Case of the Month April 2015, Page 5

A contrast enema is considered the gold standard for diagnosing and treating intussusceptions in children.
 

Steps in intussusception reduction, per ACR guidelines:

  • Anesthesia is generally not required, but sedation may be needed if the patient is in considerable distress and/or interfering with the procedure.  The surgical team must be aware of the procedure, in case of perforation.
  • Rectal catheterization is performed, with careful inflation of a rectal retention balloon under fluoroscopy. Buttocks are taped together tightly to maintain seal.
  • Pneumatic (using 80 to 120 mm Hg of air or CO2 from an inflation cuff) vs hydrostatic (liquid contrast media) approaches are possible.
  • With hydrostatic reduction (as done here) water soluble iso-osmolar contrast should be used,  in order to reduce peritoneal scarring in the event of perforation.
  • Contrast fills the bowel by gravity, with the contrast infusion bag elevated ~3 ft above the patient.  The bag should not be squeezed.
  • Continuous hydrostatic pressure is applied for around 3 to 5 min.  The procedure is stopped once contrast reaches the small bowel.  If there is no reduction, the bowel is drained of the contrast.
  • This process is repeated at least three times, after which surgery is re-consulted.

For a larger image, please click on Ardestani 7

The patient underwent a contrast enema.  The contrast column from the first bolus of rectal contrast did not extend beyond the proximal transverse colon, forming a lucent filling defect (indicated by red arrows).  This confi

rmed the presence of an iliocolic intussusception.  Note the residual contrast from the upper-GI study filling the small bowel.


The bowel was evacuated of contrast, and a second reduction attempt was made.  Subsequent serial images below show gradual reduction of the intussusception (indicated by red arrows).  The final image shows reflux of contrast into the small bowel.


The patent’s symptoms immediately improved following the procedure.  She was monitored overnight and discharged the following morning.

For a larger image, please click on Ardestani 8 , Ardestani 9 and Ardestani 10 .

The patent’s symptoms immediately improved following the procedure.  She was monitored overnight and discharged home the following morning.

References

Scorza K, Williams A, Phillips JD, Shaw J. Evaluation of nausea and vomiting. Am Fam Physician. 2007 Jul 1;76(1):76-84. Review. PubMed PMID: 17668843.

ACR Appropriateness Guidelines. 2014

http://radiopaedia.org/articles/pseudokidney-of-intussusception

ACR–SPR Practice Parameter for the Performance of Pediatric Fluoroscopic Contrast Enema Examinations.  2014

 

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