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Intussusception and total body opacification
ClinicaIRadiology (1980) 31, 697-699
0009-9260/80/01200697502.00
© 1980 Royal College of Radiologists
Intussusception and Total Body Opacification R. M. AUSTIN*, A. M. SCHWARTZ*, K. McCARTENt §, R. G. K. McCAULEY* and S. BORDEN, IV~
*Department o f Pediatric Radiology, Boston Floating Hospital, Tufts New England Medical Center, Boston, MA, tDivision o f Pediatric Radiology, Massachusetts General Hospital, ~ The Children's Hospital of Philadelphia, USA Because o f atypical clinical presentations, two children with intussusception had intravenous urography as their initial examination following plain films. In b o t h patients the intussusception was outlined by an opaque rim due to the total b o d y opacification effect on the bowel wall. One patient had a target-like blush on followup films which strongly suggested the correct diagnosis. The authors do not advocate intravenous urography to diagnose intussusception, b u t i f this study is performed because o f atypical clinical findings, the radiographic sign should be recognised and lead to a barium enema.
was noted in the left upper quadrant (Fig. la). The 12 min abdominal film showed concentric rims of enhancement, suggesting telescoped bowel seen on end (Fig. lb). Because of this appearance, a barium enema was performed and this confirmed the presence of an intussusception (Fig. lc). Attempts at hydrostatic reduction were unsuccessful and the lice-colic intussusception was reduced at surgery. The intestine showed no evidence of necrosis and resection was not necessary. Case 2. C.R., an eight-month-old male, presented with lethargy. One week prior to admission, the patient had symptoms of an upper respiratory infection. He vomited several times during the 48 h before admission. Twenty-four hours before admission, the patient became lethargic with periodic episodes of irritability and crying. His mother noted a spot of blood in his diaper. On physical examination, the patient was hypotonic and lethargic. A mass was felt in the right mid-abdomen several centimetres below the liver margin. The examination was otherwise unremarkable. The patient was transferred to the Massachusetts General PATIENTS Hospital, where, on rectal examination, red-eurrant~elly stool was noted. Because of a granular east in the urine, an Case 1. K.H., a previously healthy nine-month-old female, intravenous urogram was performed first. Following the was well until 10 days prior to admission, when non-projectile injection of 2ec/kg of Renograf'm 60, an opaque rim was non-bilious vomiting began. The vomiting resolved over the seen in the periphery of a large mass in the right abdomen next two days with medical therapy. Watery stools, without (Fig. 2a). The kidneys appeared normal. A subsequent any evidence of blood, persisted throughout this period. On barium enema revealed an flee-colic intussusception to the the day prior to admission, bilious vomiting began. She was mld-transverse colon which could not be reduced (Fig. 2b). treated for dehydration, and then transferred to the Boston The intussusceptum could not be totally reduced at surgery Floating Hospital. and a right hemicoleetomy was performed. On physical examination, a 6 X 3 cm mass was noted in the left upper quadrant as well as a smaller mass in the left flank. No stool was obtainable on rectal examination. An abdominal radiograph showed a distended small bowel loop DISCUSSION in the right abdomen and a paucity of gas distally. There The phenomenon o f total b o d y opacification was was the suggestion of a mass in the left abdomen. The clinifirst described b y O'Connor and Neuhauser (1963), cians requested an intravenous urogram for which 2.5 cc/kg of Hypaque 50 was given. On the early films, an oval rim of who attributed the effect to opacification o f the contrast enhancement, approximately 4 X 5 em in diameter entire vascular compartment, a c o n c e p t which has since been amended by the knowledge that contrast § Present address: The Children's Hospital of Philadelphia, also enters the extracellular space (Kormano and 34th Street and Civic Center Blvd., Philadelphia, PA. Dean, 1976). Address correspondence to: A. M. Schwartz. The typical presentation o f intussusception poses no major diagnostic difficulties. It usually presents in the first year o f life and most often between the fifth and ninth months (Crowe and Sumner, 1978). Bloody rectal discharge occurs in 95% o f infants and 65% o f older children according to Ravitch et al. (1979). Nearly all the infants in his series had vomiting, and 85% had a palpable abdominal mass. Colicky pain, commonly associated with intussusception, is certainly difficult to assess in the younger child. Two cases presenting with atypical clinical findings of intussusception had excretory urography rather than barium enema as part o f their initial investigations. This paper describes the urographic findings which m a y be present in such cases o f intussusception.
698
CLINICAL RADIOLOGY
(a)
(b)
Fig. 1 - Case 1. (a) Five minute IVP film showing rim of contrast (arrowheads) and already a suggestion of internal blush. The small opaque density in the mass is an artifact. (b) Twelve minute film showing target-like blush of telescoped loops of bowel seen on end (arrows). (c) Barium enema confirms intussusception.
