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410 Intussusception
Prevention Evidence-Based Research
In the main, the majority of intussusceptions in children, especially Table 68.1 presents a study to find out which sonographic patterns of
infants and toddlers, are idiopathic and difficult to prevent. Hence, intussusception are indicative of reducibility by hydrostatic reduction
prevention is aimed at educating parents or caregivers about the disease in children. Table 68.2 presents a 10-year-study to determine whether
and its potential hazard so that children will be brought early to hos- nonoperative management of intussusception is effective and safe in
pital. Primary medical caregivers also need to be educated to increase children age 3 years or older.
their index of suspicion for earlier diagnosis and intervention.
Table 68.1: Evidence-based research. Table 68.2: Evidence-based research.
Title Sonographic features indicative of hydrostatic reducibility of Title Is non-operative intussusception reduction effective in
intestinal intussusception in infancy and early childhood older children? Ten-year experience in a university affiliated
medical center
Authors Mirilas P, Koumanidou C, Vakaki M, Skandalakis P, Antypas
S, Kakavakis K Authors Simanovsky N, Hiller N, Koplewitz BZ, Eliahou R, Udassin R
Institution Agia Sophia Children’s Hospital, Goudi, Athens, Greece Institution Hadassah Medical Center, Jerusalem, Israel
Reference Eur Radiol 2001; 11: 2576–2580 Reference Pediatr Surg Int 2007; 23:261–264
Problem To find out which sonographic patterns of intussusception Problem Nonoperative management of intussusception in children
are indicative of reducibility by hydrostatic reduction in aged 3 years or more in order to determine its efficacy and
children. safety in this age group.
Intervention All children with intussusception underwent sonographic Intervention Clinical features of intussusception were collected from this
examination of the abdomen using transverse and group of children, recording the age, predisposing factors,
longitudinal scans. The sonograms were evaluated for (a) symptoms, and signs, with a review of the sonographic and
a target lesion with multiple concentric rings surrounding fluoroscopic images to assess the degree of intussusception
an echogenic centre, (b) a doughnut-like mass in the and possible underlying PLP.
transverse plane in which the thickness of the hypoechoic
external ring was measured, (c) appearance of trapped fluid Comparison/ An abdominal ultrasound scan was done in all 24 children
in the doughnut-like or target-like mass, and (d) coexistence control with 26 intussusceptions revealing a pseudokidney sign
of free fluid in the peritoneal cavity. (quality of of intussusception in all and mesenteric lymphadenopathy
in 10. Image-guided reduction was attempted in all except
Comparison/ The hydrostatic reduction rate was 100% when the head evidence) one with a small bowel obstruction; in two, barium enema
control of intussusception appeared as a target lesion; with a reduction was attempted; and in 23, air enema reduction
(quality of thickness of the hypoechoic external ring of the doughnut was performed.
≤ 7.2 mm, the reduction rate was 100%; if the thickness
evidence) Outcome/ In four children, a PLP was the cause of the intussusception:
was between 7.5 and 11.2 mm, the reduction rate was only
68.9%; if the thickness of the hypoechoic external ring of effect one Meckel’s diverticulum and three Burkitt’s lymphoma.
the doughnut-like mass was more than 14.0 mm, surgical Air enema reduction in two of the last three and barium
reduction was required. enema reduction in the last one failed to reduce the
intussusceptions. Four children failed nonoperative
Outcome/ Wall thickness was found not to be a significant prognostic management of their intussusceptions: three by pneumatic
effect factor in the reducibility of intussusception, trapped fluid reduction and one by barium enema reduction, but when
was found to be consistently a poor prognostic feature surgery was performed, no PLP was found in any of them.
of reducibility of an intussusception, and free fluid in the Finally, 18 patients with intussusception confirmed by
peritoneal cavity did not have any adverse effect on air- ultrasound scan, who did not have PLP, were successfully
reduction prognosis. reduced by using air enema.
Historical This paper is significant in the sense that if one can Historical This paper confirms the notion that all intussusceptions in
significance/ get a report of the ultrasonographic patterns of the significance/ children, regardless of age, should be managed by using
nonoperative methods (pneumatic or hydrostatic) first. It is
comments intussusception, it is possible to decide beforehand which comments
intussusceptions will easily reduce without much effort and only when this fails that surgery should be considered.
which ones will need more effort to reduce them or even
which ones should not undergo hydrostatic or pneumatic
reduction for fear of causing a perforation or reducing a
gangrenous bowel.

Key Summary Points

1. Intussusception is an occlusive-strangulation type of intestinal investigation for diagnosing intussusception. The radiograph will,
obstruction that requires early diagnosis and treatment. however, inform one about the presence of intestinal obstruction.
2. more than 90% of intussusception cases occur in the age range 7. Once the diagnosis is confirmed, it is necessary to resuscitate
from 3 months to 3 years, and they are usually idiopathic in nature. the child for an attempt at hydrostatic or pneumatic reduction
under either fluoroscopy or ultrasound guidance first. A
3. Intussusception with a pathological lead point occurs more in
the older age group, but can be seen in infants and toddlers. maximum of three attempts should be made to reduce the
intussusception.
4. Intussusception is rare but possible in neonates, so clinicians 8. All nonoperatively reduced intussusceptions should be observed
should have a high index of suspicion if there is a prolapsed for a minimum of 24 hours in hospital before being discharged.
rectal mass in such children.
9. All patients who are haemodynamically unstable, are in shock,
5. Diagnosis is clinical and confirmed by ultrasound scan of
the abdomen looking for a target lesion/doughnut sign in the have peritonitis, have bowel perforation either on admission
axial view and the pseudokidney/sandwich appearance in the or during nonoperative reduction of the intussusception, are
suspected of having a gangrenous bowel (see Figure 68.3) and
longitudinal view.
those who have failed pneumatic reduction should undergo
6. An erect plain abdominal radiograph may be requested open surgery and an attempt at manual reduction or segmental
for exclusion of pneumoperitoneum, but it is not a routine resection and end-to-end anastomosis.