Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney signs

Successful treatment of adult cecorectal intussusception caused by cecum cancer with mobile cecum: a case report

Background

Intussusception occurs when a segment of the bowel (the intussusceptum) telescopes into an adjacent segment (the intussuscipiens). Adult intussusception occurs rarely and often requires surgical resection for its treatment. We describe the case of an adult patient with extremely rare cecorectal intussusception treated using a novel combined transabdominal and trans-anal approach, which has not yet been reported in the literature.

Case presentation

A 71-year-old woman was transferred to our hospital for the treatment of upper abdominal pain. Physical examination, laboratory tests, and imaging inspections showed strangulated bowel obstruction induced by intussusception associated with the intra-rectal mass. We performed an emergency operation and treated the intussusception using a combined transabdominal and trans-anal approach. The intraoperative findings revealed bloody ascites and a potentially malignant tumor that had moved toward the anal side from peritoneal reflection. The tumor served as the lead point in the cecum with mobile cecum. After reducing the intussusception using the combined procedure, we removed the ileocecal portion. The intraoperative and histopathological findings suggested that cecum cancer with mobile cecum had caused the cecorectal intussusception. The patient had an uneventful postoperative course, except for postoperative pulmonary pneumonia.

Conclusion

To the best of our knowledge, this is the first reported case of adult cecorectal intussusception due to cecum cancer with mobile cecum successfully treated using the combined transabdominal and trans-anal approach. This combined procedure may be useful in treating the intussusception where the lead point is distal from the peritoneal reflection.

A rare case report of a neonatal idiopathic intussusception in a full-term newborn

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In contrast with the usual idiopathic intussusception appearing in infants, neonatal intussusception in full-term newborns is a very rare entity.

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It’s a challenging diagnosis since it has a misleading and variable presentation.

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Early diagnosis may be enhanced with abdominal ultrasonography that showed the classic target and pseudo kidney signs.

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An emergency laparotomy must be performed to confirm the ultrasound findings and to reduce the intussusception: Only way to save the patient.

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The overall prognosis for neonates with intussusceptions depends on early diagnosis, because once a critical condition develops, as in this case, the mortality rate is likely to rise.

Introduction

In contrast with the usual idiopathic intussusception appearing in infants, neonatal intussusception in full-term newborns is a rare entity and usually due to an organic lead point lesion. It has a misleading and variable presentation. This manuscript reports a very rare case of neonatal idiopathic intussusception in a full-term male newborn in order to highlight the difficulties in establishing an early diagnosis.

Presentation of case

We present a full-term male newborn who was referred to our department at day 7 of life with fecaloid vomiting, distended abdomen and absence of intestinal transit. No bloody stool was identified. The newborn was in poor condition, dehydrated and hypothermic. He was promptly resuscitated and an abdominal ultrasound was quickly performed, it showed an ileocecal intussusception located in the right hypochondriac region. An emergency laparotomy was performed confirming the ultrasound findings. The pathological exam of the resected bowel confirmed the presence of an intussusception with areas of hemorrhagic rearrangements but no lead point was detected. The patient died from septicemia.

Conclusion

Intussusception occurring in the neonate is still difficult to assess, because of its rarity and its uncommon mode of presentation. This case report underlines the importance to make early diagnosis, because once a critical condition develops, the mortality rate is likely to rise.

Imaging Findings of Gastrointestinal Emergency in Infants and Young Children

급성 복증(acute abdomen)은 갑자기 발생하는 심한 복부 통증으로 즉각적인 수술적 치료를 필요로 할 수도 있는 상태를 말한다. 소아 환자의 급성 복증의 원인은 다양하며, 수술적 치료를 해야 하는 질환부터 투약 치료를 받아야 하거나 임상적 관찰 만을 요하는 질환까지 다양하게 분류될 수 있다. 이러한 급성 복증의 환자에서 영상 검사의 역할은 가능하다면 복통의 원인이 되는 질환을 밝혀서 수술적 치료를 해야 하는 환자와 투약 치료를 해야 하는 환자를 구분해 주는 것이다. 장중첩증과 충수돌기염이 소아 환자에서 수술적 치료를 필요로 하는 급성 복증의 가장 흔한 원인 질환이므로, 급성 복통을 호소하는 영아에서는 장중첩증을, 좀 더 나이가 많은 소아에서는 충수돌기염을 영상 검사를 이용해 배제해 주는 것이 중요하다. 이 논문에서는 영유아 환자의 급성 복통을 유발할 수 있는 질환 중 특징적 영상 소견을 보이는 장중첩증, 충수돌기염, 중장 염전, 메켈 게실 및 중복낭종에 대해 소개하고자 한다

Current Views in the Diagnosis and Treatment of Intestinal Intussusception

Intestinal intussusceptions most often occur in young dogs and cats. Common locations for intestinal intussusceptions include enterocolic, eneteroenteric or colocolic. Ultrasonography is highly reliable for diagnosing of intussusception and for prediction of its reducibility. Abdominal structures that may mimic intussuception can be seen ultrasonographically. Intussusceptions is a surgical emergency. Immediate stabilization of the animal followed by manual reduction or intestinal excision of the affected intestine through midline celiotomy are required. Recurrence is a common postsurgical complication. Enteroplication may be considered for recurrence prevention but is not without complications. Prognosis is good in uncomplicated cases.

