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Comparative Effectiveness of Imaging Modalities for the Diagnosis and Treatment of Intussusception

Posted Apr 30, 2017 Updated Apr 10, 2023
By Anne G. Carroll MB BCh BAO LRCPI MRCSI FFRRCSI , Richard G. Kavanagh MB BSc MCh MRCSI , Caoilfhionn Ni Leidhin MB BCh BAO MRCSI , Noelle M. Cullinan MB BCh BAO LRCSI MRCPI , Lisa P. Lavelle MB BCh MRCPI FFRRCSI , Dermot E. Malone MD FRCPI FFRRCSI FRCR FRCPC
9 min read

Rationale and Objectives

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of intussusception and methods used in the treatment of ileocolic intussusception.

Methods

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome (PICO) method comparing radiography, ultrasound, and computed tomography in the detection of intussusception. The same methods were used to compare pneumatic (gas) reduction and hydrostatic (liquid) reduction using saline, water-soluble contrast, and barium. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

Results

The retrieved sensitivity for the diagnosis of intussusception using plain radiography is 48% (95% confidence interval [CI], 44%–52%), with a specificity of 21% (95% CI, 18%–24%). The retrieved sensitivity for the diagnosis of intussusception using ultrasound is 97.9% (95% CI, 95%–100%), with a specificity of 97.8% (95% CI, 97%–99%). Based on a good quality meta-analysis, the combined success rate of gas enema reduction was shown to be 82.7% (95% CI, 79.9%–85.6%) compared to a combined success rate of 69.6% (95% CI, 65.0%–74.1%) for liquid enema reduction.

Conclusions

The best available evidence recommends ultrasound as the diagnostic modality of choice for the diagnosis of ileocolic intussusception in children. In stable children without signs of peritonism, nonoperative reduction is the treatment of choice. Pneumatic (gas) reduction enema has been shown to be superior to hydrostatic (liquid) enema reduction.

Introduction

Intussusception is an invagination of the bowel into itself, usually involving both small and large bowel. The more proximal bowel that herniates into the more distal bowel is called the intussusceptum, and the bowel that contains it is called the intussuscipiens . As the intussusceptum and its mesentery telescope into the intussuscipiens, there is impairment of venous and lymphatic return, which leads to bowel wall edema. If untreated, this will progress to bowel ischemia, necrosis, and perforation. Intussusception can occur in large or small bowel, but is most commonly ileocecal .

Children with intussusception may have variable presentations, making the diagnosis often a challenging one. The classic triad of vomiting, colicky abdominal pain, and bloody (so called “red currant jelly”) stools is seen in less than 50% of patients . Indeed, the presence of bloody stool is often a late sign signifying delayed presentation and ischemic bowel.

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Research Questions

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Figure 1, Search strategy using patient, investigation, comparison, outcome (PICO) focused keywords.

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Appraisal

Diagnosis of Intussusception

Radiography

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Table 1

Test Performances for Diagnosis of Intussusception in Children

Diagnosis of Intussusception in Children Radiography

(Single View) 3-View Radiography

(Supine, Prone, and Left Lateral Decubitus) Ultrasound Ultrasound to Predict Need for Surgery Selected study Morrison et al. Roskind et al. Hryhorczuk and Strouse Munden et al. Sensitivity, % 48% (95% CI, 44%–52%) 100% (95% CI, 79.1%–100%) 97.9% (95% CI, 95%–100%) 93% (95% CI, 79%–100%) Specificity, % 21% (95% CI, 18%–24%) 17.4% (95% CI, 11.1%–26.1%) 97.8% (95% CI, 97%–99%) 100% (95% CI, 100%) Likelihood ratio + test 0.6 1.2 49.0 93.0 Likelihood ratio − test 2.4 0 0.02 0.07

