8tepedtextocaso3e4.pdf

Intussusception in children

Seiji Kitagawa, MD; Mohamad Miqdady, MD Up to date on line 16.1 This topic last updated: Fevereiro 4, 2008 Modificado: Jefferson P Piva

INTRODUCTION Intussusception,

the invagination of a part of the

intestine into itself, is the most

common abdominal emergency in early

childhood, particularly in children

younger than 2 years of age, and the

second most common cause of

intestinal obstruction after pyloric

stenosis [1]. Intussusception is unusual

in adults, and the diagnosis is

commonly overlooked. In the majority

of cases in adults, a pathologic cause is

identified [2]. In contrast, the majority

of cases in children are idiopathic.

EPIDEMIOLOGY Intussusception is

the most common cause of intestinal

obstruction in infants between 6 and 36

months of age. Approximately 60

percent of children are younger than 1

year old, and 80 percent are younger

than 2. Intussusception is rare before 3

months and after 6 years of age. In a

population-wide survey in Switzerland,

the yearly mean incidence of

intussusception was 38, 31, and 26

cases per 100,000 live births in the

first, second, and third year of life,

respectively, then fell to less than half

that rate in older age groups [3]. Most

episodes occur in otherwise healthy and

well-nourished children.

Intussusception appears to have a

slight male predominance, with a

male:female ratio of approximately 3:2.

PATHOGENESIS Intussusception

occurs most often near the ileocecal

junction (ileo-colic), although ileo-ileo-

colic, jejuno-jejunal, jejuno-ileal, or

colo-colic intussusception also have

been described. The proximal segment

of bowel telescopes into the distal

segment, dragging the associated

mesentery with it. This leads to the

development of venous and lymphatic

congestion with resulting intestinal

edema, which can ultimately lead to

ischemia, perforation and peritonitis.

A lead point can be identified in up to

25% of children with ileo-colic

intussusception. The remaining 75%

are considered to be idiopathic,

although an increasing body of

evidence suggests that viral triggers

may play a role in some cases:

The incidence of intussusception has a

seasonal variation, with peaks

coinciding with seasonal viral

gastroenteritis in some populations

[3,4] .

Intussusception has been associated

with some forms of rotavirus vaccine.

An early form of the vaccine (RRV-TV:

Rotashield) was removed from the

Invaginao intestinal 2

market because of a 22-fold increase

in intussusception among vaccinated

infants. The vaccine currently used in

the United States (PRV: Rotateq)

appears to have rates of

intussusception that are similar to

expected background rates. However,

there may be additional cases of

intussusception that have not been

reported. Providers should be alert for

cases of intussusception that may be

associated with rotavirus vaccine, and

report all suspected cases to the

Vaccine Adverse event Reporting

System (VAERS).

Approximately 30% of patients

experience viral illness (upper

respiratory tract infection, otitis

media, flu-like symptoms) before the

onset of intussusception.

A strong association with adenovirus

infection has been shown in a variety

of populations. In 30 to 40 % of

cases, there is evidence of recent

infection with enteric and non-enteric

species of adenovirus [5-9]. In a

prospective case-control study

examining a variety of potential

infectious triggers for intussusception

in Vietnam and Australia, infection

with adenovirus, as the strongest

predictor of intussusception in both

populations [9].

Viral infections, including enteric

adenovirus, can accentuate lymphatic

tissue in the intestinal tract, resulting in

hypertrophy of Peyer patches in the

lymphoid-rich terminal ileum, which

potentially acts as a lead point for ileo-

colic intussusception [5]. A role for

corticosteroids in the prevention of

recurrence has been proposed in light

of this possible association with

lymphoid hyperplasia [10,11].

A lead point is recognized more

commonly in children older than five

years [1,4,12]. A variety of pathologic

conditions associated with

intussusception, including small bowel

lymphoma [13-15], Meckel diverticulum

[16], duplication cysts [17,18] , polyps

[19], vascular malformations [20] ,

inverted appendiceal stumps [21,22] ,

parasites (eg, Ascaris lumbricoides)

[23,24], Henoch-Schnlein purpura

[25], and cystic fibrosis [26], have

been described.