Acute intestinal intussusception of the infant and the child: A 5-year study of 66 cases

BACKGROUND

Acute intestinal intussusception (AII) is defined as the telescoping of part of the intestine into the intestinal segment beneath it. The consequence is an obstruction and strangulation which can lead to necrosis of the intestinal tract that has telescoped. The aim of our work is, on the one hand, to assess our management style throughout analysis of clinical different aspects and on the other hand to set up a strategy for early diagnosis and treatment.

METHODS

It is a retrospective study over 5 years from 2010 to 2015 including infants and children who had been treated for AII in Albert Royer Children's Hospital. The following variables such as age, sex, past time before the surgical consultation, initial diagnosis, imaging data view, treatment technique and results were itemised to bear comparison. Sixty-six records were reviewed.

RESULTS

The mean age was 5.73 months with a range of 2 and 144 months. Boys constituted the majority of patients with a ratio of 2:1. Children were referred to us with the diagnosis of intestinal obstruction or gastroenteritis in 50% of cases. Past time average before consultation was 5.3 days with a range of 14 h and 30 days. Most of the patients underwent surgery within 48 h after the beginning of the clinical picture. An abdominal ultrasound scan confirmed the diagnosis of AII in 57 cases, whereas in 9 cases, it was normal or not contributive. Non-operative reduction by retrograde pneumatic pressure or barium enema represented 33.4% of patients against 56.6% for surgical treatment. We registered 5 deaths and 2 recurrences. AII remains the main cause of intestinal obstruction in infants.

CONCLUSION

Authors stressed on delay in diagnosis with the treatment consequences belonging to that status and put emphasis in the importance of close collaboration between paediatricians, surgeons and radiologist for early diagnosis and nonoperative systematic reduction.

Intussusception: past, present and future

Intussusception is a common etiology of acute abdominal pain in children. Over the last 70 years, there have been significant changes in how we diagnose and treat intussusception, with a more recent focus on the role of ultrasound. In this article we discuss historical and current approaches to intussusception, with an emphasis on ultrasound as a diagnostic and therapeutic modality.

Point-of-care ultrasound identification of pneumatosis intestinalis in pediatric abdominal pain: a case report

We describe a case report of an infant with intussusception who presented to a pediatric emergency department with diarrhea and increased irritability. Pneumatosis intestinalis (intra-mural air) detected on point-of-care ultrasonography (but not apparent on plain abdominal radiographs) alerted the emergency physicians towards the severity of disease process.

Clinics in diagnostic imaging. 159. Jejunal intussusception due to Peutz-Jeghers syndrome

A 21-year-old woman presented with acute onset of upper abdominal pain. A diagnosis of Peutz-Jeghers syndrome (PJS) was made based on the clinical picture of perioral pigmentation with imaging findings of transient jejunojejunal intussusceptions and small bowel polyps, and confirmed by characteristic histopathological appearances of Peutz-Jeghers polyps. PJS is a rare hereditary condition characterised by unique hamartomatous polyps, perioral mucocutaneous pigmentations, and increased susceptibility to gastrointestinal and extraintestinal neoplasms. Patients usually present with recurrent abdominal pain due to intussusception caused by polyps. Other modes of presentations include rectal bleeding and melaena. We describe the imaging findings of PJS and provide a brief review of bowel polyposis syndromes. The latter are relatively rare disorders characterised by multiple polyps in the large or small intestine, with associated risk of malignancies and other extraintestinal manifestations. Awareness of the manifestations and early diagnosis of these syndromes is crucial to prevent further complications.

An update on common gastrointestinal emergencies

The evaluation of the child with acute abdominal pain often poses as a diagnostic challenge due to the wide range of diagnoses. Surgical emergencies need to be rapidly identified and managed appropriately to minimize morbidity and mortality. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. This article reviews common surgical causes of abdominal pain in children.

Ileocolic versus small-bowel intussusception in children: can US enable reliable differentiation?

PURPOSE

To assess clinical and ultrasonographic (US) criteria that can be used to confidently differentiate ileocolic from small-bowel intussusception.

MATERIALS AND METHODS

Institutional review board approval was obtained for this retrospective study, and the need to obtain informed consent was waived. US and clinical data for children given a diagnosis of intussusception in the years 2007 through 2011 were evaluated. The diameters of the intussusception and the inner fat core, the outer bowel wall thickness, and the presence or absence of lymph nodes inside the intussusception and mesentery were noted. The Student t test, the Mann-Whitney test, and the Levene test were used for comparison of parametric variables, while the χ(2) and Fisher exact tests were used for comparison of categoric data.

