Sunday, May 20, 2012

How To Perform An Intussusception Reduction

What Is An intussusception? 

An intussusception occurs when one part of the bowel becomes entrapped within an adjacent segment of bowel. The bowel is said to have telescoped into itself. The portion of the bowel within the lumen is termed the intussusceptum. The portion of bowel containing the intussusceptum is termed the intussuscipiens. The terminology can be a bit confusing at first, but associate the intusscipiens as the portion of bowel which is the recipient of the intussuscepted bowel segment. The most common location in children is at the ileo-cecal junction.

While an intussusception can occur at any age, it is a common finding in the pediatric age group, especially between ages of 6 months and 2 years. The most common cause is thought to be hyperplastic lymphoid tissue after a preceding viral infection. In less than 15% of cases is there a lead point such as a mass. Intussusception of one of the common causes of small bowel obstruction in children.

Intussusception diagram
Source: Wikipedia

How To Reduce An Intussusception

The classic triad for an intussusception is intermittent abdominal pain, vomiting, and bloody stools (termed currant jelly stools). Diagnosis of an intussusception is typically made using ultrasound. The various imaging characteristics on ultrasound are beyond the scope of this post. Once the diagnosis is made, here is how a reduction can be performed:

  1. Examine the patient. Check for peritoneal signs, as peritonitis is a contra-indication to attempting a reduction.
  2. Order a set of abdominal x-rays to exclude free intraperitoneal gas. 
  3. Consult the pediatrics and pediatric surgery services so that they are aware of the situation.
  4. Prepare the fluoroscopy suite. If using contrast, hang the bag 3 to 5 feet above the table. If using air, make sure a sphygmomanometer is present to measure the pressure and a needle in case of perforation. 
  5. Place the patient prone on the table. Make sure they have been appropriately restrained.
  6. Using a soft-tipped catheter and gel, insert the enema tube into the patient's rectum.
  7. Advance the contrast into the lumen of the bowel until the obstruction is reached. 
  8. Continue giving contrast for three minutes.
  9. If the intussusception is reduced, the ileo-cecal junction should be fully visualized. If it has not been reduced after three minutes, two more attempts can be made.
  10. If the intussusception is not reduced after three attempts, refer the patient to pediatric surgery for operative reduction.
If the intussusception is successfully reduced, the patient should be admitted and observed for 24 to 48 hours for re-intussusception, which can occur 10% of the time.  

Target Sign of Intussuception on Ultrasound
Source: Radiopaedia


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