The mechanisms leading to

intussusception differ depending upon

the specific cause. As examples:

Small bowel intussusception may

occur after an episode of Henoch-

Schnlein purpura, with a bowel wall

hematoma acting as the lead point. In

these cases, intussusception typically

occurs after resolution of the

abdominal pain.

In patients with cystic fibrosis, thick

inspissated stool may act as the lead

point [26] .

Patients with celiac disease may

develop small bowel intussusception

secondary to dysmotility and

excessive secretion or bowel wall

weakness [27,28].


Patients with Crohn disease may

develop intussusception because of

inflammation and stricture formation

[29] .

Postoperative: Bowel intussusception

(usually jejuno-jejunal) also has been

described in the postoperative setting

where it is an uncommon but insidious

cause of intestinal obstruction. It

usually occurs within two weeks of a

laparotomy and is caused by adhesions.

The patient typically does well for

several days and may even resume oral

intake before developing symptoms of

mechanical obstruction. The diagnosis

can be difficult to establish because it

may be confused with postoperative

paralytic ileus. The ultrasonography and

computed tomography (CT) scanning

may be helpful. Diagnostic contrast

studies are not as helpful in

postoperative intussusception because

most cases occur in the small intestine,

CLINICAL MANIFESTATIONS:

Patients with intussusception typically

develop the sudden onset of

intermittent, severe, crampy,

progressive abdominal pain,

accompanied by inconsolable crying and

drawing up of the legs toward the

abdomen. The episodes usually occur at

15 to 20 minute intervals. They become

more frequent and more severe over

time. Vomiting may follow episodes of

abdominal pain. Initially emesis is non-

bilious, but it may become bilious as

the obstruction progresses. Between

the painful episodes, the child may

behave relatively normally and be free

of pain. As a result, initial symptoms

can be confused with gastroenteritis

[30]. As symptoms progress, increasing

lethargy develops.

In up to 70 % of cases, the stool

contains gross or occult blood [31]. The

stool may be a mixture of blood and

mucous, giving it the appearance of

currant jelly. A sausage-shaped

abdominal mass may be felt in the right

side of abdomen. However, the

classically described triad of pain, a

palpable sausage shaped abdominal

mass, and currant-jelly stool is seen in

less than 15 percent of patients at the

time of presentation [30,32] . As many

as 20% of young infants have no

obvious pain. Approximately one-third

of patients does not pass blood or

mucus or develop an abdominal mass.

Occasionally, the initial presenting sign

may be lethargy or altered

consciousness alone, without pain,

rectal bleeding, or other symptoms that

suggest an intra-abdominal process

[33-35]. In most cases, this clinical

presentation occurred in infants, and

was often confused with sepsis. Thus,

intussusception should be considered in

the evaluation of lethargy or altered

consciousness, especially in infants.

DIAGNOSIS AND NONSURGICAL

TREATMENT A high index of

suspicion coupled with early diagnosis


of intussusception may obviate the

need for surgical intervention.

For patients in whom the diagnosis is

unclear at presentation, initial workup

may include abdominal ultrasound or

abdominal plain films, provided that

these studies do not significantly delay

the definitive diagnosis and treatment

of intussusception.

Patients with a typical presentation, in

whom there is a high index of suspicion

for intussusception, may proceed

directly to an enema contrast study.

These studies can establish the

diagnosis of ileocolic intussusception,

and frequently also are therapeutic.

Before obtaining a contrast study, the

patient should be stabilized and

resuscitated with intravenous fluids; the

stomach should be decompressed with

a nasogastric tube. The patient should

be considered fit for surgery, in case

surgery is necessary, before he or she

undergoes radiographic imaging. The

surgical team should be notified before

attempted reduction because there is a

risk of perforation and because surgical

intervention may be necessary if

contrast enema fails to reduce the

intussusception.

Abdominal plain films Plain

radiographs of the abdomen may be

helpful because they may show frank

intestinal obstruction or massively

distended loops of bowel with absence

of colonic gas. Although rarely seen,

the presence of pneumoperitoneum

suggests that bowel perforation has

occurred. A target sign, consisting of

two concentric radiolucent circles

superimposed on the right kidney

representing peritoneal fat surrounding

and within the intussusception,

appeared in 26% of 94 patients in one

report [36]. A soft-tissue density

projecting into the gas of the large

bowel (intussusception image) is called

the "crescent sign".

