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Decision-making in intussusception

Spencer W Beasley GD Abbott symposium 2015

Good decision-making in intussusception

Spencer W Beasley GD Abbott symposium 2015

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Does the child have intussusception?

Suspect on clinical grounds •  Correct diagnosis made initially by medical

practitioner in only 50%

Where do the problems arise?

Relevance of age of child

Intussusception can occur at any age •  Most common between 3 months and 2 years •  Most likely to be misdiagnosed outside this age-

range

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Typical symptoms of intussusception

Classical description occurs in only 20%: triad of colic, rectal bleeding and abdominal mass

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Typical symptoms of intussusception

Classical description occurs in only 20%: triad of colic, rectal bleeding and abdominal mass

Usual symptoms are :

- vomiting 90% - abdominal pain 85% - pallor - lethargy and listlessness

Vomiting

•  Gastroenteritis unlikely if vomiting persists in absence of diarrhoea

•  Initial vomiting reflex (autonomic)

•  Later vomiting related to small bowel obstruction

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Abdominal mass •  Palpable in about 50% •  Most likely felt in first

24 hours •  Unlikely to be felt if

abdomen distended or tender

•  Central to surface marking line of colon

Rectal bleeding

•  Occurs in less than 50% •  “Red currant” stools •  Implies some ischaemia

or congestion •  Not a contraindication to

enema reduction

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Diarrhoea in intussusception

Distinguish from gastroenteritis Represents evacuation of colonic contents

distal to obstruction •  Small volume •  Short duration

Absence of history of pain

•  No pain recognised in 15% •  Predominance of other symptoms •  Difficult in interpretation of pain in infant •  Dependent on duration of observation

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Late presentation

•  Unwell listless child, looks ill •  Fever •  Dehydration •  Abdominal distension

Late presentation

•  Unwell listless child, looks ill •  Fever •  Dehydration •  Abdominal distension

Distinguish from other causes of sepsis

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Recognise conditions known to predispose to intussusception

•  Peutz-Jegher syndrome: check for subungual, perioral and perianal pigmentation

•  Gardner syndrome •  Familial polyposis •  Henoch-Schonlein

purpura

What is the role of plain radiology in management?

1. To assist in diagnosis

Equivocal or unhelpful in >50% (Pediatr Radiol

1994;24:17) Better test available: ultrasonography

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Plain Xray for diagnosis

Often unhelpful Apex of intussusception visible in the transverse colon Indirect evidence e.g. SBO

What is the role of plain radiology in management?

1. To assist in diagnosis but ultrasonography better

2.  To identify contraindications to attempted

enema reduction SBO pneumoperitoneum

but not evidence-based

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SBO per se is NOT a contraindication to attempting enema reduction

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•  Omit if diagnosis obvious •  SBO not a contraindication to attempted

enema reduction (Pediatr Surg Int 1987;2:291) •  Pneumoperitoneum (bowel perforation)

extremely rare - and there would be clinical evidence of peritonitis

Is an abdominal plain xray necessary?

Preferred diagnostic modality

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How good is ultrasonography for diagnosis?

•  Up to 100% sensitive and specific (Radiol 1994;191:781, Pediatr Surg Int 1998;14:158)

•  Identifies pathological lesion at leadpoint (Pediatr Radiol 2000;30:594)

•  Colour flow Doppler may predict reducibility (Radiol 1994;191:781)

When should ultrasonography be used for diagnosis?

•  Not necessary if diagnosis extremely likely (Pediatr Surg Int 1998;14:157)

•  Valuable when diagnosis uncertain - minimises radiation exposure

•  Initial step when sonographic guided reduction planned

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Options for treating intussusception?

•  Barium enema •  Gas (air or oxygen) enema •  Hydrostatic reduction under ultrasound •  Surgery: open or laparoscopic

•  Which should be used when? –  Depends on facilities/expertise, and clinical features

eg peritonitis or evidence of pathological leadpoint

What are the indications for attempting enema reduction?

All cases of confirmed intussusception -except:

1. clinical evidence of full thickness bowel necrosis (peritonitis or septicaemia)

2. pathological lesion at leadpoint identified or extremely likely e.g. Peutz Jegher syndrome

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Barium enema Barium enema reduction

under fluoroscopic control (50% overall success rate)

Peritonitis an absolute

contraindication Various perceived relative

contraindications

Perceived contraindications

•  Long duration of symptoms •  Age extremes •  Fever or leucocytosis •  Possibility of pathological lesion at

leadpoint •  Recurrence •  SBO on plain radiology

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Not real contraindications

•  Long duration of symptoms •  Age extremes •  Fever or leucocytosis •  Possibility of pathological lesion at

leadpoint •  Recurrence •  SBO on plain radiology

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Patients matched for duration of symptoms, age, and severity

What sort of enema should be used?

Barium enema if: - gas enema not available or there is inadequate radiology expertise - rural centre provided child stable, before transfer if unsuccessful (NZ Med J 2001)

Gas enema preferred because of higher success rate if expertise available

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Gas (air or oxygen) enema

•  Higher success rate than barium - 80-90% (J Pediatr Surg 1992;27:474, AJR 1988;150:1349)

•  Faster reduction (AJR 1988;150;1345) •  Safer - low perforation rate and minimal

peritoneal soiling (Pediatr Surg Int 1998;14:168)

•  Less radiation (Pediatr Radiol 1995;25:89)

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Ultrasonographic guided reduction

Follows straight on from diagnosis Limits radiation exposure Versatile:

with hydrostatic reduction (J Pediatr Surg 1999;34:1016) with gas enemas (Pediatr Radiol 2000;30:339, Radiol 2001;218:85)

Justification for delayed repeat gas enema

•  First attempt fails in up to 25% •  Most of these can be reduced manually or

already reduced at surgery (J Pediatr Surg 1994;29:588, Pediatr Surg Int 1999;15:214)

•  Successful in >50% (J Pediatr Surg 1994;29:588) •  Saves money and reduces hospital stay

(Aust NZ J Surg 1997;67:330)

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Rationale for delayed repeat enemas

•  Allows resolution of oedema after partial reduction

•  Makes subsequent reduction easier •  Requires at least 30 minutes

(J Pediatr Surg 1999;34:1016, J Pediatr Surg 1994;29:588) •  50% success rate with each repeat

(Pediatr Surg Int 1999;15:214)

When should a delayed repeat enema be used?

•  Partial reduction with first (or preceding) attempt

•  Child remains in good clinical condition •  No evidence of pathological lesion at

leadpoint

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When is surgery indicated?

1. Attempts at (repeated) enemas have failed 2. Full thickness bowel necrosis (peritonitis or

septicaemia) 3. Perforation during attempted reduction 4. Evidence of pathological lesion at leadpoint

Operative appearance of intussusception

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Appearance of leadpoint in idiopathic intussusception

Surgical approach

Open – Transverse right upper abdominal incision

Laparoscopic – Difficult if gross bowel dilatation –  “rocking pull” technique

Always put safety first

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Key points for suspected intussusception

•  Routine AXR not indicated •  Initial confirmation diagnosis on US •  Gas enema in all except peritonitis •  If partial reduction, repeat after interval •  Surgery reserved for repeat failed reduction,

or evidence of full thickness bowel necrosis