • Ultrasound is used more often these days[2]
  • 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
  • Circulatory support is provided using intravenous fluids
  • Complications
  • Hydrostatic reduction
  • 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]
    • 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 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

Non-operative reduction may lead to the following complications:

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. Stringer DA, Ein SH (1990). "Pneumatic reduction: advantages, risks and indications". Pediatr Radiol. 20 (6): 475–7. PMID 2392368.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.