presentation illustrating the role of ultrasound in diagnosing and treating intussusception.

1. One stop station for diagnosis
and reduction
Dr/Ahmed Bahnassy
Consultant Radiologist
PSMMC-Riyadh-KSA

2. Diagnosing intussusception

3. Ultrasound value
• High sensitivity and specificity (95-100%
respectively).
• Large ..5 X 2,5 cm
• Rapid learning curve even for unexperienced
sonographers,residents or radiologists.
• Many typical signs.

5. TYPICAL DIAGNOSTIC SIGNS
Target –Doughnut -HayFork
–Sandwitch signs.

6. Target sign(Doughnut sign)

7. Pseudokidney

8. Trapped fluid
• High correlation
with ischaemia
and
irreducibility(p=0,0
01)

9. Trapped mesentery

10. Frond surface
• Ileo-ileo-colic.
Sonograms of residual ileoileal intussusception after pneumatic reduction of ileocolic
• Low possibility
intussusception.
of reduction.
Yoon C H et al. Radiology 2001;218:85-88
©2001 by Radiological Society of North America

11. Doppler value
• Presence of flow
should encourage
more attempts and
more time (viable
bowel).
• Absence of flow (24
hours)should make
less attempts and
vigor of reduction.

12. Dangerous signs
• Maximum trapped fluid.
• Fronded surface of ileo-ileo-colic
intussusception.
• Absence of doppler flow.
– Limited attempts-low pressure.
• Pneumoperitoneum (X-ray or US)
– Contraindicated.

13. Hydrostatic Reduction
under US guidance

14. advantages:
• No ionizing radiation .
• More attempts and longer time .
• High success rate (76-95 %).
• Low incidence of perforation.

15. Preparation
Figure 1. The plastic enema ring is shown together with the Foley catheter, which is connected
by plastic tubing and a three-way tap to a pressure gauge and a 50-mL syringe.
Khong P L et al. Radiographics 2000;20:e1-e1
©2000 by Radiological Society of North America

16. Preprocedure Checklist
• 1. The patient should be stabilized clinically with an intravenous line in
place.
• 2. The patient should not have a clinical contraindication (peritonitis or
perforation).
• 3. The following supplies should be prepared:
• a. Enema ring to prevent spills;
• b. Saline (1–2 L)or Hartmann solution, warmed to body temperature, in an
enema bag;
• c. Foley catheter, the largest possible based on age;
– the following can be used as a guide:
– younger than 6 months…. 18F; 6 to 12 months … 20F; 12 to 24 months … 22F;
and older than 24 months … 24F.
d. A 20-mL syringe with water to inflate the Foley catheter balloon;
and
e. Water-resistant tape to seal the buttocks.

17. Figure 1. The plastic enema ring is shown together with the Foley catheter, which is connected
by plastic tubing and a three-way tap to a pressure gauge and a 50-mL syringe.
Khong P L et al. Radiographics 2000;20:e1-e1
©2000 by Radiological Society of North America

18. Reduction steps
• 1. Place child in the left lateral or prone position. Insert
the catheter, and inflate the balloon, checking the
position on sonography. Seal the buttocks tightly using
water-resistant tape.
• 2. Transfer the child to the supine position. Scan the
patient to confirm the expected location of the intus-
susception, and document and localize any free fluid in
the abdomen and pelvis. Elevate the enema bag to 3 ft
above the bed to generate approximately 80 mm Hg of
pressure. Observe the flow of fluid from the rec- tum
and colon on sonography to facilitate visualiza- tion of
leading edge of the intussusception .

19. Figure 2. The child is placed in the plastic enema ring, and an 18-F Foley catheter is inserted into
the rectum.
Khong P L et al. Radiographics 2000;20:e1-e1
©2000 by Radiological Society of North America

20. Figure 3. Continuous US guidance is provided during hydrostatic reduction.
Khong P L et al. Radiographics 2000;20:e1-e1
©2000 by Radiological Society of North America

21. • Follow the progression of intussusception until it
is completely reduced, 5 minutes is reached, or
perfo- ration is suspected.
• Scan the abdomen and pelvis intermittently to
look for the presence of a sudden increase in free
fluid that would suggest perforation.
• In a case of bowel perforation, abort immediately
and drain the fluid out by lowering the enema
bag below the bed. Refer to surgery.

22. Repeat attempts
• If unsuccessful after 5 minutes of continuous moni-toring, lower the
enema bag to relieve the pressure, and “rest the bowel” for 2
minutes.
• 2. During this time, scan the pelvis to confirm that the Foley
catheter is in place; assess for leaks; drain/clean the enema ring;
and retape the buttocks if necessary.
• 3. Once rested, raise the bag an extra 1 ft for every attempt, up to a
maximum of 5.5 ft (for ≈120 mm Hg of hydrostatic pressure).
• Repeat attempts may be performed up to 5 times.
• 4. If there is progressive reduction during several attempts, and
difficulty is encountered at the ileocecal valve, a delayed attempt
may be performed after resting the bowel for 30 to 60 minutes.

23. • If there is progression after the delayed attempt, a
second delayed attempt can be performed. If there is
no progression, consider aborting the procedure.
• 5. If there is no progression during the first 3 attempts,
and the head of the intussusception is still at or distal
to the splenic flexure, consider aborting the procedure.
• 6. To abort the procedure, lower the enema bag to
drain the colon to relieve the pressure, and remove the
Foley catheter. Refer the patient for surgical
intervention.

24. Successful Reduction
• 1. Follow the intussusception until successful reduction is attained,
defined by the following criteria:
• a. Visualization of the entire cecum and disappear- ance of the
intussusception
• b. Visualization of a thickened but patent ileocecal valve
• and c. Free flow of fluid into the distal small bowel
• 2. After successful reduction, continue flow for 15 to 30 seconds to
fill the small bowel and evaluate for small- bowel intussusception.
• Stop the flow of fluid while carefully scanning for any lead points
(eg, polyps, Meckel diverticulum, and duplication cyst).
• At the end of the procedure, lower the enema bag to drain the
colon, and remove the Foley catheter.
• Scan the pelvis for free fluid.

25. Reduction followed by US

26. Reduction criteria

27. Pros and cons
• High sensitivity and • New=learning curve.
specificity of US • Writing PPG
diagnosis of • Nurses orientation.
intussusception.
• Room availability .
• Available resources.
• Logistic issues.
• No transportation and
re-arrangements=save • Confidence bridge.
time.