RESULTS

There were 200 cases of intussusception in 174 patients (126 boys, 48 girls; mean age, 17.2 months (range, 0 years to 7 years 1 month); 57 (28.5%) were small-bowel and 143 (71.5%) were ileocolic intussusceptions. Mean lesion diameter was 2.63 cm (range, 1.3-4.0 cm) for ileocolic versus 1.42 cm (range, 0.8-3.0 cm) for small-bowel intussusception (P < .0001). Mean fat core diameter was 1.32 cm (range, 0.6-2.2 cm) for ileocolic versus 0.1 cm (range, 0-0.75 cm) for small-bowel intussusception (P < .0001). The ratio of inner fat core diameter to outer wall thickness was greater than 1.0 in all ileocolic intussusceptions and was less than 1.0 in all small-bowel intussusceptions (P < .0001). Lymph nodes inside the lesion were seen in 128 (89.5%) of the 143 ileocolic intussusceptions versus in eight (14.0%) of the 57 small-bowel intussusceptions (P < .0001). Children with ileocolic intussusception had more severe clinical symptoms and signs, with more vomiting (P = .003), leukocytosis (P = .003), and blood in the stool (P = .00005).

CONCLUSION

The presence of an inner fatty core in the intussusception, lesion diameter, wall thickness, the ratio of fatty core thickness to outer wall thickness, and the presence of lymph nodes in the lesion may enable reliable differentiation between ileocolic and small-bowel intussusceptions.

Right lower-quadrant pain-more than one diagnosis

When a patient presents with right-lower-quadrant pain in the emergency room, the diagnosis of appendicitis must always be considered, but the differential diagnosis for this symptom includes many other etiologies. We describe a case of an 8-year-old girl with von Willebrand disease who presented with right-lower-quadrant pain and was found to have an appendiceal wall hematoma. During her evaluation, an ultrasound of the abdomen was performed, and the results were initially interpreted as an intussusception. Although ultrasound is a highly reliable way to diagnose appendicitis and intussusception, the case illustrates that the thickened abdominal wall that occurs in a mural hematoma can appear like the "target sign" that is usually associated with intussusception, and in certain clinical scenarios, alternative forms of imaging may be of value.

Use of emergency ultrasound in the diagnostic evaluation of an infant with vomiting

The use of bedside emergency ultrasound in pediatric abdominal emergencies is becoming more widespread and can be a useful adjunct in the assessment of children who present with abdominal pain. Our case describes an infant who presented to the emergency department with vomiting, in whom an emergency ultrasound evaluation led to timely diagnosis and intervention of an unanticipated condition.

Adult ileocolic intussusception secondary to ileocaecal valve polyp

Intussusception is relatively common in children, but it is a rare cause of abdominal pain and intestinal obstruction in adults. The aetiology, clinical presentation and management of this condition differs in adults and children. Preoperative clinical diagnosis is usually difficult due to the non-specific and intermittent nature of the symptoms. Ultrasound and computed tomography can be helpful in establishing the diagnosis. We present a case of adult ileocolic intussusception with classical radiological signs and operative findings. In adults the diagnosis of intussusception should be considered in a case of intermittent abdominal pain, especially with clinical signs of intermittent bowel obstruction.

Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception

BACKGROUND

From the early 1980s onward, US has been considered a possible primary modality to assess patients for ileocolic intussusception. Since 2001, our institution has routinely used US to assess patients for ileocolic intussusception.

OBJECTIVE

We analyzed 7 years of institutional experience to assess the value of US as a primary diagnostic test for intussusception.

MATERIALS AND METHODS

This study was IRB-approved. From 1 January 2001 through 16 December 2007 814 US examinations for intussusception were performed in children aged 10 years and younger. Clinical records and radiological reports were reviewed for each patient, and cases were classified as true-positive, true-negative, false-positive, or false-negative.

RESULTS

Of the 814 US examinations, 112 (13.8%) were interpreted as positive for intussusception, and of these, 96 were confirmed by enema, 1 was confirmed by surgery, and 15 (13.4%) were false-positive. Of the 814 examinations, 700 (85.9%) were interpreted as negative for intussusception, and of these, 698 (99.7%) were true-negative, and 2 were false-negative. Less than 1% of studies were nondiagnostic. The overall sensitivity of US for detecting intussusception was 97.9% and specificity was 97.8%. The positive predictive value of the test was 86.6% and the negative predictive value was 99.7%.

CONCLUSION

US is a sensitive and specific test for detecting ileocolic intussusception and should be utilized as a first-line examination for assessment of possible pediatric intussusception.