The presence of air in the ascending

colon can help to exclude

intussusception in cases with a low

clinical suspicion of the disease. In a

retrospective study from a single

center, plain radiographs with three

views (supine, lateral, and prone) were

used to screen patients with suspected

intussusception [37]. The presence of

air in the ascending colon on at least

two of these views had high sensitivity

for excluding intussusception in this

patient population with a low clinical

suspicion of disease (sensitivity 96.3

percent, 95% CI 89.2-100). However,

the sensitivity of plain radiographs may

be considerably lower in different

clinical settings or when fewer views

are analyzed. Therefore, we do not

recommend relying on plain

radiography to exclude intussusception

if there is a significant clinical suspicion

of the disease.

Ultrasonography Ultrasonography

also can be useful; its sensitivity and

specificity approach 100 percent in the


hands of an experienced

ultrasonographer [38-40] . The classic

ultrasound image of intussusception is a

"bull's eye" or "coiled spring" lesion

representing layers of the intestine

within the intestine. In addition, a lack

of perfusion in the intussusceptum

detected with color duplex imaging may

indicate the development of ischemia.

An advantage of ultrasonography is

that it can diagnose the rare ileoileal

intussusception and identify the lead

point of intussusception in

approximately two-thirds of cases in

which underlying pathology exists [41].

Ultrasonography may also be useful in

predicting which children are most

likely to need surgical intervention for

small bowel intussusception. In a small

retrospective study, cases in which the

intussusceptum was less than 3.5 cm

were more likely to resolve

spontaneously during or shortly after

the ultrasonographic examination as

compared to cases with a longer

intussusceptum [42] .

Reduction under ultrasonographic

control without fluoroscopy has been

described [43,44] . Signs of successful

reduction include the disappearance of

the intussusception and the retrograde

flow of the water-soluble contrast into

the small intestine. Ultrasound guided

water enema also has been used [45].

Signs of successful reduction with water

include the disappearance of the

intussusception and the appearance of

water and bubbles in the terminal

ileum.

Contrast studies The standard

procedure for diagnosis and treatment

of ileocolonic intussusception is a

contrast (air or radiopaque) enema

[46]. Broad-spectrum antibiotics may

be administered before attempting

nonoperative reduction since there is a

risk of perforation with these

procedures.

As compared with ileocolonic

intussusception, small bowel (ileoileal,

jejunoileal, or jejunojejunal)

intussusception is less likely to be

reducible by contrast enema [47,48].

Intussusceptum length as measured by

ultrasonography may be helpful in

determining which patients may be

managed expectantly, and which are

likely to require surgical intervention.

Barium and water-soluble

contrast Traditionally, barium has

been the preferred contrast agent in

most North American and European

centers [49-51]. Before instilling

barium, a water-soluble contrast enema

should be considered, particularly if

there is a high risk of perforation.

Water-soluble agents reduce the risk of

electrolyte disturbances and peritonitis

in patients in whom perforation has

occurred.

Barium enema reduction of

intussusception can be performed if

there is no evidence of perforation. The


standard method of reduction is to

place a reservoir of barium 1 meter

above the patient so that constant

hydrostatic pressure is generated. With

experience (and depending upon the

clinical status of the patient), a

physician may undertake a more

aggressive reduction.

In a typical ileo-colic intussusception,

the barium column appears as an

intraluminal-filling defect. The

intussusception can be found in any

part of the large bowel, even the

rectum. Occasionally, some barium may

coat the outer surface of the

intussuscipiens, resulting in a coiled

spring pattern.

Successful reduction is indicated by the

free flow of contrast into the small

bowel. Reduction is complete only when

a good portion of the distal ileum is

filled with barium, thus excluding ileo-

ileal intussusception. Other indications

of successful reduction include relief of

symptoms and disappearance of the

abdominal mass. A characteristic sound

also may be appreciated with

auscultation. In occasional patients, the

contrast material does not reflux freely

into the small bowel even with a

complete reduction, but no filling defect

in the cecum is present apart from the

ileocecal valve and symptoms and signs

of these patients resolve.

A post-reduction filling defect in the

cecum commonly is seen, probably the

result of residual edema in the ileocecal

valve. However, benign and malignant

lesions cannot be distinguished by

radiologic examination alone. As a

result, a repeat study or even

laparotomy may indicate if any concern

of a benign or malignant lead point

exists [53].

