Air enema reduction of intussusception: The success rate

and factors affecting outcome

Poster No.: C-0304

Congress: ECR 2019
Type: Scientific Exhibit
Authors: 1 2 1 2
C. Towiwat , P. Visrutaratna ; Bangkok/TH, Chiang Mai/TH
Keywords: Outcomes, Outcomes analysis, Ultrasound, Fluoroscopy,
Conventional radiography, Paediatric
DOI: 10.26044/ecr2019/C-0304

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Page 1 of 14
Aims and objectives

The most common cause of acute bowel obstruction in infants is intussusception,

invagination of a proximal segment of the bowel (intussusceptum) into a more distal
segment (intussuscepiens). If the intussusception is not diagnosed and treated promptly,
reduced arterial blood supply, bowel infarction, and perforation may follow. These
complications may cause peritonitis and even death (1). The current diagnostic imaging
approach should include: (a) abdominal radiograph to exclude other diagnoses or
perforation, (b) ultrasound to diagnose either intussusception or alternative causes for a
child's abdominal symptoms, (c) surgical consultation to exclude the contraindications for
air enema reduction which include peritonitis, profound shock, and pneumoperitoneum,
and (d) air enema reduction (2).

The previously published success rate of air enema reduction of intussusception varied
from 51% (3) to 95.25% (4). In Thailand the success rate performed by pediatric
radiologists was 68% (5). A recent survey in the United Kingdom and Ireland showed that
the success rate of air enema reduction performed by radiologists was 61.2% (6).

Ultrasound plays an important role in the diagnosis of intussusception and in evaluation

of its reducibility (2). The reported abnormalities associated with a decreased success
rate at air enema reduction included trapped interloop fluid between the intussusceptum
and intussuscepiens, lack of color doppler flow in the bowel wall, small bowel obstruction,
and more distal location (2, 7-9). Ascites and the presence of lymph nodes within the
intussuscepiens have not been shown to affect the reduction outcomes (10).

Therefore, the purpose of this study was to determine the success rate of air enema
reduction, the percentage of small bowel obstruction in patients involving failed air enema
reduction, and the percentage of trapped interloop fluid and its average largest dimension
in patients involving failed air enema reduction.

Page 2 of 14
Methods and materials

Patient Population: In this retrospective study, the data was reviewed for 188 pediatric
patients who were diagnosed with intussusception confirmed on sonography and
underwent air enema reduction from May 2007 to November 2016. Three patients were
excluded from the study because there was no available abdominal radiograph and/or
sonographic images prior to the air enema reduction procedure. Therefore, 185 patients
were included in this study.

Data Analysis: The abdominal radiograph and sonographic images of each patient were
reviewed by a radiology resident and a pediatric radiologist. Then the presence of small
bowel obstruction (Figure 1) and trapped interloop fluid between the intussusceptum and
intussuscipien were determined with consensus. For those patients with the presence
of trapped interloop fluid, the maximal diameter and its perpendicular diameter were
measured on a selected axial sonographic image through the intussusception (Figure 2)
and the larger of the two diameters was recorded.

The fluoroscopic imaging series during air enema reduction procedure of each patient
were reviewed by a radiology resident and a pediatric radiologist. Then the sites of
intussusception in the colon were identified with consensus which were as follows:
ascending colon, transverse colon, descending colon, and sigmoid colon and rectum
(Figures 3a - 3e). The outcome of the air enema reduction of each site was recorded.

Statistical Analysis: The software SPSS, version 17.0 (SPSS, Chicago, Ill), was used
to determine the percentage of success rate of air enema reduction, the percentage of
small bowel obstruction in patients involving failed air enema reduction, the percentage of
trapped interloop fluid in patients involving failed air enema reduction, and the percentage
of each site of intussusception and its outcome after air enema reduction. Bivariate
association, using Chi-square test, was used to analyze the associations between the
outcomes of air enema reduction and the presence of trapped interloop fluid and between
the outcomes of air enema reduction and small bowel obstruction. A p-value of less than
0.05 was considered to indicate a statistically significant difference.