Intramural and subserosal echogenic foci on US in large-bowel intussusceptions: prognostic indicator for reducibility?

BACKGROUND

In large-bowel intussusceptions, several US signs are known to indicate a lower likelihood of reducibility by enema. US can demonstrate echogenic dots or lines (foci) in the bowel wall, which might indicate an ischemic bowel.

OBJECTIVE

To determine the presence of echogenic intramural and subserosal foci in large-bowel intussusceptions and to evaluate the degree of correlation with reducibility.

MATERIALS AND METHODS

Between 2001 and 2008, 74 consecutive US examinations were retrospectively evaluated by two pediatric radiologists for intramural and subserosal echogenic foci, or trapped gas, in the intussusception. The degree of correlation between the sonographic findings and reducibility was evaluated.

RESULTS

Of 73 intussusceptions examined by US, 56 (76%) were reducible and 17 (23%) were not reducible. Out of 10 intussusceptions with intramural gas, 11 with subserosal gas, and 14 with intramural and subserosal gas, 8 (80%), 6 (56%), 9 (64%), respectively, were not reducible. The presence of intramural gas or subserosal gas or both predicted a lower chance of reduction, but with regard to the effect of these findings together, intramural gas was the only significant predictor.

CONCLUSION

Having intramural gas in large-bowel intussusception significantly decreases the chance of reduction.

[Ultrasound-guided water enema for reduction of childhood intussusception]

INTRODUCTION

Intussusception is a common abdominal emergency in infants and children. Ultrasonography and barium enema are very useful in diagnosis and treatment of this condition. The aim of the study was to assess the accuracy of ultrasound-guided saline enema for intussusception and to determine if some factors may improve the outcome of this technique.

MATERIAL AND METHODS

Intussusception was diagnosed in 63 patients at the Clinic of Pediatric Surgery in Novi Sad. The study period was divided into two 2-year phases: phase I, from 2001 through 2002, and phase II, from 2003 through 2004. During phase I, besides barium enema and fluoroscopy, we started using ultrasonography and ultrasound-guided hydrostatic saline enema in the diagnosis and reduction of intussusception. In phase II, this method of reduction was routinely used in all cases. Our technique of ultrasonic reduction was similar to the conventional hydrostatic barium reduction, except the reservoir was higher than that of barium, analgosedation of patients was performed and in case of difficult and prolonged reduction, gentle manual pressure to the abdomen at right lower quadrant was used.

RESULTS

In phase I the diagnostic accuracy of ultrasonography in detecting intussusception was 53.8%, and 100% in phase II. The success rate of ultrasound-guided saline enema was 55.5% in phase I, and 83.8% in phase II. Only 6 patients (16.2%) underwent operative manual reduction of intussusception in phase II. There were no cases with boewl gangrene or perforations in both groups.

CONCLUSIONS

Ultrasonography is a useful screening tool in the diagnosis of intussusception. Tme main advantage of hydrostatic reduction with ultrasound guidance is avoidance of ionizing radiation. The success rate of this method of reduction may be increased with an integrated team approach to the management and with modifications of the technique.

Clinical entity and treatment strategies for adult intussusceptions: 20 years' experience

PURPOSE

Intestinal intussusception in adults is rare and the optimal management of this problem remains controversial. The purpose of this study was to determine the causes of intussusceptions in adults and to assess their treatment.

METHODS

A retrospective review of patients older than aged 18 years who were diagnosed with intestinal intussusception at Tri-Service General Hospital between July 1984 and July 2004 was conducted.

RESULTS

During the 20-year period, there were 292 patients with intussusception, 24 (8.2 percent) of which were adults. Abdominal pain was the most common presenting complaint (79.2 percent). The diagnosis of adult intussusception was made preoperatively in 18 cases (75 percent) and intraoperatively in 6 cases (25 percent). Of the 24 patients, 20 (83.3 percent) had a defined lesion; 11 (55 percent) lesions were benign and 9 (45 percent) were malignant. In eight patients (33.3 percent), the intussusception was reduced; perforation occurred in one patient (12.5 percent). Segmental resections were performed on 14 patients (58.3 percent), right hemicolectomies on 6 patients (25 percent), laparoscopic low anterior resection on 1 patient (4.2 percent), appendectomy on 1 patient (4.2 percent), and diverticulectomy on 1 patient (4.2 percent). Intraoperative colonoscopy was performed on three patients (12.5 percent) before reduction (lipomas were noted in 2 of the patients (66.7 percent) with limited resection of the ileum and preservation of the antireflux ileocecal valve. There was one perioperative mortality (4.2 percent) and seven postoperative morbidities (29.2 percent).

CONCLUSIONS

Adult intussusception is an unusual and challenging condition and is a preoperative diagnostic problem. We discuss our 20 years of experience in treatment strategies for dealing with such unusual problems.

