einstein. 2008; 6(3):359-61

case report

Ultrasound-guided hydrostatic reduction of intestinal intussusception: description of three cases

Reversão de intussuscepções intestinais por meio de enema guiado por ultra-sonografia: descrição de três casos

Martha Hanemann Kim1, Michelle Rosemberg2, Frederico Celestino Miranda3, Aureliano Torquato Brandão4, Rodrigo Gobbo Garcia5, Miguel José Francisco Neto6, Marcelo Buarque de Gusmão Funari7

aBstractWith the objective of reporting the technique of ultrasound-guided hydrostatic reduction of intestinal intussusception, three cases with confirmed diagnosis of the disease submitted to reduction with this technique are described. All cases had successful reductions with no complications. One patient experienced a recurrence of the invagination eight days after treatment, which was surgically corrected. The technique of hydrostatic reversal of intestinal intussusception guided by ultrasound may be used in place of the conventional barium enema, since it is a minimally invasive and safe method, with high rates of success and few complications.

Keywords: Enema/methods; Ultrasonography; Intussusception; Intestinal obstruction; Treatment outcome; Case reports

resUMoCom o objetivo de divulgar a técnica de reversão hidrostática da intussuscepção intestinal, guiada por ultra-sonografia, são descritos três casos do diagnóstico confirmado da afecção, que foram submetidos à reversão por meio dessa técnica. Nos três casos a reversão foi atingida com sucesso, sem complicações. Um paciente apresentou recidiva da invaginação após oito dias do tratamento, sendo submetido à correção cirúrgica. A técnica de reversão hidrostática de intussuscepção intestinal guiada por ultra-som pode ser utilizada no lugar do enema opaco convencional apresentando-se como um método pouco invasivo, seguro, com altos índices de sucesso e poucas complicações.

Descritores: Enema/métodos; Ultra-sonografia; Intussuscepção; Obstrução intestinal; Resultado de tratamento; Relatos de casos

INtroDUctIoNIntestinal intussusception is defined as the invagination of a segment of the bowels into the lumen of an upstream segment. It corresponds to 1% of intestinal obstructions(1) and is the most common cause of intestinal obstruction in infants, with greatest frequency during the first year of life.

In most cases, there are no detectable predisposing factors, and a cause for the invagination is found in only 2 to 8% of cases, which may be a result of Meckel’s diverticulum, terminal ileum lymphoma, intestinal polyp, or others(1). In adults, in 65% of the cases, its occurrence is related to neoplasms(1-2).

The most common form starts in the ileocecal or ileocecocolic valve, but may also be ileocolic and colocolic(1).

The classic clinical triad, composed of acute abdominal pain, blood in the stools resembling jelly (bowel damage), and palpable mass, is present in only 50% of children with intestinal invagination(3).

Radiological diagnosis is pathognomonic when an intestinal loop within a bowel segment (Figures 1A and 1B) is visualized, and may contain fat

Study carried out at the Ultrasonography Service of the Department of Imaging of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil. 1 Medical residency preceptor at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.2 Resident of Radiology at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.3 Graduate student from the Ultrasonography Course at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.4 Radiologist at the Ultrasonography Service of the Department of Imaging of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.5 Radiologist at the Ultrasonography Service of the Department of Imaging of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.6 PhD; Assistant physician at the Ultrasonography Division of Instituto de Radiologia da Faculdade de Medicina da Universidade de São Paulo – FMUSP; Coordinator of the Medical Residency at the

Ultrasonography Service of the Department of Imaging of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.7 PhD; Assistant physician at the Computed Tomography Division of Instituto de Radiologia da Faculdade de Medicina da Universidade de São Paulo – FMUSP, São Paulo (SP), Brasil; Coordinator of the

Department of Imaging at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.

