Ultrasound and intussusception..One stop station for diagnosis and reduction

One stop station for diagnosis and reduction

Dr/Ahmed BahnassyConsultant Radiologist

PSMMC-Riyadh-KSA

Ultrasound and intussusception

Diagnosing intussusception

Ultrasound value

• High sensitivity and specificity (95-100% respectively).

• Large ..5 X 2,5 cm• Rapid learning curve even for unexperienced

sonographers,residents or radiologists.• Many typical signs.

TYPICAL DIAGNOSTIC SIGNS

Target –Doughnut -HayFork –Sandwitch signs.

Target sign(Doughnut sign)

Pseudokidney

Trapped fluid

• High correlation with ischaemia and irreducibility(p=0,001)

Trapped mesentery

Frond surface

• Ileo-ileo-colic.• Low possibility

of reduction.

Sonograms of residual ileoileal intussusception after pneumatic reduction of ileocolic intussusception.

Yoon C H et al. Radiology 2001;218:85-88

©2001 by Radiological Society of North America

Doppler value

• Presence of flow should encourage more attempts and more time (viable bowel).

• Absence of flow (24 hours)should make less attempts and vigor of reduction.

Dangerous signs

• Maximum trapped fluid.• Fronded surface of ileo-ileo-colic

intussusception.• Absence of doppler flow.

– Limited attempts-low pressure.• Pneumoperitoneum (X-ray or US)

– Contraindicated.

Hydrostatic Reduction under US guidance

advantages:

• No ionizing radiation .• More attempts and longer time .• High success rate (76-95 %).• Low incidence of perforation.

PreparationFigure 1. The plastic enema ring is shown together with the Foley catheter, which is connected

by plastic tubing and a three-way tap to a pressure gauge and a 50-mL syringe.

Khong P L et al. Radiographics 2000;20:e1-e1

©2000 by Radiological Society of North America

Preprocedure Checklist

• 1. The patient should be stabilized clinically with an intravenous line in place. • 2. The patient should not have a clinical contraindication (peritonitis or

perforation). • 3. The following supplies should be prepared:• a. Enema ring to prevent spills; • b. Saline (1–2 L)or Hartmann solution, warmed to body temperature, in an

enema bag; • c. Foley catheter, the largest possible based on age;

– the following can be used as a guide:– younger than 6 months…. 18F; 6 to 12 months … 20F; 12 to 24 months … 22F; and

older than 24 months … 24F.

d. A 20-mL syringe with water to inflate the Foley catheter balloon; and e. Water-resistant tape to seal the buttocks.

Figure 1. The plastic enema ring is shown together with the Foley catheter, which is connected by plastic tubing and a three-way tap to a pressure gauge and a 50-mL syringe.

Khong P L et al. Radiographics 2000;20:e1-e1

©2000 by Radiological Society of North America

Reduction steps

• 1. Place child in the left lateral or prone position. Insert the catheter, and inflate the balloon, checking the position on sonography. Seal the buttocks tightly using water-resistant tape.

• 2. Transfer the child to the supine position. Scan the patient to confirm the expected location of the intus- susception, and document and localize any free fluid in the abdomen and pelvis. Elevate the enema bag to 3 ft above the bed to generate approximately 80 mm Hg of pressure. Observe the flow of fluid from the rec- tum and colon on sonography to facilitate visualiza- tion of leading edge of the intussusception .

Figure 2. The child is placed in the plastic enema ring, and an 18-F Foley catheter is inserted into the rectum.

Khong P L et al. Radiographics 2000;20:e1-e1

©2000 by Radiological Society of North America

Figure 3. Continuous US guidance is provided during hydrostatic reduction.

Khong P L et al. Radiographics 2000;20:e1-e1

©2000 by Radiological Society of North America

• Follow the progression of intussusception until it is completely reduced, 5 minutes is reached, or perfo- ration is suspected.

• Scan the abdomen and pelvis intermittently to look for the presence of a sudden increase in free fluid that would suggest perforation.

• In a case of bowel perforation, abort immediately and drain the fluid out by lowering the enema bag below the bed. Refer to surgery.

Repeat attempts• If unsuccessful after 5 minutes of continuous moni-toring, lower

the enema bag to relieve the pressure, and “rest the bowel” for 2 minutes.

• 2. During this time, scan the pelvis to confirm that the Foley catheter is in place; assess for leaks; drain/clean the enema ring; and retape the buttocks if necessary.

• 3. Once rested, raise the bag an extra 1 ft for every attempt, up to a maximum of 5.5 ft (for ≈120 mm Hg of hydrostatic pressure).

• Repeat attempts may be performed up to 5 times.• 4. If there is progressive reduction during several attempts, and

difficulty is encountered at the ileocecal valve, a delayed attempt may be performed after resting the bowel for 30 to 60 minutes.

• If there is progression after the delayed attempt, a second delayed attempt can be performed. If there is no progression, consider aborting the procedure.

• 5. If there is no progression during the first 3 attempts, and the head of the intussusception is still at or distal to the splenic flexure, consider aborting the procedure.

• 6. To abort the procedure, lower the enema bag to drain the colon to relieve the pressure, and remove the Foley catheter. Refer the patient for surgical intervention.

Successful Reduction• 1. Follow the intussusception until successful reduction is attained,

defined by the following criteria: • a. Visualization of the entire cecum and disappear- ance of the

intussusception • b. Visualization of a thickened but patent ileocecal valve • and c. Free flow of fluid into the distal small bowel • 2. After successful reduction, continue flow for 15 to 30 seconds to fill

the small bowel and evaluate for small- bowel intussusception. • Stop the flow of fluid while carefully scanning for any lead points (eg,

polyps, Meckel diverticulum, and duplication cyst). • At the end of the procedure, lower the enema bag to drain the colon,

and remove the Foley catheter. • Scan the pelvis for free fluid.

Reduction followed by US

reduction caecum.avi

Reduction criteria

reduction.avi

Pros and cons

• High sensitivity and specificity of US diagnosis of intussusception.

• Available resources.• No transportation and

re-arrangements=save time.

• New=learning curve.• Writing PPG• Nurses orientation.• Room availability .• Logistic issues.• Confidence bridge.

Thank you