[Ultrasonography in the diagnosis of hypertrophic pyloric stenosis and intussusception--emergency conditions in pediatric gastroenterology]

Hypertrophic pyloric stenosis (HPS) is the most common abdominal surgical condition in newborns and infants, while intussusception is the most frequent problem in children between the ages of 6 months and 2 years. The aim of this study was to show the advantages of ultrasonography in diagnosis of hypertrophic pyloric stenosis and intussusception and also to point out the efficiency of ultrasound guided hydrostatic reduction of childhood intussusception, as a nonoperative therapeutic option.

MATERIAL AND METHODS

This study had a prospective design and included 208 patients in a 2-year period (2004-2005). Both US examinations were done using a linear 7.5 MHz probe, and the main ultrasound criteria for HPS were increased pyloric muscle thickness of 3 mm and over, as well as pyloric length over 15 mm, typical ultrasonic findings of intussusception included a target sign or a pseudokidney sign. Sonographically guided hydrostatic reduction of intussusceptions was also performed.

RESULTS

HPS was predominant in male infants, and the mean age was 40 days. The mean pyloric muscle thickness was 4.95 mm in infants with HPS, and the average length of the antroplyloric canal was 19.26 mm. In patients with intussusception, male predominance was also observed and the mean age was 1 year and 79 days. The intussusceptum was most often located in the cecoascending (53.6%) and transverse colon (21.4%). US-guided hydrostatic reduction of intussusception was successful in 82.14% of all cases.

DISCUSSION

Our findings are in absolute agreement with literature data regarding the average age of patients, both with HPS and intussusception, thickness of the muscular layer, length of the antropyloric canal, and extremely successfid US-guided hydrostatic reduction of intussusceptions.

CONCLUSION

Ultrasonography has proved to be a remarkably precise diagnostic modality in diagnosing HPS and intussusception, but also makes nonoperative treatment of intussusceptions possible in extremely high percentage.

Current radiological management of intussusception in children

Intussusception is the most common abdominal emergency situation in infants and small children. There has been great progress in diagnostic and therapeutic management of intussusception. Ultrasound (US) has been shown to be the first-choice imaging technique in diagnosing intussusception for reasons of high accuracy, simultaneous exclusion of differential diagnoses, and disclosure of additional pathologies. Controversial opinions exist worldwide concerning the nonoperative treatment of intussusception in infants and children. Pneumatic reduction under fluoroscopic guidance and hydrostatic reduction under US monitoring are the preferred techniques. The aim should be a success rate of at least 90% in idiopathic intussusception. This review summarizes different types of intussusception and outlines diagnostic aspects as well as several treatment concepts.

Intermittent sonographic guidance in air enemas for reduction of childhood intussusception

OBJECTIVE

The purpose of this study was to prospectively assess the value of intermittent sonographic guidance in nonsurgical air reduction of childhood intussusception.

METHODS

The study group included 86 consecutive childhood intussusceptions confirmed on sonography for which we designed an air enema. With intermittent sonographic guidance of our own method, air was gradually injected to the initial intracolonic pressure of 60 mm Hg, which we attempted for 30 seconds on the initial attempt. If the air enema reduction attempts were not successful at a given pressure setting, we repeated the technique at each pressure setting upgraded by increments of 20 mm Hg up to 120 mm Hg. Surgery was performed when even repeated reduction attempts at the maximum intracolonic pressure of 120 mm Hg were unsuccessful. We calculated the successful reduction rate for the intussusceptions at each pressure setting.

RESULTS

The overall success rate of sonographically guided air enema reductions was 95% (82/86). The success rates of air enema reductions at 60, 80, 100, and 120 mm Hg showed progressive increases of 53% (42/86), 67% (58/86), 78% (67/86), and 95% (82/86), respectively, with no immediate recurrence and no gross perforation.

CONCLUSIONS

The use of intermittent sonographic guidance in air enemas is thought to help safely increase successful reductions of childhood intussusception even with sufficient air enema attempts.

Tetra-layered sign of adult intussusception (new ultrasound approach)

Two-dimensional ultrasound is the principle method for the detection of intussusception. The aim of this study was to establish a pathognominic ultrasound criterion for diagnosing intestinal intussusception to facilitate a proper clinical decision. We have developed a new approach to diagnosing colonic intussuception based on the hypothesis that ultrasound image of the invaginated segment should reveal four border layers. We called this sign tetra-layered sign (TLS). In a prospective manner, all adult patients diagnosed with intussusception using the TLS approach in the period from July 1990 and July 2005 were included in this study. All patients underwent explorative laparotomy, and our preoperative diagnoses were compared with the surgical outcome. Thirty patients were diagnosed with intestinal intussusception using the TLS ultrasound sign. Surgery confirmed the preoperative diagnosis in all cases. Conventional ultrasound is very reliable in diagnosing intestinal intussusception in adult patients when utilizing the simple ultrasound applicable TLS. This facilitates the decision-making, improves the clinical outcome and reduces the associated costs.