After the successful reduction of an

ileo-colic intussusception, a

temperature higher than 38C

(100.4F) often is noted because of the

release of endotoxin, cytokines, or

bacterial translocation. The patient

should be admitted to the hospital for

12 to 24 hours for observation.

Nasogastric suction usually is

maintained until bowel function has

returned and the patient has had

passage of a bowel movement.

Feedings then are advanced as

tolerated.

Air contrast Air reduction

techniques have gained popularity as

an alternative to the contrast

hydrostatic methods [54-57]. The

technique begins with insertion of a

Foley catheter into the rectum.

Fluoroscopy is used to assess the

presence of bowel gas in the abdomen.

Air is then instilled, initially by hand

pump, until the diagnosis is established

and the intussusceptum is pushed back

gently [49,50] .

An electric pump is connected if the

intussusceptum stops moving despite

the use of the hand pump. Both of

these pumps must have a pressure


release system so that the pressure

remains between 80 and 120 mmHg.

Carbon dioxide can be used instead of

air. It has the advantage of being

absorbed rapidly from the gut, is

associated with less discomfort, and is

less dangerous than air, which

potentially could cause an air embolism

(although air embolisms have not been

reported). Reflux of air into the

terminal ileum and the disappearance

of the mass at the ileocecal valve

indicate reduction.

An advantage of this method is the

ease with which the intussusception can

be reduced with less radiation exposure

and cost, and the relatively harmless

nature of air in the peritoneal cavity,

compared with that of other contrast

materials.

Risk and complications The main

risk of hydrostatic or pneumatic

reduction is perforation of the bowel,

which occurs in 1% or fewer patients

[58-60]. The perforation usually occurs

on the distal side of the

intussusception, often in the transverse

colon, and commonly where the

intussusception was first demonstrated

by radiographic studies [61,62] . The

risk of perforation is greatest in infants

younger than 6 months of age who

have had symptoms for three days or

longer and in patients with evidence of

small bowel obstruction [63].

Nonoperative reduction should not be

attempted in patients with prolonged

symptoms or any signs of peritoneal

irritation or free peritoneal air.

Success rate Nonoperative

reduction using barium or air contrast

techniques is successful in

approximately in 60 to 90% of patients

with ileo-colic intussusception [3,64-

66]. Success is more likely to be

achieved in patients with idiopathic

intussusception (ie, no identifiable lead

point), although it also can be

accomplished in patients with a

recognized lead point [53]. Successful

radiographic reduction is more likely if,

during reduction, the small bowel is

visualized before the appendix [67].

lleo-ileo-colic intussusception may be

more difficult to reduce because the

barium often percolates along the loops

of small bowel in the colon, reducing

the effective pressure of the enema.

In addition, success is less likely to be

achieved in infants younger than 1 year

of age (particularly younger than 3

months), in children older than 5 years

of age, and when plain films show signs

of intestinal obstruction [30,58,64] .

Although some authors have noted a

reduced likelihood of reduction when

symptoms have been present for longer

than 48 hours [30,58,66,68] , others

have found no such correlation [65] . In

these high-risk cases, the barium study

should still be performed to confirm the

diagnosis and attempt therapy, but a

pediatric surgeon should be readily

available in the imaging department.


Recurrence after successful

nonoperative reduction is close to 10%

[30,69,70]. Recurrence is not

necessarily an indication for surgery.

Each recurrence should be handled as if

it were the first episode, provided that

each is successfully reduced [71].

SURGERY Surgery is indicated when

nonoperative reduction is incomplete or

when a persistent filling defect,

indicating a mass lesion, is noted [71] .

As noted above, a residual filling defect

may be seen because of edema of the

ileocecal valve. Thus, when a filling

defect appears to be associated with

edema in the area, an ultrasonographic

or repeat contrast study should be

performed provided that symptoms

have resolved.

Broad-spectrum intravenous antibiotics

should be given before surgery. Manual

reduction at operation is attempted in

most cases, but resection with primary

anastomosis needs to be performed if

manual reduction is not possible or if a

lead point is seen.

