1. Discussion
By Int. 謝志成

2. Outline Basic knowledge about intussusception
Radiology aspect of intussusception
Diagnostic tools and specific signs
Therapeutic method in radiology—enema

3. Intussusception Proximal Distal
Telescoping of a portion of the intestine into itself
Proximal
Distal
A.T. Byrne et al. The imaging of intussusception, Clinical Radiology (2005) 60, 39–46

4. Intussusception Most common cause of intestinal obstruction in 3m-6y
60% younger than 1y/o, most commonly 5-10 month old
Higher incidence in spring and autumn
Intussusception in 5m – 2y/o rarely had leading point
and usually responsive to non-operative reduction
Intussusception in older child or adult had leading point
and usually require operative reduction

5. Symptoms of Intussusception
Classic triad : in only 1/3 patients
abdominal pain, vomiting, bloody stool
Preceding upper airway infection
Intermittent colicky pain
Bilious or non-bilious vomiting
Diarrhea / Currant jelly stool
Palpable abdominal mass

6. Causes of Surgical leading Point
Meckel diverticulum
Enlarged mesenteric lymph node
Benign or malignant tumors of mesenteric or intestine
lymphoma, polyp, harmartoma, neurofibroma, etc.
Mesenteric or Duplication cyst
Submucosal hematoma (HSP, coagulation disorder, etc.)
Inverted appendiceal stump
Sutures or staples along an anastomosis

7. Radiology aspect of intussusception

8. Diagnostic tools Abdominal plain film Ultrasound
Enema and enema reduction
Computed tomography & Magnetic resonance imaging

9. Plain film Poor sensitivity and specificity
First report was by Lehmann in 1914
Target sign and meniscus sign
Diagnostic value
For R/O Exclusion of intussusception and other disease
Highly susp. Confirmation of intussusception
Sure Exclusion of perforation and bowel obstruction

10. Plain film Meniscus sign Target sign
del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

11. Ultrasound High sensitivity: 98~100%
Fast, non-invasive, easy to perform and reproducible
Transverse —Target lesion, doughnut sign
Longitudinal – a sandwich-like appearance, pseudokidney sign
Diagnostic value
Highly reliable in children, may false positive in adult
False negative in large amount of bowel gas
Color duplex for blood flow detection

12. del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

13. Ultrasound doughnut pseudokidney
del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

14. Enema Also therapeutic, Potential risk for perforation
Spring coil sign
If enema reduction fail for three times, surgical intervention is indicated
A.T. Byrne et al. The imaging of intussusception, Clinical Radiology (2005) 60, 39–46

15. Coil spring Meniscus sign Coil spring
del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319
Meniscus sign
Coil spring

16. Enema reduction Contra-indication
Unstable patient– dehydration, shock, peritonitis
Evidence of perforation—free air
Media– barium, water soluble contrast, saline, air
Fluoroscopy or ultrasound guided
Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

17. Fluoroscopy vs. Ultrasound
Ultrasound-guided
No radiation
Visualization of all component of intussusception
recognition of pathologic lead points
But poor in recognition of perforation during reduction
Fluoroscopy-guided
Familiar to use
Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

18. Pneumatic vs. Hydrostatic
Pneumatic reduction
Clean, quick and easy to perform
Less radiation exposure
But possible of partial reduction, or difficult in large bowel gas
Hydrostatic reduction
Vast experience and familiar
Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

19. Reduction rate
By symptom—pain only 98%, vomiting 82%, bloody stool 44%
Duration : 12hr 85%, 48hr 70%
Age: the younger ,the easier
Leading point: only 1/3
Presence of blood flow in Doppler US suggest reducible
Med 95, 小外共筆,No14

20. *different patient population and different protocol
Reduction rate: 12.5%~100%
Perforation:0%~4.26%
*different patient population and different protocol

21. Method to improve reduction rate
Medications—glucagon or sedatives
Transabdominal manipulation
Delayed repeated attempted enema
Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108

22. CT and MRI
Not indicated for children, but are useful tools for evaluated underline disease and leading points

23. Reference
A.T. Byrne et al. The imaging of intussusception, Clinical Radiology (2005) 60, 39–46
Alan Daneman, Oscar Navarro, Intussusception Part 2: An update on the evolution of management, Pediatr Radiol (2004) 34: 97–108
del-Pozo et al, Intussusception in children, RadioGraphics, 1999,Vol 19, No. 2:299~319

24. Thank you for your attention