Comparison between children and adults intussusception. Description of two cases and review of literature.

INTRODUCTION: Intussusception is a common condition in children, it is rare in adults. Adult intussusception differs from pediatric intussusception in various respects, including etiology clinical characteristics and therapy. METHODS: We present and discuss a new case of intussusception in children and adults. RESULTS: In child the Barium Enema x-ray examination is identified an endoluminal filling defect to refer to the apex of the invaginated loop at the rectal level, with slow ascent during the progressive injection of the radiopaque contrast medium. At the end of the procedure, incomplete reduction of the picture is documented. The patient undergoes emergency surgery where the presence of an ileo-ceco-colic invagination is documented. Intussusception is reduced by taxis. In the adult laparoscopic right hemicolectomy was performed. High-grade B-cell Burkitt's lymphoma was confirmed by immunohistochemistry. DISCUSSION: In contrast to intussusceptions in children, in the adult population, a demonstrable etiology is found in most of the cases. In adults surgery is always indicated. The non-invasive resolutive intervention most commonly used in the child and best known consists in the rectal introduction of a radiopaque contrast medium (air or barium) at controlled pressure until. CONCLUSIONS: Although intussusceptions occur at all ages, there are major differences in the clinical presentation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective. KEY WORDS: Intussusception in children, Intussusception in adults, Intussusception symptoms, Radiology and treatment.

Visual diagnosis: an 11-month-old with nausea, vomiting, and an abdominal mass.

Children with intussusception can present with a wide variety of symptoms, including vomiting, fever,lethargy, and abdominal pain. The classic triad of abdominal pain, hematochezia, and palpable abdominal mass is seen in a few patients.• Early diagnosis of intussusception depends on a high level of clinical suspicion in any child with non specific abdominal findings followed by appropriate radiographic or ultrasonographic evaluation and confirmation with a contrast enema.• Abdominal radiography, although an appropriate component of the initial workup for gastrointestinal symptoms, lacks the sensitivity to reliably exclude the presence of intussusception.• Because ultrasonography is a safe, sensitive, and specific test for the diagnosis of intussusceptions, it should be performed early whenever there is clinical suspicion of intussusception.• Contrast enema is the gold standard for diagnosis and first-line treatment of intussusception. There is an increasing trend for pneumatic reduction of intussusception compared with hydrostatic reduction.Intravenous placement, fluid resuscitation, and notification of the pediatric surgeon should be completed before contrast enema.

The peroral pneumocolon revisited: a valuable fluoroscopic and CT technique for ileocecal evaluation.

The peroral pneumocolon represents a time-honored but somewhat forgotten and underutilized technique for improved ileocecal evaluation at small bowel fluoroscopy. The peroral pneumocolon entails fluoroscopically guided gaseous insufflation per rectum following the arrival of barium at the cecum at conventional small bowel follow-through examination. In most cases, high-quality double contrast evaluation of the terminal ileum can be achieved, often superior to enteroclysis examination for this critical location. The peroral pneumocolon improves diagnostic confidence, including assessment of disease activity, and may result in a reversal of the diagnostic impression. This simple procedure will be discussed and a spectrum of fluoroscopic findings with CT and endoscopic correlation will be provided to demonstrate the added yield of this technique in the evaluation of known or suspected Crohn's disease. Application of the pneumocolon technique to CT for combined small and large bowel evaluation ("CT coloenterography") will also be discussed, which represents an attractive new option for investigating inflammatory bowel disease and other bowel-related conditions. Through the use of automated low-pressure carbon dioxide delivery per rectum, supplemented by IV glucagon for relaxation of the ileocecal valve, a CT-based pneumocolon examination may prove to be a useful hybrid technique for bowel evaluation in the future.

Vomiting and apparent life-threatening event.

We describe a 6-month-old girl who had an apparent life-threatening event after a vomiting episode resulting in activation of emergency medical services for transport to the emergency department. The differential diagnosis for this presentation is broad but easily narrowed down given the additional clinical information. Her resultant diagnosis of intussusception is a common diagnosis but with an uncommon presentation.

Ileocecal valve: spectrum of normal findings at double-contrast barium enema examination.

