USG (Ultrasonography) Guided Hydro-reduction: promising management of Intussusception (a common Paediatric Abdominal emergency)
Intussusception is the sliding of the one portion of intestine into the adjacent intestine which may lead to obstruction of the intestine leading to variable complaints, e.g. excessive crying with a short period of relief, vomiting, blood in stools.
Diagrammatic representation of Intestinal Intussusception
With on the left side of the diagram showing normal anatomy of the small and large intestine. Middle image showing IC (ileocaecal) (junction between the small and large intestine) and on the right side of the diagram showing ileocolic intussusception in the terminal ileum is inserting/herniating (intussusceptum) inside the caecum and ascending colon (intussuscipiens) which is receiving segment of intestine.
How serious is the problem??
It is one of the commonest reasons for abdominal pain, under 2 years of age which requires urgent management. In younger children, the usual underlying cause is infection-induced enlarged mesenteric lymph nodes which acts as a leading point for the herniation to occur. In older children, the underlying causes are enlarged lymph node or mass or following an episode of Gastroenteritis/Diarrhoea.
What does it do the body?
When it does happen, it blocks the passage of fluid and faecal matter (stool) in the intestine, leading to abdominal distention and vomiting and with longer duration, the swelling of the involved intestine and can lead to blood in stools.
It can hamper the blood supply to the bowel (intestine) which can lead to bowel rupture and permanent damage (which is known as gangrene).
How to detect Intussusception?
Generally, the provisional diagnosis is made on clinical assessment by the physician which can be later confirmed on imaging. Ultrasonography of the abdomen is the investigation of choice for the detection. In hands of experienced radiologists, it can be diagnosed on ultrasonography with specificity and sensitivity reaching up to 100 percent.
In way past, the only option was to do surgery and reduce and/or remove the abnormal intestine. However, with advances, alternative non-operative options like Fluoroscopic (series of x-ray images) guided pneumo (with air) or barium (a high-density positive contrast material) reduction or USG guided hydro-reduction (with normal saline usually), as 1st line of treatment. This treatment is successful when the herniation is involving the large intestine or terminal portion of the small intestine into the large intestine which is the commonest type of intussusception (colo-colic/ileocolic/ ileo-ileo-colic).
Literature is suggestive of higher success rates and advantages of USG guided hydro-reduction as compared to fluoroscopy-guided pneumo or barium reduction.
In our institute as a combined effort paediatric radiologist and the paediatric surgeon, we are doing USG guided hydrostatic reduction of intussusception (by the force of normal saline trying to push the herniated bowel back to its position) under sedation. The results of success are higher if the duration of symptoms is less than 24 hours, however, the procedure can be tried up to 3 days duration of the symptoms, based on the vascular supply of the involved part during USG which suggests the viability and is deciding factor for attempting USG guided hydro-reduction in cases with delayed presentation.
By keeping operation theatre prepared for potential conversion into the surgical treatment, and under sedation maximum of 3 attempts lasting for 3-5 mins can be done. In this procedure, a small tube (foley’s catheter) is inserted in the rectum and from the height of the 100-120 cm pre-warmed normal saline is infused through the tube in the large intestine to generate pressure which eventually reduces the abnormal herniated segment in most of the cases. In case of failure of the hydro-reduction, a technique patient is directly taken to the operation theatre for surgery.
- Recurrent Intussusception, which needs to be assessed after 24 hours of first successful attempt or if the child has symptoms.
- Rarely intestinal perforation/gangrene.
- No radiation is given to the child as compared to a fluoroscope guided method.
- Least invasive technique with high success rates (88% according to the recent literature) hence avoiding the longer hospital stay, lesser complications, and morbidity as compared to a patient undergoing surgical intervention.
- Reduction of the bowel herniation is done under sonographic vision which gives higher changes of confidence to a successful procedure.
Hereby, we would like to recommend, the USG guided hydrostatic normal saline reduction as the first line of management for childhood intussusception in health care centres where facilities and expertise and resources are available.