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408 Intussusception

ileal or ileo-ileocolic, and a long duration of symptoms before
admission to hospital (>24 hours).
Before any mode of treatment is decided upon, the child must be
vigorously resuscitated with fluids, including blood if the need arises.
A nasogastric tube (NGT) is used to decompress the stomach, an
intravenous (IV) line with a large-bore paediatric cannula appropriate
for the age is set up, and a urethral catheter is passed into the bladder ileocolic intussusception
to monitor the effectiveness of the resuscitative measures by aiming at
obtaining 0.5–2 ml of urine per kilogram body weight per hour. Broad-
spectrum antibiotics must be started.
Give 20 ml/kg body weight of IV fluids (normal saline (NS) or
Ringer’s lactate (RL)) in a minimum of 30–45 minutes to a maximum
of 1 hour. Repeat this until the child is well hydrated, then put on
maintenance fluids using 4.3% or 10% dextrose in one-fifth NS (see
Chapter 5, Fluid and Electrolyte Management). The maintenance fluid (A) (B)
(NS or RL) is given as 4 ml/kg/hr for the first 10 kg, then 2 ml/kg/hr Figure 68.8: (A) Air reduction of an ileocolic intussusception. (B) Barium enema
for the next 10 kg, up to 20 kg and 1 ml/kg/hr for anything more than showing intussusceptum in the distal ascending colon.
20 kg, all in 24 hours. Thus, a 25-kg child will receive: (4 × 10 × 24) +
(2 × 10 × 24) + (1 × 5 × 24) = 960 + 480 + 120 = 1,560 ml of fluid in surgical reduction. Surgery is also advised if there is leakage of fluid
24 hours as maintenance fluid. into the peritoneal cavity as a result of perforation of the bowel.
As stated above, childhood intussusceptions can be managed Leakage of air can cause gross abdominal distention, splinting of the
nonoperatively or surgically. Nonoperative reduction of intussusception diaphragm resulting in acute respiratory distress, and a life-threatening
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is now considered by most paediatric surgeons as the method of choice abdominal compartment syndrome. The pneumoperitoneum thus
for its treatment and involves the use of various agents, gaseous or fluid. caused is readily recognizable, and immediate intervention in the form
NOR can be carried out by using fluids such as barium, 6,17,27 normal of abdominal paracentesis using a large-bore needle (gauge 14 or 16)
saline, and water-soluble contrast media. This method is referred to in the radiology unit before transporting the patient to the operation
6
6,24
as hydrostatic, as opposed to pneumatic or air enema reduction (AER), theatre can be life saving.
in which only air is used. These agents may be used under either We believe that the best results are obtained following NOR of
4,18
fluoroscopic or ultrasound guidance. Note, however, that barium can intussusception.
induce chemical peritonitis when it leaks through a bowel perforation Alternative Methodology
into the peritoneal cavity. Water is not suitable because it will be absorbed In the absence of a fluoroscope and/or US facilities in an institution, air
should the procedure be prolonged and cause water intoxication.
enema reduction of intussusception can be done in the operating room
The Procedure for NOR with the child under anaesthesia. This method has been developed
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Nonoperative reduction is usually performed in the radiology unit by locally, and we attest to its safety and suitability for poorly resourced
(paediatric) radiologists with a paediatric surgeon in attendance. The regional or district hospitals in West Africa, where children with intus-
procedure can also be performed by a paediatric surgeon trained in susception are brought very late to hospital.
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ultrasonography. The procedure involves allowing the fluid (barium The AER method involves submerging the free end of the NGT
solution, water-soluble contrast medium, or NS) to flow at a height of in a kidney dish filled with water and inserting a 20 or 22 Fr Foley
about 100 cm above the level of the buttocks into the rectum and further catheter into the rectum (fully blowing up the balloon). An aneroid
up the colon to meet the intussusceptum and, under sustained pressure, sphygmomanometer is attached to the Foley catheter (Figure 68.9(A–D)),
to reduce it. This is all done under fluoroscopy or US guidance, and the and air is then insufflated into the rectum between pressures of 80 to 140
process of reduction is followed carefully. The reduction is considered mm Hg. Before insufflating air into the rectum, the surgeon first palpates
successfully if there is reflux of fluid back into the terminal ileum the abdomen under anaesthesia, since the child is now completely
through the ileocaecal valve (Figure 68.8(a)). relaxed, and determines the position of the mass in the peritoneal cavity.
Air can also be used for reduction of the intussusception. As the air is insufflated, the surgeon continuously palpates and follows
Fluoroscopy-guided or US-guided pneumatic reduction of the the progress of the mass from wherever it was proximally. When the
intussusception is considered superior to hydrostatic reduction because intussusception is completely reduced, air flows proximally into the
it is safer, faster, and cleaner, and it requires less radiation. Also, small intestines and into the stomach. The air passes through the NGT
pneumatic reduction has a higher success rate than hydrostatic and is noticed as a continuous flow of bubbles in the kidney bowl filled
reduction. It is advisable to use pressures not exceeding 120 mm Hg with water. What is important here is that the air flow into the kidney
for the pneumatic reduction of intussusceptions in children. Pressures dish must be continuous, which confirms that the intussusceptum has
less than 80 mm Hg are noneffective. reduced. The balloon of the Foley catheter is deflated and the catheter
After a successful enema reduction (hydrostatic or pneumatic), the removed; some of the air will escape through the anal orifice, resulting
child should be kept in hospital for a period of 24 hours for observation in the abdomen becoming soft again and less tense.
and then can be discharged home. Feeding can also be resumed Then, the abdomen is again examined to feel for the mass. Normally,
immediately after the procedure. one cannot palpate the intussusception after a successful reduction
The recurrence rate of NOR is less than 10%. Recurrence may be (except for the palpation of the reduced oedematous bowel, which
due to incomplete reduction (but under fluoroscopy- or US-guided requires some experience for one to accept that it is oedematous bowel
reduction, that is less likely) or due to the presence of a PLP. A recurrent and not the intussusception that one is feeling beneath the fingers).
intussusception should be treated by first trying NOR again; if that fails The patient is sent to the recovery ward to recover from anaesthesia
or a PLP is observed, then surgery is advised. and can be fed 3 hours after the procedure. The patient is observed
It is recommended that if the first attempt at enema reduction of for 24 hours, within which period a repeat ultrasound scan is done
the intussusception fails, two or three more attempts can be made, and to confirm the successful reduction of the intussusception or, in the
if these fail to reduce the intussusception, the child should undergo absence of an ultrasound machine, about 10 to 20 ml of barium solution