Dr Prashant Jain
Dr Ashish Prasad
Intussusception is one of the most common causes of acute abdomen in infancy. This condition is usually idiopathic in children between 6 months and 2 years of age with an incidence of 1-2 cases per thousand children. The vast majority of childhood cases of intussusception are ileocolic; that is, the ileum becomes telescoped into the colon. The diagnosis should be suspected in a child presenting with intermittent colicky abdominal pain with drawing up of legs, poor feeding, vomiting and per rectal passage of blood mixed with mucus (red currant jelly). The importance of early diagnosis lies in the fact that the condition can be managed by non operative treatment (Ultrasound Guided Hydrostatic Reduction) with success rate of more than 90%. Ultrasound is a highly sensitive modality for the diagnosis of intussusception with an almost 100% accuracy with a classical sign of target or doughnut.
Ultrasound-guided hydrostatic reduction (HSR) is currently the standard management of intussusception, with a success rate of more than 90%. Peritonitis and advanced intestinal obstruction are considered as contraindications for hydrostatic reduction.
The advantages of US guided HSR are -:
- avoids radiation exposure
- provides more information than fluoroscopic techniques
- the reduction process can be monitored, visualizes all the components of the intussusception including post reduction edematous ileocaecal valve and
- can more easily recognize pathological lead points.
The technique – : The procedure is done under mild sedation in the minor OT in the emergency department itself. A well-lubricated, 18–20 French Foley’s catheter is introduced 6–9 cm into the rectum, its balloon is inflated to keep it retained. The catheter is then connected to the intravenous fluid column about 100–150 cm from the level of the pubis of the patient. HSR isthen carried out under USG guidance, with normal saline flowing freely into the rectum without application of any external force to the saline bag. The sonologist monitors the reduction of intussusception on ultrasound. Two to three attempts, 4–6 h apart can be made prior tolabelingit irreducibleand subjecting the patient to surgery. Each sitting of saline reduction is carried out for a maximum of 20–25 min after which the procedure is abandoned.Repeat attempts are undertaken only in clinically stable patients where the initial attempt achieves at least partial reduction. Failure to reduce is an indication of Laparoscopic/open reduction. The risks of failure is more in cases of age group <1 year, delayed presentation (> 48 hours) and in the presence of pathological lead point.
After successful reduction, the patient is admitted in the ward for observation.The recurrence rate of intussusception after successful hydrostatic reduction is 10-15%. In such a scenario the management is repeat hydrostatic reduction unless the cause of intussusception is a pathological lead point.