Since then, contrast enhancement has been demonstrated in a variety of gastrointestinal abnormalities. Crowe and Sumner (1978) have shown enhancement of a distended stomach in a newborn with duodenal and oesophageal atresia. Griscom (1978) has reported lucencies by total body opacification in a variety of gastrointestinal abnormalities including duplications and pancreatic pseudocysts. To our knowledge, the two cases presented in this paper are unusual in that they demonstrate intussusception by means of total body opacification. In the first case, the intussuscipiens opacified first, presumably because of its intact vascular supply. It can be postulated that arterial compression and venous stasis in the intussusceptum prevented its opacification at the same time as the intussuscipiens. In this case the intussuscipiens was initially opacified, with the intussusceptum seen on later radiographs. This
(c)
INTUSSUSCEPTION AND TOTAL BODY OPACIFICATION
(a)
699
(b)
Fig. 2 - Case 2. Films showing lobular rimmed mass (arrows) during IVP (a), which corresponds to intussuscipiens on barium enema (b).
merely confirms the well-known fact that enhancement is largely dependent on vascular supply. In the second case, it was probable that only the intussuscipiens opacified. It may be surmised in retrospect that this failure to opacify could have suggested the ischaemic and haemorrhagic intussusception found at surgery. We do not suggest that intravenous urography should play a role in the diagnosis o f obvious cases of intussusception. However, when a dense rim with or without a more specific target-like opacification is noted in a patient with abdominal symptoms and signs which may be non-specific, intussusception should be considered, and a barium enema performed.
REFERENCES
Crowe, J. E. & Sumner, T. E. (1978). Combined esophageal and duodenal atrcsia without tracheoesophageal fistula: characteristic radiographic changes. American Journal of Roentgenology, 130, 167-168. Griseom, N. T. (1978). Total body opacification. American Journal of Roentgenology, 131,919-925. Kormano, M. & Dean, P. B. (1976). Extravascular contrast material, the major component of contrast enhancement. Radiology, 121,379-382. O'Connor, J. F. & Neuhauser, E. B. D. (1963). Total body opacification in conventional and high dose urography in infancy. American Journal of Roentgenology, 90, 63-71. Ravitch, M. M., Welch, K. J., Benson, C. D., Aberdeen, E. A. & Randolph, J. G. (1979). Pediatric Surgery, pp. 989991. Yearbook Medical Publishers, Inc., Chicago.
0009-9260/80/01200697502.00
© 1980 Royal College of Radiologists
Intussusception and Total Body Opacification R. M. AUSTIN*, A. M. SCHWARTZ*, K. McCARTENt §, R. G. K. McCAULEY* and S. BORDEN, IV~
*Department o f Pediatric Radiology, Boston Floating Hospital, Tufts New England Medical Center, Boston, MA, tDivision o f Pediatric Radiology, Massachusetts General Hospital, ~ The Children's Hospital of Philadelphia, USA Because o f atypical clinical presentations, two children with intussusception had intravenous urography as their initial examination following plain films. In b o t h patients the intussusception was outlined by an opaque rim due to the total b o d y opacification effect on the bowel wall. One patient had a target-like blush on followup films which strongly suggested the correct diagnosis. The authors do not advocate intravenous urography to diagnose intussusception, b u t i f this study is performed because o f atypical clinical findings, the radiographic sign should be recognised and lead to a barium enema.