Adult ileal intussusception: an unusual emergency condition

Adult intussusception occurs infrequently and differs from the childhood condition in its presentation, cause, and treatment. Nonspecific symptoms can delay diagnosis; most cases are diagnosed at emergency laparotomy. Increased use of computed tomographic scanning to evaluate patients with abdominal pain can enhance reliable preoperative diagnosis. Treatment entails simple bowel resection in most cases. Reduction is controversial, especially in cases of colonic intussusception. This report describes the diagnosis and management of a case of adult ileal intussusception caused by an inflammatory fibroid polyp-a rare lesion of the gastrointestinal tract.

Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module

OBJECTIVE

This article uses case examples to review the current evidence for the management of children with clinically suspected intussusception.

CONCLUSION

In this educational module, we review the evidence for diagnostic and management strategies in children with clinically suspected intussusception.

Ileoileal invagination without obstruction in a four-year-old boy

Intussusception is one of the most common causes of acute abdomen in the first year of life. Its clinical presentation is vomiting, bloody stools, severe colicky abdominal pain, and mass. The authors reported a case of intussusception with an inappropriate clinical picture, but both characteristic ultrasonography and computed tomography findings led to the diagnosis of ileo-ileal intussusception.

Intussusception in children: can we rely on screening sonography performed by junior residents?

BACKGROUND

Ultrasonography is an important tool in the screening and diagnosis of patients with suspected intussusception.

OBJECTIVE

To retrospectively evaluate the accuracy and performance of junior residents and compare it to that of senior residents and staff radiologists.

MATERIALS AND METHODS

Between January 1999 and February 2003, 151 patients with suspected intussusception underwent screening US. The mean age of the patients was 13.8 months. Patients were divided into three groups according to examiner: staff radiologist, senior resident or junior resident.

RESULTS

Sixty-five patients had both US and air enema. Forty-four patients had a positive US result; 37 (84%) were true positive and 7 (16%) were false positive. Twenty-one patients had a negative US result; 18 (86%) were true negative and 3 (14%) were false negative. Eighty-six patients underwent screening US only and were then kept under observation in the emergency room. They were all diagnosed as having a non-surgical condition. The total accuracy rate was 93%, sensitivity was 84%, specificity was 97%, positive predictive value was 93% and negative predictive value was 94%. Accuracy rate, sensitivity and specificity were 92%, 85% and 98% for staff radiologists, 94%, 75% and 96% for senior residents and 95%, 83% and 97% for junior residents, respectively.

CONCLUSIONS

Junior residents perform as well as staff radiologists in screening US for suspected intussusception and have gained both the respect and confidence of the paediatricians.

Ultrasonographic findings of intestinal intussusception in seven cats

The medical records of seven cats with intestinal intussusception that were diagnosed by abdominal ultrasonography and exploratory laparotomy were reviewed. In transverse ultrasonographic sections the intussusception appeared as a target-like mass consisting of one, two or more hyperechoic and hypoechoic concentric rings surrounding a C-shaped, circular or non-specific shaped hyperechoic centre. Part of the intestine representing the inner intussusceptum, located close to the hyperechoic centre and surrounded by concentric rings, was also detected. In longitudinal sections the intussusception appeared as multiple hyperechoic and hypoechoic parallel lines in four cases and as an ovoid mass in three cases. In one case the ovoid mass had a 'kidney' configuration. Additional ultrasonographic findings associated with intestinal intussusception included an intestinal neoplasm in one cat. The results of the present study demonstrate that the ultrasonographic findings of intestinal intussusception in cats bear some similarities to those described in dogs and humans, are relatively consistent, and facilitate a specific diagnosis.

The effect of screening sonography on the positive rate of enemas for intussusception

BACKGROUND

The referring physicians at our institution used the enema as a diagnostic test in children with suspected intussusception.

OBJECTIVE

To determine the change in rate of positive enema findings performed for suspected intussusception with the intervention of screening ultrasound (US).

MATERIALS AND METHODS

Since October 1995, 224 children (mean age 2.2 years) with suspected intussusception were referred for enema examination. In January 2001, US was introduced as a screening test for intussusception. Enemas were performed for all children with positive US findings and were offered for those with negative US findings if clinical suspicion persisted.

RESULTS

Before 2001, 184 children underwent enema with intussusception documented in 40 (22%). Since January 2001, 40 children have been seen with suspected intussusception (12/40 positive or 30%). Two directly underwent enema (1/2 positive); 38 children underwent US. In 12 of 38 children, the US finding was positive, and an intussusception was found at enema examination in 11 of 12. In 26 cases, the US finding was negative. Seven of the 26 children with a negative sonogram finding had an enema, which was also negative. Nineteen enemas were canceled. With a screening US, the positive rate for enemas is now 58% (11/19). We know of no case of intussusception missed at US.