PURPOSE: To characterize the spectrum of normal findings of the ileocecal valve at double-contrast barium enema examination to allow differentiation between a normal valve and one infiltrated by tumor. MATERIALS AND METHODS: A search of radiology and endoscopy files showed 106 patients who underwent double-contrast barium enema examination and colonoscopy. The radiographic images were reviewed by two authors to determine the morphology of the ileocecal valve and to evaluate whether it appeared normal or abnormal. The radiographic data were then correlated with endoscopic and pathologic findings. RESULTS: The ileocecal valve was visible in 91 (86%) of 106 patients. It was round or ovoid in 71 patients (78%) and triangular in 20 (22%). In the 88 patients with a normal valve at colonoscopy, mean valve height was 1.7 cm, and mean width was 2.8 cm. The valve was smooth in 75 patients (85%) and smoothly lobulated in 13 (15%). The lips of the valve were symmetric in 77 patients (88%) and asymmetric in 11 (12%). All 87 patients with a normal valve at double-contrast barium enema examination had a normal valve at colonoscopy, whereas the two patients with a valve suspicious for tumor at barium enema examination had neoplasms (one carcinoma and one villous adenoma) at colonoscopy. CONCLUSION: The ileocecal valve may show a spectrum of normal findings at double-contrast barium enema examination and may appear as a round, ovoid, or triangular structure with a maximal height of nearly 4 cm. The valve may be large, asymmetric, or smoothly lobulated, even in the absence of tumor.

Ileal endometriosis: radiographic findings in five cases.

PURPOSE: To determine the radiographic findings in five patients with ileal endometriosis. MATERIALS AND METHODS: A search of radiology files revealed five patients with surgically proved endometriotic implants in the ileum at enteroclysis (three patients), at small-bowel follow-through (one patient), and at double-contrast barium enema study (one patient). The radiographic findings were reviewed retrospectively. Clinical, surgical, and histopathologic findings were also reviewed. RESULTS: All five patients were nulliparous women (mean age, 34.4 years; age range, 28-41 years). Four patients presented with abdominal and/or pelvic pain, but only one of these four had cyclic pain that coincided with menstruation. Barium studies revealed endometriotic implants in the terminal ileum within 10 cm of the ileocecal valve in four patients and in the mid-ileum in one. The radiographic findings consisted of extrinsic mass effect with variable spiculation and tethering of folds in two patients, annular lesions with spiculated folds and abrupt or tapered borders in two, and a plaque-like lesion in one. In four patients who underwent double-contrast barium enema studies, associated endometriotic implants were found in the rectosigmoid colon. CONCLUSION: Ileal endometriosis usually involves the terminal ileum within 10 cm of the ileocecal valve and manifests as a spectrum of findings on barium studies. Ileal endometriosis should therefore be considered when these findings are present in young, nulliparous women with abdominal or pelvic pain.

Intussusception: the accuracy of ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the therapeutic value of ultrasound (US)-guided saline enema for intussusception and the usefulness of a delayed attempt after at least 30 minutes when reduction has not been complete. METHODS: One hundred ninety-five cases of intussusception were diagnosed with ultrasonography. US-guided saline hydrostatic reduction was performed in 194 with an additional attempt after at least 30 minutes in those cases in which only partial resolution had been achieved. The method was changed (the volume of the reservoir bag and the caliber of the catheter were increased) so we analyze two different periods; 85 cases are included in the first period and 110 in the second. RESULTS: The global rate of successful reduction was 81.9% (159 of 194 cases), and it raised to 88.2% (97 of 110 cases) in the second period. In 15.5% cases (30 of 194) reduction was achieved in a delayed attempt at least 30 minutes after the initial partial resolution. The rate of recurrence was 9.7%. No perforation was seen. CONCLUSIONS: The accuracy of US-guided saline enema in achieving intussusception reduction is high, similar to other methods, avoiding radiation exposure. A delayed attempt after a period of rest increases the rate of reductions.

Massive enterolithiasis associated with ileal dysgenesis.