was noted in the left upper quadrant (Fig. la). The 12 min abdominal film showed concentric rims of enhancement, suggesting telescoped bowel seen on end (Fig. lb). Because of this appearance, a barium enema was performed and this confirmed the presence of an intussusception (Fig. lc). Attempts at hydrostatic reduction were unsuccessful and the lice-colic intussusception was reduced at surgery. The intestine showed no evidence of necrosis and resection was not necessary. Case 2. C.R., an eight-month-old male, presented with lethargy. One week prior to admission, the patient had symptoms of an upper respiratory infection. He vomited several times during the 48 h before admission. Twenty-four hours before admission, the patient became lethargic with periodic episodes of irritability and crying. His mother noted a spot of blood in his diaper. On physical examination, the patient was hypotonic and lethargic. A mass was felt in the right mid-abdomen several centimetres below the liver margin. The examination was otherwise unremarkable. The patient was transferred to the Massachusetts General PATIENTS Hospital, where, on rectal examination, red-eurrant~elly stool was noted. Because of a granular east in the urine, an Case 1. K.H., a previously healthy nine-month-old female, intravenous urogram was performed first. Following the was well until 10 days prior to admission, when non-projectile injection of 2ec/kg of Renograf'm 60, an opaque rim was non-bilious vomiting began. The vomiting resolved over the seen in the periphery of a large mass in the right abdomen next two days with medical therapy. Watery stools, without (Fig. 2a). The kidneys appeared normal. A subsequent any evidence of blood, persisted throughout this period. On barium enema revealed an flee-colic intussusception to the the day prior to admission, bilious vomiting began. She was mld-transverse colon which could not be reduced (Fig. 2b). treated for dehydration, and then transferred to the Boston The intussusceptum could not be totally reduced at surgery Floating Hospital. and a right hemicoleetomy was performed. On physical examination, a 6 X 3 cm mass was noted in the left upper quadrant as well as a smaller mass in the left flank. No stool was obtainable on rectal examination. An abdominal radiograph showed a distended small bowel loop DISCUSSION in the right abdomen and a paucity of gas distally. There The phenomenon o f total b o d y opacification was was the suggestion of a mass in the left abdomen. The clinifirst described b y O'Connor and Neuhauser (1963), cians requested an intravenous urogram for which 2.5 cc/kg of Hypaque 50 was given. On the early films, an oval rim of who attributed the effect to opacification o f the contrast enhancement, approximately 4 X 5 em in diameter entire vascular compartment, a c o n c e p t which has since been amended by the knowledge that contrast § Present address: The Children's Hospital of Philadelphia, also enters the extracellular space (Kormano and 34th Street and Civic Center Blvd., Philadelphia, PA. Dean, 1976). Address correspondence to: A. M. Schwartz. The typical presentation o f intussusception poses no major diagnostic difficulties. It usually presents in the first year o f life and most often between the fifth and ninth months (Crowe and Sumner, 1978). Bloody rectal discharge occurs in 95% o f infants and 65% o f older children according to Ravitch et al. (1979). Nearly all the infants in his series had vomiting, and 85% had a palpable abdominal mass. Colicky pain, commonly associated with intussusception, is certainly difficult to assess in the younger child. Two cases presenting with atypical clinical findings of intussusception had excretory urography rather than barium enema as part o f their initial investigations. This paper describes the urographic findings which m a y be present in such cases o f intussusception.
698
CLINICAL RADIOLOGY
(a)
(b)
Fig. 1 - Case 1. (a) Five minute IVP film showing rim of contrast (arrowheads) and already a suggestion of internal blush. The small opaque density in the mass is an artifact. (b) Twelve minute film showing target-like blush of telescoped loops of bowel seen on end (arrows). (c) Barium enema confirms intussusception.
Since then, contrast enhancement has been demonstrated in a variety of gastrointestinal abnormalities. Crowe and Sumner (1978) have shown enhancement of a distended stomach in a newborn with duodenal and oesophageal atresia. Griscom (1978) has reported lucencies by total body opacification in a variety of gastrointestinal abnormalities including duplications and pancreatic pseudocysts. To our knowledge, the two cases presented in this paper are unusual in that they demonstrate intussusception by means of total body opacification. In the first case, the intussuscipiens opacified first, presumably because of its intact vascular supply. It can be postulated that arterial compression and venous stasis in the intussusceptum prevented its opacification at the same time as the intussuscipiens. In this case the intussuscipiens was initially opacified, with the intussusceptum seen on later radiographs. This
(c)
INTUSSUSCEPTION AND TOTAL BODY OPACIFICATION
(a)
699
(b)
Fig. 2 - Case 2. Films showing lobular rimmed mass (arrows) during IVP (a), which corresponds to intussuscipiens on barium enema (b).
merely confirms the well-known fact that enhancement is largely dependent on vascular supply. In the second case, it was probable that only the intussuscipiens opacified. It may be surmised in retrospect that this failure to opacify could have suggested the ischaemic and haemorrhagic intussusception found at surgery. We do not suggest that intravenous urography should play a role in the diagnosis o f obvious cases of intussusception. However, when a dense rim with or without a more specific target-like opacification is noted in a patient with abdominal symptoms and signs which may be non-specific, intussusception should be considered, and a barium enema performed.
REFERENCES
Crowe, J. E. & Sumner, T. E. (1978). Combined esophageal and duodenal atrcsia without tracheoesophageal fistula: characteristic radiographic changes. American Journal of Roentgenology, 130, 167-168. Griseom, N. T. (1978). Total body opacification. American Journal of Roentgenology, 131,919-925. Kormano, M. & Dean, P. B. (1976). Extravascular contrast material, the major component of contrast enhancement. Radiology, 121,379-382. O'Connor, J. F. & Neuhauser, E. B. D. (1963). Total body opacification in conventional and high dose urography in infancy. American Journal of Roentgenology, 90, 63-71. Ravitch, M. M., Welch, K. J., Benson, C. D., Aberdeen, E. A. & Randolph, J. G. (1979). Pediatric Surgery, pp. 989991. Yearbook Medical Publishers, Inc., Chicago.