CONCLUSION

Screening US has decreased unnecessary enemas for clinically suspected intussusception, increasing positive findings from 22% to 58%. This has in turn reduced children's exposure to radiation.

Ultrasonographic signs of intestinal intussusception associated with acute enteritis or gastroenteritis in 19 young dogs

The ultrasonographic pattern of intestinal intussusception was studied in 19 young dogs with acute enteritis or gastroenteritis. The intussusception was observed to be a target-like mass consisting of a hyperechoic or anechoic center surrounded by multiple hyperechoic and hypoechoic concentric rings in transverse sections. In longitudinal sections, the intussusception appeared as multiple hyperechoic and hypoechoic parallel lines, as a tumor-like or pseudokidney mass, and as a trident-like configuration. Ultrasonography may provide a sensitive, specific, and accurate method of diagnosing intestinal intussusception in young dogs.

The diagnosis and treatment of adult intussusception

BACKGROUND

Intussusception in adults is often diagnosed on computed tomography (CT), and the optimal treatment of this entity is not universally agreed upon. We report our experience in an attempt to clarify the usefulness of CT scan and the optimal treatment of this entity.

STUDY

Seven cases of adult intussusception were encountered at our institute between 1991 and 2001. Data related to presentation, diagnosis, treatment, and pathology were analyzed.

RESULTS

Preoperative diagnosis was made in four patients by CT scan and/or ultrasonography. Two patients had colonic cancer and one had jejunal cancer. Three of four patients with small bowel intussusception underwent reduction before resection and the other one underwent resection without reduction because of severe ischemic bowel.

CONCLUSIONS

The CT scan is most useful in making the diagnosis of intussusception. Colonic lesions should be resected without reduction. Small bowel lesions should be reduced only in patients in whom a benign diagnosis has been strongly suggested preoperatively or in patients in whom resection may result in short gut syndrome.

Pediatric abdominal applications of color Doppler ultrasonography

Color Doppler ultrasonography (US) is a valuable imaging method because of the important information it provides with respect to organ perfusion, vessel patency, and tumor characterization. In addition, it is a noninvasive technique that does not use ionizing radiation. This review summarizes current applications of color Doppler US in the diagnosis of diseases or abnormalities of the liver and biliary tree, the urinary and gastrointestinal tracts, and the inguinal region.

Sonographic detection of lymph nodes in the intussusception of infants and young children: clinical evaluation and hydrostatic reduction

OBJECTIVE

Our aim was to assess the sonographic appearance of enlarged lymph nodes in the intussusception in infants and young children and to investigate whether the enlarged lymph nodes affect the hydrostatic reduction rate of intussusception.

MATERIALS AND METHODS

This retrospective case control study included a total of 65 children with intussusception, consisting of two groups: a study group of 28 patients with lymph nodes detected in intussusception and a reference group of 37 patients of similar age without lymph nodes in intussusception. The selection criterion for the study group was the presence of a minimum of two lymph nodes, of which at least one had a long axis of 11 mm or greater. The intussusception patterns, target or doughnut-like, and the presence of trapped fluid in the intussusception were also evaluated. Clinical records were reviewed for associated disease. The reducibility of both study and reference groups was assessed and correlated with all the sonographic features mentioned.

RESULTS

Twenty-two of the 28 patients in the study group and none in the reference group had a recent or a current history of gastroenteritis. The overall hydrostatic reduction rate was 46.4% in patients with enlarged lymph nodes in the intussusception and 81.1% (p < 0.005) in patients without enlarged lymph nodes in the intussusception. Larger rather than numerous lymph nodes significantly affected the reducibility rate. Most of the reference group patients had a hydrostatic reduction at first attempt, whereas a second attempt at hydrostatic reduction was required in most of the study group patients.

CONCLUSION

Enlarged lymph nodes in the intussusception are mainly found in patients with a current or recent history of gastroenteritis and decrease the overall hydrostatic reduction rate.

Duodenojejunal intussusception secondary to hamartomatous polyps of duodenum surrounding the ampulla of Vater

Duodenojejunal intussusception is a rare pediatric emergency. A case of duodenojejunal intussusception secondary to hamartomatous polyps of the second portion of duodenum in a 10-month-old boy is reported. Surgical excision of the polyps and reduction of the intussusception were performed. Pathologic examination found hamartomatous polyps. This is the third case report of children in literature, but this is the first case of a child with intussusception surrounding the ampulla of Vater and a successful excision performed without damaging the ampulla of Vater.