A 20-year-old man with massive ileal enterolithiasis was investigated with plain radiography, ultrasound, computed tomography, barium follow through and double contrast barium enema. Ileocecal valve agenesis was found at surgery. The enteroliths were located in the distal ileum, which communicated with the large intestine via an ileotransverse fistula.

The use of scintigraphy to provide "proof of concept" for novel polysaccharide preparations designed for colonic drug delivery.

PURPOSE: The aim of the present study was to provide "proof of concept" data in man for novel polysaccharide preparations designed for colonic drug delivery using gamma scintigraphy. METHODS: Two placebo calcium pectinate matrix tablet formulations were studied: one contained calcium pectinate and pectin (CaP/P) and was designed to rapidly disintegrate in the ascending colon, the other contained calcium pectinate and guar gum (CaP/GG) and was designed to disintegrate more slowly, releasing its contents throughout the ascending and transverse colon. Both formulations were enteric coated in order to protect them from the stomach. Ten healthy volunteers received either a CaP/P or CaP/GG tablet, in a randomised cross-over study. Transit and disintegration of the radiolabelled formulations was followed by gamma scintigraphy. Rat studies were conducted in order to verify that the expected colonic degradation of the polysaccharide formulations was as a consequence of bacterial enzyme attack. RESULTS: The in vivo clinical study confirmed the results obtained in the rat and bench in vitro fermentation models; complete tablet disintegration for Formulation CaP/GG appeared to be slower than that of Formulation CaP/P and the time and the location of complete tablet disintegration was more reproducible with Formulation CaP/P compared to Formulation CaP/GG. CONCLUSIONS: These results provide "proof of concept" data for the use of calcium pectinate preparations for drug delivery to the colon and highlight the value of scintigraphy in focusing the development strategy for colonic targeting preparations.

Sonographically guided hydrostatic reduction of childhood intussusception using Hartmann's solution.

OBJECTIVE: Currently, the standard methods for therapeutic reduction of intussusception in children involve considerable ionizing radiation. This study tested the effectiveness of sonographically guided hydrostatic reduction of intussusception using Hartmann's solution, a fluid with near-physiologic composition. SUBJECTS AND METHODS: Between March 1, 1994, and January 31, 1996, all children clinically suspected of having intussusception were evaluated by sonography. Those with positive findings on sonography were entered into the study and underwent confirmatory sonographically guided meglumine diatrizoate enema. During continuous sonographic monitoring, we used Hartmann's solution for attempted reduction of intussusception. Criteria for successful reduction were disappearance of the intussusceptum and passage of fluid through the ileocecal valve. Another sonographically guided meglumine diatrizoate enema was used to confirm successful reduction. RESULTS: We detected 25 consecutive intussusceptions in 22 patients. The patients were 12 girls and 10 boys, with a mean age of 14 months (range, 1-72 months). Sonograms revealed in all patients doughnut or pseudokidney signs or both. The sites of intussusception were the transverse colon (17 of 25), hepatic flexure (4 of 25), ascending colon (2 of 25), splenic flexure (1 of 25), and descending colon (1 of 25). Other findings were dilated fluid-filled small bowel (11 of 25) and free intraperitoneal fluid (9 of 25). The success rate of our sonographically guided attempts at hydrostatic reduction was 76% (19 of 25). Success was proven by meglumine diatrizoate enema in all 19 patients. The mean time of the reduction procedure was 18 min (range, 2-45 min). No complications occurred. All six patients in whom hydrostatic reduction was unsuccessful underwent surgery. Five of these patients had ileoileocolic intussusceptions. On sonography, when surrounded by fluid, ileoileocolic intussusceptions had a typically complex, fronded appearance. The remaining patient in whom hydrostatic reduction was unsuccessful had ileocolic intussusception. Of six ileoileocolic intussusceptions, one was hydrostatically reduced and a second was converted into an ileoileal intussusception before requiring surgery. The other four intussusceptions were surgically treated. CONCLUSION: Our data suggest that sonographically guided hydrostatic reduction with Hartmann's solution can be used to treat ileocolic intussusception and to diagnose ileoileocolic intussusception.

Intussusception.

