Fluoroscopically controlled enema reduction of intussusception

FLUOROSCOPICALLY CONTROLLED ENEMA REDUCTION OF I N T U S S U S C E P T I O N E. D. HUNTINGTOI~, ~V~.D., AND R. E. WILLIAMS, M.D. CHICAGO, ILL. E possibility of nonoperative reduction of ilcoeolonic intussusT Hceptions by enema has recently been recalled to the medical mind by a publication of Edwin Miller, 1 in which he reviews the work of Hipsley ~ of Australia. The frequent success of this ancient procedure has been largely lost sight of in this day of surgically minded practitioners. Various writers have condemned the procedure as " u n scientific," of "historical interest o n l y , " and as " d a n g e r o u s " and "uncertain." Hipsley in I00 consecutive cases was able to reduce sixty-two by pressure enemas, using saline solution, with the patient anesthetized; of these sixty-two cases he found it necessary to verify the reduction by lapar0tomy in eighteen cases. His mortality for the entire series of 100 cases was 5 per cent. l~etan ~ in 1927 suggested reduction by fluoroscopically controlled enema technic. An essentially similar method was independently described by Stephens* the following year. Each writer reported a saccessfully reduced case. The advantages claimed for the fluoroscopic method by these writers are safety, anesthetic unnecessary, and certain recognition of success or failure. The method described by both ~ e t a n and Stephens is b r i e f y as follows: Tile barium mixture is introduced with minimal pressure until the colon is filled to the advancing point os the intussuscep.tum (the enema source not being' big'her than 3 feet above the table); then with the gravity pressure shut off, the barium is forced against the intussuseeptum by manual pressure extelmally on the already filled colon under visual guidance and control. As the intussuseeptum recedes more of the mixture is introduced and manual pressure again applied. As soon as the intussusception seems reduced, the colon is completely filled by gravity pressure to make certain the reduction is complete; if such is the ease the colon fills completely and the barium mixture can be seen passing into the terminal ileum. These fluoroscopic observations are checked by an immediate roentgenograph. Retan lists the following' points as evidence of complete disinvagination: (1) The co]0n will fill completely with leak into the ileum as

819

820

THE JOURNAL OF PEDIATRICS

e v i d e n c e d b y fluoroscopic v i e w a n d c o n f i r m e d b y r o e n t g e n o g r a p h ; (2) t h e a b d o m i n a l t u m o r d i s a p p e a r s ; a n d (3) the child is relieved of his s y m p t o m s , shock, p a i n , v o m i t i n g , etc. W e b e l i e v e t h i s m e t h o d h a s s e v e r a l a d v a n t a g e s . I t is i n t e l l i g e n t , scientific, s a f e l y c o n s e r v a t i v e , a n d a n a l o g o u s to t h e c o n s e r v a t i v e a n d p r o p e r c o n d u c t of l a b o r as c o m p a r e d to r o u t i n e a b d o m i n a l section. DiagJaosis is d e f i n i t e l y e s t a b l i s h e d e v e n i f t h e p r o c e d u r e fails. V i s u a l c o n t r o l m a k e s f o r effectiveness, s a f e t y , a n d c e r t a i n t y as to success or f a i l u r e . A n a n e s t h e t i c is u n n e c e s s a r y . I f r e d u c t i o n of the i n t u s s u s c e p t i o n f a i l s n o h a r m is done, a n d app r o p r i a t e s u r g i c a l t r e a t m e n t c a n be p r o m p t l y i n s t i t u t e d . I f o n l y p a r t i a l Success is o b t a i n e d , t h e p r o c e d u r e is still w e l l w o r t h while, s i n c e i n t h e o p e n e d a b d o m e n it is f a r s i m p l e r to d e a l w i t h a m a s s t h a t e x t e n d s no f u r t h e r t h a n t h e h e p a t i c f l e x u r e t h a n w i t h one w h i c h e x t e n d s to t h e s i g m o i d p o r t i o n of t h e colon. R e t a n has a d v i s e d t h a t t h i s m e t h o d b e u s e d o n l y w i t h i n t h e first t w e l v e h o u r s of t h e i n t u s s u s c e p t i o n , on t h e o r e t i c a l s a f e t y c o n s i d e r a tions. B u t t h e d e g r e e of s e v e r i t y ( e x t e n t , a g g l u t i n a t i o n , edema, s t r a ~ l g u l a t i o n , a n d l e s s e n e d v i t a l i t y ) c e r t a i n l y does n o t d e p e n d on the t i m e e l e m e n t alone. A n d , m o r e o v e r , w h o c a n d e t e r m i n e h o w l o n g t h e c o n d i t i o n h a s b e e n p r e s e n t i n a g i v e n case? U s u a l l y one c a n o n l y k n o w h o w l o n g t h e p a t i e n t h a s h a d s y m p t o m s of g a s t r o i n t e s t i n a l distress, w h i c h o f t e n a n t e d a t e , s o m e t i m e s f o r days, t h e a c t u a l o c c u r r e n c e of t h e i n t u s s u s c e p t i o n . H i p s l e y f a i l s to s t a t e the c r i t e r i o n b y w h i c h he d e t e r m i n e d h o w l o n g t h e a c t u a l i n t u s s u s c e p t i o n h a d e x i s t e d i n his p a t i e n t s ; other writers are equally indefinite. W e p r e s e n t b r i e f l y the case h i s t o r y of a s u c c e s s f u l l y r e d u c e d i n t u s s u s c e p t i o n i n w h i c h a f l u o r o s c o p i c a l l y c o n t r o l l e d b a r i u m e n e m a was used, w i t h r o e n t g e n o g r a p h s t a k e n b e f o r e a,nd a f t e r r e d i l c t i o n . R o b e r t 1% aged two years, w a s seen on Sept. 26,. 1933, because of severe pain