REFERENCES

1. Lloyd, DA, Kenny, SE. The surgical abdomen. In: Pediatric Gastrointestinal Disease: Pathopsychology, Diagnosis, Management, 4th ed, Walker, WA, Goulet, O, Kleinman, RE, et al (Eds), BC Decker, Ontario, 2004. p. 604.

2. Erkan, N, Haciyanli, M, Yildirim, M, et al. Intussusception in adults: an unusual and challenging condition for surgeons. Int J Colorectal Dis 2005; 20:452.

3. Buettcher, M, Baer, G, Bonhoeffer, J, et al. Three-year surveillance of intussusception in children in Switzerland. Pediatrics 2007; 120:473.

4. West, KW, Grosfeld, JL. Intussusception. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, Wyllie, R, Hyams, JS, WB Saunders, Philadelphia 1999. p.427.

5. Bhisitkul, DM, Todd, KM, Listernick, R. Adenovirus infection and childhood intussusception. Am J Dis Child 1992; 146:1331.

6. Guarner, J, de Leon-Bojorge, B, Lopez-Corella, E, et al. Intestinal intussusception associated with adenovirus infection in Mexican children. Am J Clin Pathol 2003; 120:845.

7. Hsu, HY, Kao, CL, Huang, LM, et al. Viral etiology of intussusception in Taiwanese childhood. Pediatr Infect Dis J 1998; 17:893.

8. Montgomery, EA, Popek, EJ. Intussusception, adenovirus, and children: a brief reaffirmation. Hum Pathol 1994; 25:169.

9. Bines, JE, Liem, NT, Justice, FA, et al. Risk factors for intussusception in infants in Vietnam and Australia: adenovirus implicated, but not rotavirus. J Pediatr 2006; 149:452.

10. Lin, SL, Kong, MS, Houng, DS. Decreasing early recurrence rate of acute intussusception by the use of dexamethasone. Eur J Pediatr 2000; 159:551.

11. Shteyer, E, Koplewitz, BZ, Gross, E, Granot, E. Medical treatment of recurrent intussusception associated with intestinal lymphoid hyperplasia. Pediatrics 2003; 111:682.

12. Blakelock, RT, Beasley, SW. The clinical implications of non-idiopathic intussusception. Pediatr Surg Int 1998; 14:163.

13. Abbasoglu, L, Gun, F, Salman, FT, et al. The role of surgery in intraabdominal Burkitt's lymphoma in children. Eur J Pediatr Surg 2003; 13:236.

14. Brichon, P, Bertrand, Y, Plantaz, D. [Burkitt's lymphoma revealed by acute intussusception in children]. Ann Chir 2001; 126:649.

15. Gupta, H, Davidoff, AM, Pui, CH, et al. Clinical implications and surgical management of intussusception in pediatric patients with Burkitt lymphoma. J Pediatr Surg 2007; 42:998.

16. St-Vil, D, Brandt, ML, Panic, S, et al. Meckel's diverticulum in children: a 20-year review. J Pediatr Surg 1991; 26:1289.


17. Chen, Y, Ni, YH, Chen, CC. Neonatal intussusception due to a cecal duplication cyst. J Formos Med Assoc 2000; 99:352.

18. Rizalar, R, Somuncu, S, Sozubir, S, et al. Cecal duplications: a rare cause for secondary intussusception. Indian J Pediatr 1996; 63:563.

19. Hwang, CS, Chu, CC, Chen, KC, Chen, A. Duodenojejunal intussusception secondary to hamartomatous polyps of duodenum surrounding the ampulla of Vater. J Pediatr Surg 2001; 36:1073.

20. Morgan, DR, Mylankal, K, el Barghouti, N, Dixon, MF. Small bowel haemangioma with local lymph node involvement presenting as intussusception. J Clin Pathol 2000; 53:552.

21. Tatekawa, Y, Muraji, T, Nishijima, E, et al. Postoperative intussusception after surgery for malrotation and appendicectomy in a newborn. Pediatr Surg Int 1998; 14:171.

22. Hamada, Y, Fukunaga, S, Takada, K, et al. Postoperative intussusception after incidental appendicectomy. Pediatr Surg Int 2002; 18:284.

23. Chikamori, F, Kuniyoshi, N, Takase, Y. Intussusception due to intestinal anisakiasis: a case report. Abdom Imaging 2004; 29:39.