Intussusception is the invagination of one bowel segment into another. It is an emergent condition that most commonly affects infants between five and nine months of age, but it can also occur in other age groups. The etiology is usually idiopathic in infants five to nine months of age; neonates, older children and adults more commonly have lead points such as a Meckel's diverticulum or a neoplasm. Early diagnosis is essential to avoid treatment delays, which can increase morbidity and mortality. It has been reported that patients with intussusception present with abdominal pain, vomiting and bloody stools, but this classic triad is often absent. More commonly, lethargy and irritability are the presenting signs. A rectal examination, with testing for occult blood, is an important part of the evaluation and is frequently positive. Barium enema is the gold standard for diagnosis and also has therapeutic potential for reducing the intussusception. Ultrasound is an accurate, low-risk screening tool when performed and interpreted by an experienced ultrasonographer. Surgical reduction is performed if nonoperative reduction is contraindicated or unsuccessful, or if a lead point is suspected.

Multipolypoid intussusceptum: a distinctive appearance of ileoileocolic intussusception at the ileocecal valve.

Objective. To determine whether ileoileocolic intussusception can be diagnosed by a distinctive appearance during pneumatic reduction. Materials and methods. We reviewed the clinical, pathologic, and imaging findings of 11 patients with ileoileocolic intussusceptions seen in our hospital between January 1989 and July 1994. The patients ranged in age from 4 months to 4 years and 2 months. We specifically evaluated the appearance of these intussusceptions on air enemas performed in nine of these patients. Another 22 air enemas of all patients with surgically proven ileocolic intussusception seen during the same time period were also reviewed for comparison. Results. In seven of the nine patients with ileoileocolic intussusception who had air enemas, the intussusceptum clearly had two or more separate polypoid components once it was reduced to the cecum. This distinctive appearance was not seen until the intussusceptum was tethered at the ileocecal valve. The intussusceptum was also reduced to the cecum in 19 patients from the control group with ileocolic intussusception. In contrast to the ileoileocolic intussusceptums, these intussusceptums were either smoothly marginated (16 patients) or slightly lobular (three patients). Conclusion. In most patients with ileoileocolic intussusception, the intussusceptum has two or more polypoid components at the level of the ileocecal valve which are easily distinguished from the smoothly marginated or slightly lobular intussusceptum seen with ileocolic intussusception.

Intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities.

PURPOSE: To evaluate the ability of fluoroscopic images obtained during air enemas to depict or exclude lead points of intussusceptions and other abnormalities that require surgical treatment in the absence of intussusception. MATERIALS AND METHODS: The clinical, radiologic, surgical, and pathologic findings were reviewed in 14 patients with lead points or other lesions. RESULTS: Fluoroscopic images failed to depict a lead point in 10 patients. The air enema easily reduced intussusceptions with benign lead points in seven patients. Fluoroscopic images depicted pathologic lead points in two patients and were normal in two patients with intussusception. Fluoroscopic images failed to depict an abnormality that required surgery in the absence of intussusception in two patients. CONCLUSION: Successful reduction of an intussusception does not always rule out a lead point. Other imaging studies, the patient's condition, and laparotomy may also be necessary to diagnose and treat lead points and other lesions.

Caecal mass on barium enema study--a case for routine colonoscopy.

Prolapse of the ileal mucosa through the ileo-caecal valve or minor ileo-caecal intussuception is not uncommon and may occasionally be mistaken radiologically for a caecal neoplasm, especially if intestinal obstruction, abdominal pain or rectal bleeding is present. Colonoscopic visualisation and biopsy is important before surgery is advised. We describe a case of ileal mucosa prolapse masquerading as a caecal neoplasm on barium enema study. Colonoscopy showed prolapse of the ileal mucosa which was easily reduced by air insufflation and therefore unnecessary surgery was avoided.

[The initial experiences with a new method for treating invagination: sonography-guided hydrostatic reduction]. / Erste Erfahrungen mit einer neuen Methode zur Behandlung der Invagination: die sonographisch gesteuerte hydrostatische Reposition.