Sonographic findings in intussusception caused by a lipoma in the muscular layer of the colon

Lipomas of the gastrointestinal tract are uncommon tumors. Almost all gastrointestinal lipomas are submucosal or subserosal, and most are asymptomatic, although they may cause abdominal pain, bowel obstruction, and gastrointestinal bleeding. The diagnosis of gastrointestinal lipoma is usually not made before surgery. We present a case of colonic intussusception caused by a lipoma that was located in the muscular layer of the colon and was diagnosed preoperatively by sonography. The descending colon appeared edematous and thick. There was layering within the lumen of the descending colon, mimicking the target sign. At the distal end of the intussusception, there was a 4.7-cm, hyperechoic, rounded lesion with a smooth margin. Surgery revealed a polypoid mass originating from the splenic flexure and causing intussusception of the colon, and pathologic analysis confirmed the diagnosis of lipoma of the muscular layer of the colon.

Sonographic features of small-bowel intussusception in pediatric patients

OBJECTIVE

Small-bowel intussusception (SBI) for pediatric patients is unusual and difficult to diagnose preoperatively. This study sought to determine the sonographic findings of pediatric SBI.

METHODS

The sonographic features and surgical findings of 13 pediatric patients (7 boys, 6 girls; age range 4 months-15 years; average age 4 years and 2 months) with SBI encountered in the authors' hospital over a 12-year period were retrospectively reviewed.

RESULTS

Most of the patients presented with nonspecific symptoms, including vomiting, abdominal pain, and/or irritable crying. Sonographic screening in the emergency department revealed a doughnut or crescent-in-doughnut sign, or a multiple-concentric-rings sign for 11 of the 13 patients, and the lesions appeared short. Eight lesions were found in the paraumbilical or left abdominal regions. Sonographic measurement of the size of the lesions from these 11 patients ranged from 2 cm to 3.7 cm (average 2.77 cm). Subsequent barium enemas were performed for these 11 patients, none of which revealed colon lesions. Surgery revealed ileoileal intussusceptions for eight cases, jejunoileal for three, and jejunojejunal for the remaining two. Bowel ischemia or necrosis and pathologic lead points were demonstrated for seven and six patients, respectively, although none were recognized preoperatively.

CONCLUSIONS

Small-bowel intussusception is often over-looked due to nonspecific clinical presentations. Sonographic demonstration of a 2-3-cm sized, short, doughnut-like lesion, especially in the left abdomen or paraumbilical regions, should lead to strong suspicion of SBI.

Intussusception in children: US-guided pneumatic reduction--initial experience

PURPOSE

To assess the feasibility and effectiveness of ultrasonography (US)-guided pneumatic reduction of intussusception in children.

MATERIALS AND METHODS

The study group consisted of 49 consecutive patients (aged 2 months to 7 years; 36 boys, 13 girls) who underwent 52 reductions of intussusception during 9 months. Intussusception was diagnosed in all patients with the known US criteria, and all patients underwent a US-guided pneumatic reduction attempt wholly within the US examination room. A pressure of 60 mm Hg was maintained for 30 seconds, with US guidance. The procedure was considered to be successful when US showed the disappearance of the intussusceptum and the edematous terminal ileum with an abrupt transition into the normal proximal ileum. When the intussusception was not reduced, the procedure was repeated, with pressure increased to 120 mm Hg.

RESULTS

The overall success rate of US-guided pneumatic reduction was 92% (48 of 52 reductions), with no immediate recurrence. Of the two patients who had intussusceptions that were irreducible, one had residual ileoileal intussusception at surgery, and the other had an ileal polyp as a lead point. Perforation occurred in two (4%) of 52 cases; one patient underwent right hemicolectomy due to bowel necrosis and had a pinpoint perforation in the normal proximal transverse colon, and the other underwent manual reduction of ileoileocolic intussusception, with microperforation in the proximal transverse colon.

CONCLUSION

US-guided pneumatic reduction seems to be a feasible and effective method for the treatment of intussusception in children because of its radiation-sparing effect and high success rate.

Intussusception

Intussusception is the invagination of one portion of the intestine into another and is the most common form of intestinal obstruction in infants. This report reviews the clinical presentation and diagnostic and treatment options available for intussusception. The etiologies of childhood intussusception are discussed. Details and literature review are provided on the advantages and disadvantages of ultrasonography, barium enema, air contrast enema, and surgery in the diagnosis and treatment of intussusception.

Painless intussusception and altered mental status

A 7-month-old child presented to the emergency department (ED) with 2 hours of painless, nonprojectile emesis and a normal mental status. Over a 3-hour period in the ED, the child remained pain-free, but developed hematemesis, hematochezia, and lethargy, progressing to unresponsiveness. The patient was evaluated for toxic ingestion, intracranial bleed, sepsis/meningitis, and intraabdominal pathology. The diagnosis was made by an abdominal ultrasound, which demonstrated an ileal-cecal intussusception that ultimately required surgical reduction. This case illustrates an insidious and poorly understood presentation of a common childhood affliction, as well as the utility of abdominal ultrasound in evaluating a hemodynamically stable patient with intussusception.