Discussion By Int. 謝志成

Outline Basic knowledge about intussusception Radiology aspect of intussusception Diagnostic tools and specific signs Therapeutic method in radiology—enema

Intussusception Proximal Distal Telescoping of a portion of the intestine into itself Proximal Distal A.T. Byrne et al. The imaging of intussusception, Clinical Radiology (2005) 60, 39–46

Intussusception Most common cause of intestinal obstruction in 3m-6y 60% younger than 1y/o, most commonly 5-10 month old Higher incidence in spring and autumn Intussusception in 5m – 2y/o rarely had leading point and usually responsive to non-operative reduction Intussusception in older child or adult had leading point and usually require operative reduction

Symptoms of Intussusception Classic triad : in only 1/3 patients abdominal pain, vomiting, bloody stool Preceding upper airway infection Intermittent colicky pain Bilious or non-bilious vomiting Diarrhea / Currant jelly stool Palpable abdominal mass

Causes of Surgical leading Point Meckel diverticulum Enlarged mesenteric lymph node Benign or malignant tumors of mesenteric or intestine lymphoma, polyp, harmartoma, neurofibroma, etc. Mesenteric or Duplication cyst Submucosal hematoma (HSP, coagulation disorder, etc.) Inverted appendiceal stump Sutures or staples along an anastomosis

Radiology aspect of intussusception

Diagnostic tools Abdominal plain film Ultrasound Enema and enema reduction Computed tomography & Magnetic resonance imaging

Plain film Poor sensitivity and specificity First report was by Lehmann in 1914 Target sign and meniscus sign Diagnostic value For R/O Exclusion of intussusception and other disease Highly susp. Confirmation of intussusception Sure Exclusion of perforation and bowel obstruction

Plain film Meniscus sign Target sign del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

Ultrasound High sensitivity: 98~100% Fast, non-invasive, easy to perform and reproducible Transverse —Target lesion, doughnut sign Longitudinal – a sandwich-like appearance, pseudokidney sign Diagnostic value Highly reliable in children, may false positive in adult False negative in large amount of bowel gas Color duplex for blood flow detection

del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

Ultrasound doughnut pseudokidney del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

Enema Also therapeutic, Potential risk for perforation Spring coil sign If enema reduction fail for three times, surgical intervention is indicated A.T. Byrne et al. The imaging of intussusception, Clinical Radiology (2005) 60, 39–46

Coil spring Meniscus sign Coil spring del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319 Meniscus sign Coil spring

Enema reduction Contra-indication Unstable patient– dehydration, shock, peritonitis Evidence of perforation—free air Media– barium, water soluble contrast, saline, air Fluoroscopy or ultrasound guided Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

Fluoroscopy vs. Ultrasound Ultrasound-guided No radiation Visualization of all component of intussusception recognition of pathologic lead points But poor in recognition of perforation during reduction Fluoroscopy-guided Familiar to use Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

Pneumatic vs. Hydrostatic Pneumatic reduction Clean, quick and easy to perform Less radiation exposure But possible of partial reduction, or difficult in large bowel gas Hydrostatic reduction Vast experience and familiar Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

Reduction rate By symptom—pain only 98%, vomiting 82%, bloody stool 44% Duration : 12hr 85%, 48hr 70% Age: the younger ,the easier Leading point: only 1/3 Presence of blood flow in Doppler US suggest reducible Med 95, 小外共筆,No14

*different patient population and different protocol Reduction rate: 12.5%~100% Perforation:0%~4.26% *different patient population and different protocol

Method to improve reduction rate Medications—glucagon or sedatives Transabdominal manipulation Delayed repeated attempted enema Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

CT and MRI Not indicated for children, but are useful tools for evaluated underline disease and leading points

Reference A.T. Byrne et al. The imaging of intussusception, Clinical Radiology (2005) 60, 39–46 Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108 del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

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