During the last four months we have been treating all 15 sonographically diagnosed intussusceptions by a new method; this is based on the introduction of a saline enema under sonographic control. In 13 cases the method was successful according to imaging and clinical criteria. In two patients conservative reduction was impossible: in one patient partial resection of the ileum was necessary and in the other there was a recurrence which was reduced at operation. There were no complications. The advantages of the method are reduced radiation exposure, complete evaluation of the course of the procedure with definite criteria for success, the ability to recognise an ileo-ileal invagination and to determine the head of the intussusceptum. We can see no disadvantages compared with conventional methods. We regard this method as optimal in future for the treatment of infantile intussusceptions.

Indications for laparotomy after hydrostatic reduction for intussusception.

A criterion for successful hydrostatic reduction of intussusception is reflux into the terminal ileum. In our practice, absence of reflux into the terminal ileum is not an indication for laparotomy if the radiographic appearances suggest edema of the ileocecal valve. The aim of this study was to validate our approach. We reviewed the case notes of patients with a diagnosis of intussusception (n = 107; age 11.74 +/- 1.48 months; mean +/- SEM) treated from 1987 to 1991. Eleven required primary laparotomy for peritonitis. Ninety-six patients who had a contrast enema were studied. Edema of the ileocecal valve was defined as a persistent filling defect in the cecum after apparently complete hydrostatic reduction, without reflux of contrast into the distal small bowel. In 59 patients hydrostatic reduction was successful: 11 (18.6%) had edema of the ileocecal valve and no reflux contrast into the terminal ileum (group B). All improved clinically after the enema and needed no further treatment. In 37 patients hydrostatic reduction of the intussusception was unsuccessful and an operation was performed: 26 (70.3%) required manual reduction of the intussusception (group C) and 11 (29.7%) underwent bowel resection (group D). None of the patients with edema of ileocecal valve required further treatment or developed recurrent intussusception. In none of the patients who had an operation was the intussusception found to have been reduced by the contrast enema. There were no deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal tuberculosis in AIDS.

The radiological appearance of intestinal tuberculosis (IT) in six patients with AIDS is presented. Involvement of the ileocecal segment (five cases), cecum (four cases), and duodenum (one case) was seen on computed tomographic (CT) or barium studies. There were no significant differences in radiological manifestations of IT among patients with or without AIDS, but all six patients had an advanced stage of their disease at the time of diagnosis.

Intestinal tuberculosis: findings on double-contrast barium enema.

Seven cases of intestinal tuberculosis in an active stage were studied by the double-contrast barium enema (DCBE) method. Formerly, diagnosis of intestinal tuberculosis in the early stage by single-contrast barium enema (SCBE) and barium meals was based on functional phenomena, such as spasm and hypermotility of the ileocecal region. Presently, this can be better accomplished by DCBE. DCBE enables the detection of shallow ulcers with their characteristic elevated margins. These ulcers are frequently slim and transversally oriented. Confluence of ulcers may create whole girdle ulcers or affect entire segments. In more advanced stages, characteristic deformities, also evident by SCBE, such as symmetrical annular stenoses, shortening, retraction, pouch formation, and the frequently observed pathology of the ileocecal valve and the cecal region, acquire a new dimension with DCBE.

Effectiveness of pneumatic reduction of ileocolic intussusception in children.

A total of 158 consecutive therapeutic air enemas were performed upon 133 patients during a 2-year period. Perforation and/or an impairment of the general condition of the children were the only main contraindications for the reduction attempt (five patients). Successful reductions were achieved in 89% of cases with no complications. Operation was performed in all 17 cases of unsuccessful reduction: resection in four cases, easy manual reduction in nine, difficult manual reduction in two, and spontaneous reduction in two. There were 16 (12%) patients with one or more recurrent episodes. In 23 (16%) cases, following pneumatic reduction, a swollen ileocecal valve showing a multiple appearance was observed. This fact sometimes results in a differential diagnosis with incomplete reduction; in all these cases, small bowel aeration was always a sign of complete reduction. No significant difference was noted between a swollen ileocecal valve and patient age, duration of symptoms, presence of small bowel obstruction, and further recurrences. Air enema has improved our previous success obtained with hydrostatic reduction (79%), as well as being a simpler, cleaner, and faster technique for intussusception reduction in children.