24. Khuroo, MS. Ascariasis. Gastroenterol Clin North Am 1996; 25:553. 25. Choong, CK, Beasley, SW. Intra-abdominal manifestations of Henoch-Schonlein purpura. J

Paediatr Child Health 1998; 34:405. 26. Holmes, M, Murphy, V, Taylor, M, Denham, B. Intussusception in cystic fibrosis. Arch Dis

Child 1991; 66:726. 27. Martinez, G, Israel, NR, White, JJ. Celiac disease presenting as entero-enteral

intussusception. Pediatr Surg Int 2001; 17:68. 28. Mushtaq, N, Marven, S, Walker, J, et al. Small bowel intussusception in celiac disease. J

Pediatr Surg 1999; 34:1833. 29. Cohen, DM, Conard, FU, Treem, WR, Hyams, JS. Jejunojejunal intussusception in Crohn's

disease. J Pediatr Gastroenterol Nutr 1992; 14:101. 30. West, KW, Stephens, B, Vane, DW, Grosfeld, JL. Intussusception: Current management in

infants and children. Surgery 1987; 102:704. 31. Losek, JD, Fiete, RL. Intussusception and the diagnostic value of testing stool for occult

blood. Am J Emerg Med 1991; 9:1. 32. Yamamoto, LG, Morita, SY, Boychuk, RB, et al. Stool appearance in intussusception:

assessing the value of the term "currant jelly." Am J Emerg Med 1997; 15:293. 33. Pumberger, W, Dinhobl, I, Dremsek, P. Altered consciousness and lethargy from

compromised intestinal blood flow in children. Am J Emerg Med 2004; 22:307. 34. Goetting, MG, Tiznado-Garcia, E, Bakdash, TF. Intussusception encephalopathy: an

underrecognized cause of coma in children. Pediatr Neurol 1990; 6:419. 35. Singer, J. Altered consciousness as an early manifestation of intussusception. Pediatrics

1979; 64:93. 36. Ratcliffe, JF, Fong, S, Cheong, I, O'Connell, P. Plain film diagnosis of intussusception:

prevalence of the target sign. AJR Am J Roentgenol 1992; 158:619. 37. Roskind, CG, Ruzal-Shapiro, CB, Dowd, EK, Dayan, PS. Test characteristics of the 3-view

abdominal radiograph series in the diagnosis of intussusception. Pediatr Emerg Care 2007; 23:785.

38. Daneman, A, Alton, DJ. Intussusception. Issues and controversies related to diagnosis and reduction. Radiol Clin North Am 1996; 34:743.

39. Lim, HK, Bae, SH, Lee, KH, et al. Assessment of reducibility of ileocolic intussusception in children: usefulness of color Doppler sonography. Radiology 1994; 191:781.

40. Harrington, L, Connolly, B, Hu, X, et al. Ultrasonographic and clinical predictors of intussusception. J Pediatr 1998; 132:836.

41. Navarro, O, Dugougeat, F, Kornecki, A, et al. The impact of imaging in the management of intussusception owing to pathologic lead points in children. A review of 43 cases. Pediatr Radiol 2000; 30:594.

42. Munden, MM, Bruzzi, JF, Coley, BD, Munden, RF. Sonography of pediatric small-bowel intussusception: differentiating surgical from nonsurgical cases. AJR Am J Roentgenol 2007; 188:275.

43. Yoon, CH, Kim, HJ, Goo, HW. Intussusception in children: US-guided pneumatic reduction--initial experience. Radiology 2001; 218:85.

44. Shehata, S, El Kholi, N, Sultan, A, El Sahwi, E. Hydrostatic reduction of intussusception: barium, air, or saline?. Pediatr Surg Int 2000; 16:380.


45. Choi, SO, Park, WH, Woo, SK. Ultrasound-guided water enema: an alternative method of nonoperative treatment for childhood intussusception. J Pediatr Surg 1994; 29:498.

46. del-Pozo, G, Albillos, JC, Tejedor, D, Calero, R. Intussusception in children: current concepts in diagnosis and enema reduction. Radiographics 1999; 19:299.

47. Koh, EP, Chua, JH, Chui, CH, Jacobsen, AS. A report of 6 children with small bowel intussusception that required surgical intervention. J Pediatr Surg 2006; 41:817.