in the abdomen. This pain had begu~ at about 5 A.~. and recurred at frequent intervals during the next two hours. Vomiting occurred at 7 A(~. while one of us was examining him; shortly after a spontaneous normal bowel movement occurred. There was a palpable and visible mass in the right lower quadrant of the abdomen; it was sausage shaped and about 2 inches long. The mass was tender, but the rest of the abdomen was of normal sensitivity, and there was no rigidity. The child was sent to the hospital with a tentative diagnosis of acute intussusception. On admission to the hospital the temperature was 98.8 ~ F. (rectal); respirations, 26; and pulse, 130. Atropine sulphate, gr. ~oo, was given hypodermically, and the child sent to the x-ray division at 9 A.~. At this time the tumor mass was in the epigastrium. A thin barium enem~ was given with the double purpose of check ing the clinical diagnosis and of attempting pressure reduction of the invagination. The examination confirmed the diagnosis (~ig. 1), but the enema failed to reduce the invagination while being observed under the fluoroscope. The child expelled a large part of the enema soon after the rectal tube was removed, and the nurses commented that he seemed relieved of all pain. On return to the ward, the child

tIUNTINGTON

AND WILLIAMS:

INTUSSUSCEPTION REDUCTION

821

F i g . 1 . - - T h e e n e m a r e a d i l y d i s t e n d e d t h e colon u n t i l it c a m e to t h e site of t h e t u m o r m a s s , a t w h i c h p o i n t it w a s t o t a l l y o b s t r u c t e d , a l t h o u g h it " p u s h e d " t h e i n t u s s u s c e p t u m back to the r i g h t upper q u a d r a n t . F i n e l i n e s o f o p a c i t y soon e x t e n d e d p a s t t h e p o i n t of i n i t i a l o b s t r u c t i o n , e v i d e n t l y r e p r e s e n t i n g " s e e p a g e " a b o u t t h e i n v a g i n a t e d p o r t i o n , i.e., i n f i l t r a t i o n b e t w e e n t h e o p p o s i n g s u r f a c e s of t h e i n v a g i n a t e d a n d r e c e i v i n g p o r t i o n s of t h e gut, r e s p e c t i v e l y .

Fig. 2 . - - T h e e n e m a h a s c o m p l e t e l y filled t h e colon, a n d t h e r e is s o m e p a s s a g e into the ileum.

822

THE

JOURNAL

OF

PEDIATRICS

fell asleep, a n d on p a l p a t i n g t h e a b d o m e n it w a s f o u n d t h a t t h e t u m o r m a s s h a d d i s a p p e a r e d . R e - e x a m i n a t i o n u n d e r t h e fluoroscope w i t h a b a r i u m e n e m a showed t h e colon filling n o r m a l l y ( F i g . 2). T h e c h i l d ' s p r e v i o u s h i s t o r y w a s normal. P h y s i c a l e x a m i n a t i o n revealed no abn o r m a l i t i e s other t h a n t h o s e n o t e d above. T h e r e h a s been no recurrence of this c o n d i t i o n to date.

One of us (E. D. H.) has had occasion to see three other successful reductions b y enemas of clinically typical intussusceptions. In all t h r e e cases the p a t h o l o g y had existed but a few hours. In the last two years in two infants a t t e m p t e d r e d u c t i o n b y enema u n d e r the fluoroscope was unsuccessful; in o,ne the condition had been p r e s u m a b l y present over three days, and in the otl;er over one day. Both cases were with difficulty r e d u c e d at o p e r a t ,i/ o n . It is our impression that the medical publications, especially those r e a c h i n g the general practitioner, have neglected to keep the profession conscious of this grave condition occurring in ~afancy and childhood. Too often the diagnosis is not made until t w e n t y - f o u r or more hours have elapsed; bloody stools are too often the first sign to arouse the a t t e n d a n t f r o m his lethargy. F l a t r o e n t g e n o g r a p h s of the abdomen would be helpful even in intussusception of the small intestine ; if the colon is involved, opaque enema is diagnostic from the first. I f the diagnosis is made early, fluoroscopica]]y controlled enema offers a good chance of n o n o p e r a t i v e r e d u c t i o n in ileocolonic invagin a t i o n ; if it fail or if the invagiaation be the small intestine, early operative reduction is available at an optimum time. REFERENCES l. 2. 3. 4.

Miller, E d w i n : A n n . Surg. 48: 706, ]933. I-Iipsley, P . L . : IVL J. A u s t r a l i a 2: 201, ]926. Reran, G.M.: A m . J. Dis. Child. 33: 765~ 1927. S t e p h e n s , V. 1~.: A m . J; Dis. Child. 35: 61, 1928. 1357 WEST ]03aD STI~EET