Pediatr Radiol (1992) 22:326-327
Pediatric Radiology 9 Springer-Verlag 1992
Air reduction of an intussusception caused by a pathologic lead point in an infant S. D o n 1, M. D. Cohen 1, L. J. Wells 1, and F. J. Rescorla 2 1Department of Radiology, 2Department of Surgery, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis, Indiana, USA Received: 4 February 1992; accepted: 18 February 1992
Abstract. L e a d p o i n t s that are the cause of a n ileocolic int u s s u s c e p t i o n are rare in infants [1J, as is successful reduct i o n using b a r i u m [2]. A i r r e d u c t i o n of a n i n t u s s u s c e p t i o n with a p a t h o l o g i c lead p o i n t has n o t b e e n p r e v i o u s l y reported. We r e p o r t a case of a n i n f a n t with an ileocolic intuss u s c e p t i o n s e c o n d a r y to a d u p l i c a t i o n cyst that was successfully r e d u c e d with air. T h e pathologic lead p o i n t was r e c o g n i z e d at the time of r e d u c t i o n a n d c o n f i r m e d with water-soluble contrast. A i r is b o t h a diagnostic a n d therapeutic contrast agent.
Case report A 41/2-month-old white male in previously good health developed a fever and upper respiratory symptoms 2 weeks prior to admission. The child was admitted to the local hospital 24 h prior to referral with fever, bilious vomiting and dehydration. An abdominal radiograph was obtained and demonstrated a small bowel obstruction. The child was resuscitated with intravenous fluids and transferred to our institution. Upon arrival the child was noted to have a distended abdomen with visible loops of small bowel with peristalsis. The abdomen was nontender and no palpable masses were identified. The stool guaiac test was negative. After consultationwith the surgeons it
was decided to attempt an air contrast enema for both diagnosis and therapy. The Shiels intussusception air reduction system (Custom Medical Pro ducts, Mainville,OH) without a pop-off valve was used to instill air into the rectum. The intussusceptionwas encountered in the hepatic flexure and was rapidly reduced with free flow of air into the small bowel under fluoroscopic guidance at a pressure less than 60 mm Hg. However, there remained a mass filling defect outlined by air in the region of the terminal ileum separate from the cecum and ileocecal valve (Fig. 1). To confirm the suspicion of a pathologic lead point Omnipaque 180 (Winthrop, New York, NY) was instilled into the colon. At this point it was noted that the intussusception had recurred. A second air reduction was successful. However, the mobile mass remained in the terminal ileum (Fig. 2). Due to the presence of a lead point causing a recurrent intussusception,the infant was taken to surgery. At the time of exploration a large duplication cyst was found in the terminal ileum, The mass was resected and bowel continuityrestored with an end-end ileocolostomy. The infant recovered uneventfully.
Discussion Since the p u b l i c a t i o n of a large series f r o m the People's R e public of C h i n a using air to reduce i n t u s s u s c e p t i o n , there has b e e n a n i n c r e a s i n g i n t e r e s t in N o r t h A m e r i c a , W e s t e r n
Fig. 1. Steep LPO position. Soft tissue mass (arrows)separate from the cecum (arrowhead) Fig. 2. Shallow LPO position. The cecum (openarrow)and appendix are contrast filled while the mass is outlined by contrast (arrows).Contrast is freely refluxed into the terminal ileum
(curvedarrow)
327 E u r o p e and Australia in the use of air to reduce ileocolic intussusceptions [3, 4]. While air has been shown to be more effective than barium [4], barium is still used as the contrast agent in many North American pediatric centers [5]. One concern that radiologists have raised with the air contrast method is the failure to correctly identify a lead point causing the intussusception [5]. Intussusception caused by lead points represent only 5 % of the total number of intussusceptions seen in childhood [1]. These children usually present at greater than 2 years of age. The present case is unusual in the fact that the patient's age is younger than that typical for intussusception due to a lead point. Barium enema is rarely successful in reducing ileocolic intussusception with a pathologic lead point [1]. When they are able to be reduced a filling defect in the contrast column is noted that is separate from the ileocecal valve [2]. To our knowledge this is the first report of successful air reduction of an intussusception caused by a pathologic lead point. The identification of the lead point mass can be seen with air contrast outlining the mass. In this case an enema
with nonionic contrast media was used to confirm the presence of amass.