Page 3 of 14
Images for this section:

Fig. 1: Abdominal radiograph (AP supine view) demonstrates the presence of small
bowel obstruction.

© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/

Thailand

Page 4 of 14
Fig. 2: Transverse sonographic image of an intussusception with trapped interloop fluid.
Two diameters (white arrows) were measured. The larger diameter was recorded.

© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/

Thailand

Page 5 of 14
Fig. 3: Fluoroscopic images during air enema reduction demonstrate intussusception
(white arrows) in different portions of the colon (3a: ascending colon, 3b: transverse colon,
3c: descending colon, 3d: sigmoid colon, and 3e: rectum).

© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/

Thailand

Page 6 of 14
Results

Success Rate: Out of 185 patients who have been diagnosed with intussusception
and underwent the air enema reduction, 125 patients (67.6%) have been successfully
reduced. Meanwhile, the other 60 patients (32.4%) remained irreducible (Figure 4).

Small Bowel Obstruction: Out of 60 patients involving failed air enema reduction, small
bowel obstruction was present in 48 patients (80%). Meanwhile, out of 125 patients
involving successful reduction, small bowel obstruction was present in 52 patients
(41.6%) (Figure 5). By using Chi-square test to analyze these data, the presence of small
bowel obstruction has shown a significant correlation with failed air enema reduction (p-
value < 0.05).

Trapped Interloop Fluid: Out of 60 patients involving failed air enema reduction, trapped
interloop fluid was present in 37 patients (61.7%). Meanwhile, out of 125 patients
involving successful reduction, trapped interloop fluid was present in 41 patients (32.8%)
(Figure 6). By using Chi-square test to analyze these data, the presence of trapped
interloop fluid has shown a significant correlation with failed air enema reduction (p-value
< 0.05).

Average Largest Dimension: The average largest dimension of the trapped interloop
fluid in the patients involving failed air enema reduction was 13.6 mm. Meanwhile,
the average largest dimension of the trapped interloop fluid in the patients involving
successful air enema reduction was 8.4 mm. (Figure 7)

Sites of Intussusception and Air Enema Reduction Outcomes: Each site of

intussusception and its air enema reduction outcome were demonstrated in Table 1.

Page 7 of 14
Images for this section:

Fig. 4: Pie chart with percentage outcomes of air enema reduction.

© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/

Thailand

Page 8 of 14
Fig. 5: Column chart demonstrates percentages of small bowel obstruction in patients
involving successful and failed air enema reduction.

© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/

Thailand

Page 9 of 14
Fig. 6: Column chart demonstrates percentages of trapped interloop fluid in patients
involving successful and failed air enema reduction.

© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/

Thailand

Page 10 of 14
Fig. 7: Column chart demonstrates average largest dimensions of trapped interloop fluid
in patients involving successful and failed air enema reduction.

© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/

Thailand

Table 1: Sites of intussusception and air enema reduction outcomes.

Page 11 of 14
© Radiology Department, Faculty of Medicine, Chiang Mai University - Chiang Mai/
Thailand

Page 12 of 14
Conclusion

In conclusion, the success rate of air enema reduction of intussusception in this study
was 67.6%. The results of statistical analysis in this study showed that both small
bowel obstruction and trapped interloop fluid significantly correlated with failed air enema
reduction. The more distal the intussusception was in the colon, the greater percentage
of failed air enemareduction it had.

Although the presence of small bowel obstruction, trapped interloop fluid, and distal
location of the intussusception are associated with an increased percentage of failed air
enema reduction, they are not considered as contraindications for air enema reduction.
The air enema reduction may still be performed, unless absolute contraindications are
present. However, as these findings are poor outcome predictors for air enema reduction,
we can use them to urge the medical team to be prepared for the prompt operative
reduction that might follow.

Page 13 of 14
References

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intussusception in children. Eur Radiol 2007; 17: 2411-21.

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