(Radiographics. 2000;20:E1-e1.)
© RSNA, 2000
Ultrasound-guided Hydrostatic Reduction of Childhood Intussusception: Technique and Demonstration1
Pek Lan Khong, FRCR,
Wilfred C. G. Peh, FRCR,
Christina H. L. Lam, DCR,
Kwong Leung Chan, FRCS,
Wei Cheng, FRCS,
Wendy W. M. Lam, FRCR,
Victor H. G. Ai, FRCR,
Htut Saing, FRCS,
Paul K. H. Tam, FRCS,
Lilian L. Y. Leong, FRCR and
Louis C. K. Low, FRCP
1 From the Departments of Diagnostic Radiology (P.L.K., W.C.G.P., C.H.L.L., W.W.M.L., V.H.G.A., L.L.Y.L.), Surgery (K.L.C., W.C., H.S., P.K.H.T.) and Pediatrics (L.C.K.L.), The University of Hong Kong and Queen Mary Hospital, Hong Kong. Received November 17, 1999; revision requested May 9, 2000; revision received May 31; accepted June 7.
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Abstract
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The authors review the technique of ultrasound-guided hydrostatic reduction of childhood intussusception and illustrate, in real-time fashion, the treatment of three cases with this technique. Two cases of successful reduction of ileocolic intussusception are demonstrated. The third case is an example of the complex fronded appearance of ileo-ileocolic intussusception and failed reduction. This technique is recommended as an alternative method for the treatment of childhood intussusception, as it does not involve ionizing radiation and is a simple and safe procedure.
Index Terms: Children, gastrointestinal tract, 70.73 • Intestines, US, 70.12986 • Intussusception, 70.73
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Introduction
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The hydrostatic reduction of childhood intussusception with ultrasound (US) guidance is a well-recognized alternative method for the reduction of childhood intussusception. The other nonsurgical methods are reduction with barium or air with fluoroscopic guidance. The main advantage of hydrostatic reduction with US guidance is the avoidance of ionizing radiation, which is especially important in children. As US is often the first-line imaging modality for the diagnosis of intussusception, the procedure can be performed wholly within the ultrasound room after the diagnosis is made. This is efficient and saves time, since the patient does not have to be taken to a different room for fluoroscopy. The results of hydrostatic reduction of childhood intussusception with tap water, saline, or Ringer's solution have been described by various authors (1-6). To date, we have performed hydrostatic reduction with Hartmann's solution in 64 episodes of intussusception occurring in 58 children from March 1994 to July 1999. During the first 30 months of our series, all sonographically diagnosed intussusceptions and all successful reductions were confirmed with meglumine diatrizoate enemas. Thirty-three episodes of intussusception occurred in 30 patients during this period. Since the correlation between the results of US and barium enema examinations was 100%, the pre- and postreduction enemas were discontinued after the first 30 months of the series. In our previously published data, we reported success rates of 92.9% for ileocolic intussusception and 10% for ileo-ileocolic intussusception, with an overall success rate of 71.1%. The mean reduction time for the successful cases of ileocolic intussusception reduction was 12.6 minutes (7). In addition, we found that with US, when the mass is surrounded by fluid in the cecum, the ileocolic type of intussusception could be differentiated from the ileo-ileocolic type (8). A typical complex fronded appearance is seen in the ileo-ileocolic intussusception compared with the appearance of a simple mass in the ileo-colic type (8). This report aims to review the technique of US-guided hydrostatic reduction of childhood intussusception and to demonstrate this technique in real time.
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Technique
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All children with suspected intussusception are assessed by the pediatric surgeon prior to arrival at the ultrasound suite. If the US scan is positive for intussusception, informed consent is obtained for hydrostatic reduction. An intravenous line is set up and blood samples are taken for electrolytes and cross-matching. The child is sedated with intramuscular meperidine hydrochloride (0.5 mg/kg dose). Blood pressure and pulse rate are monitored before and during the procedure. The pediatric surgeon is present in the ultrasound suite throughout the procedure, and the operating theater is notified in case emergency surgery is required. The child is placed on an inflatable plastic enema ring (Fig 1), within which is placed a suction device that allows continuous suction of fluid from the enema ring. The enema ring ensures that the ultrasound couch and suite are kept clean and that the expelled bowel contents and excess fluid can be readily removed by suction.
A Foley catheter of the largest appropriate size (10- to 18-F) is inserted into the rectum, and the balloon is gently inflated (Fig 2). Hartmann's solution, warmed to body temperature, is slowly hand injected into the Foley catheter with a 50-mL syringe. Hartmann's solution was chosen for hydrostatic reduction because of its near-physiologic composition. This fluid is classified as a balanced salt solution, as it is similar in composition to extracellular fluid. It consists of 131 mmol/L sodium, 5 mmol/L potassium, 29 mmol/L bicarbonate, 111 mmol/L chloride, and 2 mmol/L calcium. It has a pH of 6.5 and an osmolality of 278 mmol/L, and it contains 9 kcal/L. A consistent force of injection is maintained, and hydrostatic pressure is kept to within 100 mm Hg by checking the pressure gauge attached to the Foley catheter via a three-way tap. During reduction, the intussuceptum is observed under continuous US guidance (Fig 3) as it proceeds to the cecum and reduces across the ileocecal valve (9).