References 1. Ein SH (1976) Leading points in childhood intussusception. J Pediatr Surg 11:209-211 2. Ein SH, Shandling B, Reilly BJ, StringerDA (1986)Hydrostaticreduction of intussuseptions caused by lead points. J Pediatr Surg 21: 883-886 3. Gu L, Alton DJ, Daneman A, Stringer DA, Liu R Wilmot DM, Reilly BJ (1988) Intussusception reduction in children by rectal insufflation of air. AJR 150:1345-1348 4. Phelan E, de Campo JR Malecky G (1988) Comparison of oxygen and barium reduction of ileocotic intussusception. A JR 150: 13491352 5. Bisset GS III, Kirks DR (1988) Intussusception in infants and children: Diagnosis and therapy. Radiology 168:141-145 S.Don, M.D. Indiana University Medical Center 702 Barnhill Drive Indianapolis, IN 46202-5200 USA
Pediatric Radiology 9 Springer-Verlag 1992
Air reduction of an intussusception caused by a pathologic lead point in an infant S. D o n 1, M. D. Cohen 1, L. J. Wells 1, and F. J. Rescorla 2 1Department of Radiology, 2Department of Surgery, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis, Indiana, USA Received: 4 February 1992; accepted: 18 February 1992
Abstract. L e a d p o i n t s that are the cause of a n ileocolic int u s s u s c e p t i o n are rare in infants [1J, as is successful reduct i o n using b a r i u m [2]. A i r r e d u c t i o n of a n i n t u s s u s c e p t i o n with a p a t h o l o g i c lead p o i n t has n o t b e e n p r e v i o u s l y reported. We r e p o r t a case of a n i n f a n t with an ileocolic intuss u s c e p t i o n s e c o n d a r y to a d u p l i c a t i o n cyst that was successfully r e d u c e d with air. T h e pathologic lead p o i n t was r e c o g n i z e d at the time of r e d u c t i o n a n d c o n f i r m e d with water-soluble contrast. A i r is b o t h a diagnostic a n d therapeutic contrast agent.
Case report A 41/2-month-old white male in previously good health developed a fever and upper respiratory symptoms 2 weeks prior to admission. The child was admitted to the local hospital 24 h prior to referral with fever, bilious vomiting and dehydration. An abdominal radiograph was obtained and demonstrated a small bowel obstruction. The child was resuscitated with intravenous fluids and transferred to our institution. Upon arrival the child was noted to have a distended abdomen with visible loops of small bowel with peristalsis. The abdomen was nontender and no palpable masses were identified. The stool guaiac test was negative. After consultationwith the surgeons it
was decided to attempt an air contrast enema for both diagnosis and therapy. The Shiels intussusception air reduction system (Custom Medical Pro ducts, Mainville,OH) without a pop-off valve was used to instill air into the rectum. The intussusceptionwas encountered in the hepatic flexure and was rapidly reduced with free flow of air into the small bowel under fluoroscopic guidance at a pressure less than 60 mm Hg. However, there remained a mass filling defect outlined by air in the region of the terminal ileum separate from the cecum and ileocecal valve (Fig. 1). To confirm the suspicion of a pathologic lead point Omnipaque 180 (Winthrop, New York, NY) was instilled into the colon. At this point it was noted that the intussusception had recurred. A second air reduction was successful. However, the mobile mass remained in the terminal ileum (Fig. 2). Due to the presence of a lead point causing a recurrent intussusception,the infant was taken to surgery. At the time of exploration a large duplication cyst was found in the terminal ileum, The mass was resected and bowel continuityrestored with an end-end ileocolostomy. The infant recovered uneventfully.
Discussion Since the p u b l i c a t i o n of a large series f r o m the People's R e public of C h i n a using air to reduce i n t u s s u s c e p t i o n , there has b e e n a n i n c r e a s i n g i n t e r e s t in N o r t h A m e r i c a , W e s t e r n
Fig. 1. Steep LPO position. Soft tissue mass (arrows)separate from the cecum (arrowhead) Fig. 2. Shallow LPO position. The cecum (openarrow)and appendix are contrast filled while the mass is outlined by contrast (arrows).Contrast is freely refluxed into the terminal ileum
(curvedarrow)
327 E u r o p e and Australia in the use of air to reduce ileocolic intussusceptions [3, 4]. While air has been shown to be more effective than barium [4], barium is still used as the contrast agent in many North American pediatric centers [5]. One concern that radiologists have raised with the air contrast method is the failure to correctly identify a lead point causing the intussusception [5]. Intussusception caused by lead points represent only 5 % of the total number of intussusceptions seen in childhood [1]. These children usually present at greater than 2 years of age. The present case is unusual in the fact that the patient's age is younger than that typical for intussusception due to a lead point. Barium enema is rarely successful in reducing ileocolic intussusception with a pathologic lead point [1]. When they are able to be reduced a filling defect in the contrast column is noted that is separate from the ileocecal valve [2]. To our knowledge this is the first report of successful air reduction of an intussusception caused by a pathologic lead point. The identification of the lead point mass can be seen with air contrast outlining the mass. In this case an enema
with nonionic contrast media was used to confirm the presence of amass.
References 1. Ein SH (1976) Leading points in childhood intussusception. J Pediatr Surg 11:209-211 2. Ein SH, Shandling B, Reilly BJ, StringerDA (1986)Hydrostaticreduction of intussuseptions caused by lead points. J Pediatr Surg 21: 883-886 3. Gu L, Alton DJ, Daneman A, Stringer DA, Liu R Wilmot DM, Reilly BJ (1988) Intussusception reduction in children by rectal insufflation of air. AJR 150:1345-1348 4. Phelan E, de Campo JR Malecky G (1988) Comparison of oxygen and barium reduction of ileocotic intussusception. A JR 150: 13491352 5. Bisset GS III, Kirks DR (1988) Intussusception in infants and children: Diagnosis and therapy. Radiology 168:141-145 S.Don, M.D. Indiana University Medical Center 702 Barnhill Drive Indianapolis, IN 46202-5200 USA