Corresponding author: Martha Hanemann Kim – Rua Prefeito Prestes Maia, 247 – Vila Zampol – CEP 09424-310 – Ribeirão Pires (SP), Brasil – e-mail: marthahanemannkim@terra.com.br

Received on: Sep 13, 2007 – Accepted on: Jul 11, 2008

einstein. 2008; 6(3):359-61

360 Kim MH, Rosemberg M, Miranda FC, Brandão AT, Garcia RG, Francisco Neto MJ, Funari MBG

and mesenteric vessels invaginating into the affected segment(1). Just as with computed tomography and magnetic resonance imaging(1), ultrasonography may be used for diagnosis, with the advantage of allowing a saline solution enema, a minimally invasive treatment, through which the entire reduction process may be accompanied in real-time with high rates of success(4). Cases of spontaneous reduction may also be caught by ultrasonography(5-6).

The use of ultrasonography enables replacing barium or air with saline solution as a contrast medium, further increasing the safety of the procedure, since saline is less harmful in case of any complications (intestinal perforation, peritonitis, or septic shock) during treatment. If there are signs of complications, surgical resolution should be chosen(3).

case reportsThree patients with confirmed diagnosis of intestinal invagination, who were quickly submitted to ultrasound-guided enema reduction, were followed up. All showed a detectable intestinal flow upon color Doppler study.

After anesthetic sedation, the patients were submitted to rectal catheterization using a Foley size eight catheter through which 0.9% normal saline, warmed to 37 °C, was instilled with no pressurization, with the saline bag placed about 100 cm above the level of the patient. Progression of the saline solution to

the point of invagination was accompanied exclusively by ultrasound monitoring (Philips® HDI 5000 L12-5 Probe), see Figures 2A, 2B, 2C and 3. Reduction was accelerated by maneuvers of compression and changing lateral decubitus. Figure 4 shows the association of color Doppler, which allows the assessment of the degree of bowel damage.

a

B

Figures 1a and 1B. Images compatible with loop inside a segment located in the right hypochondrium, corresponding to an ileocecal invagination associated to slight parietal thickening

Figures 2a, 2B and 2c. Images demonstrating ultrasound-guided hydrostatic reduction. Procedure conducted under sedation

B

c

a

Figure 3. Ultrasound control after hydrostatic reduction. Observe slight residual parietal edema and small amount of free peritoneal fluid

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Ultrasound-guided hydrostatic reduction of intestinal intussusception: description of three cases 361

Figure 4. Color Doppler shows parietal flow in the loops, demonstrating viable segments

Technical success was attained in all cases, with an average time of ten minutes from onset of therapy, and there were no immediate complications.

One patient experienced recurrence of the invagination, eight days after treatment and was submitted to surgical correction.

DIscUssIoNEnema is a minimally invasive method that allows effective resolution of intestinal invagination. Ultrasonography using high-resolution transducers enables adequate monitoring of the procedure, dispensing the use of ionizing radiation in an essentially pediatric population. The association with color Doppler allows indirect assessment of viability of the intestinal loop affected, with inference of its status regarding damage(3). Intestinal hypoperfusion, identifiable by the method, is a relative contraindication of the procedure.

The use of general anesthesia makes the procedure more comfortable for the patient and increases the effectiveness of the method, reducing spasticity of the affected intestinal segments and increasing the effectiveness of the maneuvers of compression and changes in decubitus, as it eliminates motor agitation and muscle tension.

Use of warmed saline solution instilled without pressurization allows a less traumatic intestinal reduction, reducing the rate of complications.

coNcLUsIoNsWe believe that ultrasound-guided enema may be used in place of conventional barium enema to reverse intestinal invagination, and represents a minimally invasive method that is safe, with high rates of success and few complications, which is currently used as first option at our institution.

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clinical-imaging correlation. Radiology.1999;212(3):853-60.

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3. del-Pozo G, Albillos JC, Tejedor D, Calero R, Rasero M, de-la-Calle U, et al. Intussusception in children: current concepts in diagnosis and enema reduction. Radiographics.1999;19(2):299-319.

4. Yoon CH, Kim HJ, Goo HW. Intussusception in children: US-guided pneumatic reduction – initial experience. Radiology.2001;218(1):85-8.

5. Swischuk LE, John SD, Swischuk PN. Spontaneous reduction of intussusception: verification with US. Radiology.1994;192(1):269-71.

6. del-Pozo G, Albillos JC, Tejedor D. Intussusception: US findings with pathologic correlation – the crescent-in-doughnut sign. Radiology.1996;199(3): 688-92.