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Figure 3. Continuous US guidance is provided during hydrostatic reduction. During the procedure, the child's buttocks are held together to form a tight seal to reduce leakage of fluid.
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The criteria for successful reduction are disappearance of the intussusceptum through the ileocecal valve, followed by passage of water and air bubbles from the cecum into the terminal ileum. The peritoneal cavity is also scanned intermittently for the presence of a sudden increase in fluid and sudden simultaneous loss of fluid from the bowel, indicating perforation. In our series, colonic perforation occurred in one case and was diagnosed at the time of occurrence. This patient was found to have an ileo-ileocolic intussusception at subsequent surgery. For intussusceptums that fail to progress, the possibility of ileo-ileo-colic intussusception should be considered. This type of intussusceptum, when surrounded by fluid in the cecum, has a complex fronded appearance. In these patients, we adopt a less aggressive approach as the reduction success rate is small and surgical treatment is usually required (8). In all other cases, the procedure is attempted to a maximum of three times, after which it is terminated. After successful reduction, the terminal ileum is scanned for the presence of a lead point or residual mass.
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Demonstration
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This US demonstration comprises three examples, presented as Quicktime movies. The first example is a case of successful reduction of an ileocolic intussusception, demonstrating reduction of the intussusceptum from the mid-transverse colon to the terminal ileum. The second example is another case of successful reduction of an ileocolic intussusception, demonstrating the reduction of the intussusceptum from the cecum across the ileocecal valve. The third case is an example of the complex fronded appearance of an ileo-ileocolic intussusception, with nonprogression at the cecum and eventual failed reduction.
Case 1
History.—A 12-month-old boy was noticed to be irritable for about 8 hours before admission. He subsequently developed bloody diarrhea and vomiting. He had no significant past medical or surgical history. At examination, he was afebrile and no abdominal mass was palpable. Supine abdominal radiographs were nonspecific. There was no soft-tissue mass or dilated bowel loops. The clinical diagnosis of intussusception was made. This was confirmed with US scans, which demonstrated the typical "doughnut" and "pseudokidney" signs of intussusception. The intussusception was located in the mid-transverse colon.
US Demonstration.—The intussusceptum was reduced
under US guidance. 
Click here to see movie.
Case 2
History.—A 12-month-old, previously healthy girl presented with the classical clinical triad of abdominal pain, blood in stools, and a palpable abdominal mass. The duration of her symptoms was about 2 days. She did not have vomiting or fever. Abdominal radiographs were normal, with no soft-tissue mass detected. US scans showed the typical features of intussusception.
US Demonstration.—The intussusceptum was reduced
under US guidance. 
Click here to see movie.
Case 3
History.—A 6-month-old boy presented with intermittent crying for 8 hours and was suspected to have colicky abdominal pain. He had no history of diarrhea, bloody stools, or vomiting. At examination, a mass was palpated at the epigastrium. His abdomen was otherwise soft and nontender. Supine abdominal radiographs were unremarkable. US scans showed typical features of intussusception.
US Demonstration.—Reduction of the intussusceptum
was attempted under US guidance. 
Click here to see movie.
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Conclusion
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The technique of US-guided hydrostatic reduction of childhood intussusception was reviewed and supplemented with a real-time demonstration in three cases. The demonstration shows the clarity with which the intussusception and the hydrostatic reduction process can be visualized with US. As a bonus, the ileocolic and ileo-ileocolic types of intussusception can be differentiated in the fluid-filled cecum, with treatment implications. We would therefore recommend this technique as an alternative method for the treatment of childhood intussusception. It is emphasized that this procedure should only be done in centers in which pediatric surgical expertise and backup are readily available.
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Footnotes
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Corresponding author: W.C.G.P., Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore 169608, Republic of Singapore (e-mail: gdrpcg{at}sgh.gov.sg)
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References
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Choi SO, Park WH, Woo SK. Ultrasound-guided water enema: an alternative method of nonoperative treatment for childhood intussusception. J Pediatr Surg 1994; 29:498-500.[Medline]
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Gonzalez-Spinola J, Del Pozo G, Tejedor D, Blanco A. Intussusception: the accuracy of ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction. J Pediatr Surg 1999; 34:1016-1020.[Medline]
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Peh WCG, Khong PL, Chan KL, et al. Sonographically guided hydrostatic reduction of childhood intussusception using Hartmann's solution. AJR 1996; 167:1237-1241.[Abstract/Free Full Text]
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Peh WCG, Khong PL, Lam C, et al. Ileoileocolic intussusception in children: diagnosis and significance. Br J Radiol 1997; 70:891-896.[Abstract]
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Peh WCG, Khong PL, Lam C, et al. Reduction of intussusception in children using sonographic guidance. AJR 1999; 173:985-988.[Free Full Text]
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Abstract
Introduction