48. Ko, SF, Lee, TY, Ng, SH, et al. Small bowel intussusception in symptomatic pediatric patients: experiences with 19 surgically proven cases. World J Surg 2002; 26:438.

49. Dobranowski J. Manual of procedures in gastrointestinal radiology, Springer-Verlag, New York 1990.

50. Stringer, DA, Babyn, P. Pediatric gastrointestinal imaging and intervention, 2nd ed, BC Decker, Philadelphia 2000.

51. Ein, SH, Stephens, CA. Intussusception: 354 cases in 10 years. J Pediatr Surg 1971; 6:16. 52. Franken, EA Jr, Smith, WL, Chernish, SM, et al. The use of glucagon in hydrostatic reduction

of intussusception: a double-blind study of 30 patients. Radiology 1983; 146:687. 53. Ein, SH, Shandling, B, Reilly, BJ, Stringer, DA. Hydrostatic reduction of intussusceptions

caused by lead points. J Pediatr Surg 1986; 21:883. 54. Guo, JZ, Ma, XY, Zhou, QH. Results of air pressure enema reduction of intussusception:

6,396 cases in 13 years. J Pediatr Surg 1986; 21:1201. 55. Gu, L, Alton, DJ, Daneman, A, et al. John Caffey Award. Intussusception reduction in

children by rectal insufflation of air. AJR Am J Roentgenol 1988; 150:1345. 56. Stringer, DA, Ein, SH. Pneumatic reduction: advantages, risks and indications. Pediatr Radiol

1990; 20:475. 57. Meyer,JS, Dangman, BC, Buonomo, C, Berlin, JA. Air and liquid contrast agents in the

management of intussusception: a controlled, randomized trial. Radiology 1993; 188:507. 58. Reijnen, JA, Festen, C, van Roosmalen, RP. Intussusception: factors related to treatment.

Arch Dis Child 1990; 65:871. 59. Maoate, K, Beasley, SW. Perforation during gas reduction of intussusception. Pediatr Surg

Int 1998; 14:168. 60. Sohoni, A, Wang, NE, Dannenberg, B. Tension pneumoperitoneum after intussusception

pneumoreduction. Pediatr Emerg Care 2007; 23:563. 61. Armstrong, EA, Dunbar, JS, Graviss, ER, et al. Intussusception complicated by distal

perforation of the colon. Radiology 1980; 136:77. 62. Humphry, A, Ein, SH, Mok, PM. Perforation of the intussuscepted colon. AJR Am J Roentgenol

1981; 137:1135. 63. Mercer, S, Carpenter, B. Mechanism of perforation occurring in the intussuscipiens during

hydrostatic reduction of intussusception. Can J Surg 1982; 25:481. 64. DiFiore, JW. Intussusception. Semin Pediatr Surg 1999; 8:214. 65. van den, Ende ED, Allema, JH, Hazebroek, FW, Breslau, PJ. Success with hydrostatic

reduction of intussusception in relation to duration of symptoms. Arch Dis Child 2005; 90:1071.

66. Fragoso, AC, Campos, M, Tavares, C, et al. Pneumatic reduction of childhood intussusception. Is prediction of failure important?. J Pediatr Surg2007; 42:1504.

67. Henry, MC, Breuer, CK, Tashjian, DB, et al. The appendix sign: a radiographic marker for irreducible intussusception. J Pediatr Surg 2006; 41:487.

68. Davis, CF, McCabe, AJ, Raine, PA. The ins and outs of intussusception: history and management over the past fifty years. J Pediatr Surg 2003; 38:60.

69. Yang, CM, Hsu, HY, Tsao, PN, et al. Recurrence of intussusception in childhood. Acta Paediatr Taiwan 2001; 42:158.

70. Stein, M, Alton, DJ, Daneman, A. Pneumatic reduction of intussusception: 5-year experience. Radiology 1992; 183:681.

71. Pierro, A, Donnell, SC, Paraskevopoulou, C, et al. Indications for laparotomy after hydrostatic reduction for intussusception. J Pediatr Surg 1993; 28:1154.

72. Madonna, MB, Boswell, WC, Arensman, RM. Acute abdomen. Outcomes. Semin Pediatr Surg 1997; 6:105.

8tepedtextocaso3e4.pdf

Documents