Air encircling the intussusceptum on air enema for intussusception reduction: an indication for surgery?

Abstract

Objectives: The prompt identification of children in whom enema reduction of intussusception might fail and surgery is necessary is crucial in order to avoid futile repeat attempts and untoward complications. The purpose of this retrospective review was to determine whether air encircling the intussusceptum in the small bowel during air enema for intussusception reduction could serve as an indication for operation rather than repeat attempts at radiological reduction.

Methods: Imaging studies of 83 children aged 4 to 40 months with idiopathic intussusception who had air enema for intussusception reduction were reviewed for the presence of air encircling the intussusceptum in the distal small bowel. Findings were correlated with clinical course and surgical findings.

Results: In 12 of 83 patients, air was seen encircling the intussusceptum in the small bowel, and in 11 of these (88%) air enema failed to reduce the intussusception. In 8 of the 11, delayed repeated attempts using air enema failed to reduce intussusception. Clinical signs and their duration did not differ between those children without and those with air encircling the intussusceptum.

Conclusion: In the presence of air encircling the intussusceptum in the distal small bowel on air enema, delayed repeated attempts for intussusception reduction are unlikely to succeed, and surgery is indicated.

Figure 1

Intussusception in a 12-month-old girl who presented with fever and restlessness for 48 h. Fluoroscopy image in the prone position demonstrates the intussusception (I), surrounded by air (arrows), protruding through the ileocaecal valve on a narrow stalk (arrowheads).

Figure 2

Intussusception in a 14-month-old boy who presented with abdominal pain and bloody diarrhoea for 72 h. Fluoroscopy image in the prone position (a) demonstrates the intussusception (I), surrounded by air (arrows), protruding through the ileocaecal valve on a short stalk (arrowheads). A small amount of air is seen in the distal small bowel (white arrows). On sonography (b), the intussusceptum head (I) is surrounded by tiny echogenic dots (arrows), representing air between the intussusceptum and the intussuscipiens.

Figure 3

Intussusception in a 4-month-old boy who presented with diarrhoea for 24 h. Fluoroscopy image in the prone position (a) demonstrates the intussusception (I), surrounded by air (arrows), protruding through the ileocaecal valve. A small amount of air can be seen in the distal small bowel (white arrow). Repeat sonography (b) confirmed the persistence of the intussusception and demonstrated tiny echogenic dots representing air (arrows) between the intussusceptum head (I) and the intussuscipiens mucosa. ff, free fluid. Fluoroscopy during a delayed reduction attempt (c) demonstrates the persisting intussusception (I) and free air, delineating the transverse colon (arrowheads), as confirmed in an oblique view (d), anterior and posterior to the liver (L) and under the diaphragm (arrows).

Figure 4

Recurrent intussusception in a 36-month-old girl who presented with intermittent abdominal pain and lethargy for 10 h. Fluoroscopy image in the supine position (a) demonstrates the ileoileal intussusception (I), surrounded by air in the caecum (C, long arrows), protruding through the ileocaecal valve (long white arrow) on a short stalk (arrowheads). The double density of the ileum protruding into the caecum reflects the overlapping inner and outer layers of the intussusception. A small amount of air can be seen in the distal small bowel (short arrows). Intraoperative image (b) shows the ileoileal component (I), partially reduced from the caecum (C), the intact ileocaecal valve (arrows) and the point of intussusception (arrowheads). Discolouration along the serosal ileal margin reflects early necrosis (which proved to be reversible) of the bowel wall. (c) The ileoileal component (I) of an intussusception (arrowheads) protruding through an intact ileocaecal valve (long arrows) into the caecum (C).