Figure 2, Graphs of conditional probabilities for the diagnosis of intussusception in children. The x -axis represents the pretest probability of the disease in question, and the y -axis represents the posttest probability. The pretest probability is chosen, and a vertical line is drawn from the corresponding point on the x -axis to the “test negative” or “test positive” curve. From this point of intersection, a horizontal line is drawn to the y -axis. The posttest probability is the value at the point where the horizontal line intersects the y -axis. (a) Graph of conditional probabilities of plain radiography (single supine view) for the diagnosis of intussusception in children (8) . Sensitivity: 0.48; specificity: 0.21. As we can see from this graph, single-view supine plain radiography is a very poor test for ruling in or ruling out intussusception in children. (b) Graph of conditional probabilities of three-view plain radiography (supine, prone, and left side down lateral decubitus) for the diagnosis of intussusception in children (9) . Sensitivity: 1.00; specificity: 0.17. As we can see from this graph, three-view plain radiography is a better test for ruling out intussusception than single-view radiography, but it is a weak test for ruling in intussusception.

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Ultrasound

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Figure 3, Graphs of conditional probabilities for the diagnosis of intussusception in children. The x -axis represents the pretest probability of the disease in question, and the y -axis represents the posttest probability. The pretest probability is chosen, and a vertical line is drawn from the corresponding point on the x -axis to the “test negative” or “test positive” curve. From this point of intersection, a horizontal line is drawn to the y -axis. The posttest probability is the value at the point where the horizontal line intersects the y -axis. (a) Graph of conditional probabilities of ultrasound for the detection of intussusception in children (10) . Sensitivity: 0.98; specificity: 0.98. As we can see from this graph, ultrasound is a strong test for both ruling in and ruling out the diagnosis of intussusception in children. (b) Graph of conditional probabilities of ultrasound to predict the need for surgery with length of affected bowel greater than 3.5 cm in patients with intussusception (11) . Sensitivity: 0.93; specificity: 1.00. As we can see from this graph, ultrasound is a good test for predicting the need for surgery if the affected segment of bowel is greater than 3.5 cm in length in children with intussusception.

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Computed Tomography

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Treatment of Intussusception

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Pneumatic (Gas) Reduction

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Figure 4, Images (a) , (b) , and (c) have been taken from a pneumatic (carbon dioxide) reduction of an intussusception in a female infant under fluoroscopic guidance. The infant presented with bowel obstruction and had a history of vomiting for 72 hours. The images were taken in the prone position. The intussusceptum involving the descending colon ( arrows ) being reduced in the left iliac fossa is shown in (a) and (b) . The sudden appearance of a pneumoperitoneum ( arrows ) indicating a perforation as a complication of the pneumatic reduction is shown in (c) . The child was transferred to surgery where the intussusception was fully reduced, and a small perforation in the descending colon was repaired. There was no significant peritoneal spillage associated with the perforation. The infant went on to make a full recovery.

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Table 2

Test Performances (Benefits and Harms) in the Treatment of Intussusception in Children

Nonoperative Treatment of Intussusception in Children Gas Reduction Enema Liquid Reduction Enema_P_ Value Meta-analysis Sadigh et al. Sadigh et al. Combined success rate 82.7% (95% CI, 79.9%–85.6%) 69.6% (95% CI, 65.0%–74.1%) <.001 Pooled perforation rate 0.39% (95% CI, 0.23%–0.55%) 0.43% (95% CI, 0.24%–0.62%) .73 Early recurrence rate (within 48 h) 3.1% (95% CI, 1.1%–5.1%) 3.2% (85% CI, 1.9%–4.5%) .93

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Hydrostatic/Liquid Reduction (Saline or Water-soluble Contrast Media)

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Barium Reduction

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Delayed Repeat Enema

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Applicability to Practice

Diagnosis of Intussusception

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Treatment of Intussusception

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Evaluation of the Evidence

Diagnosis of Intussusception

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Treatment of Intussusception

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Academic Radiology, Volume 24, Issue 5
Journals General Radiology
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