INTUSSUSCEPTION CHILDREN - Postgraduate Medical Journal · June 1950 NORDENTOFT:Intussusception in...

334 POSTGRADUATE MEDICAL JOURNAL _Jufl? 1950

I ought perhaps to add one further observationabout the litigation of such claims. In a recentcase the claim was brought against the surgeonand the sister who had been responsible for thecounting of the swabs. I suppose that this wasdone on the basis that the combined duties of thetwo of them together covered the whole field ofactivity, within which any negligence connectedwith the non-extraction of the swab must haveoccurred. A similar joinder of defendants wouldbe likely to be made in any similar case. If morethan two persons may be involved in the negli-gence, more than two may be brought in asdefendants. This is, after all, a natural pro-cedure, if it is certain or almost certain that,

assuming negligence to have occurred, one ormore of (say) three persons are guilty of thenegligence, but it is still uncertain to which theblame is to be attributed, and only the investiga-tion of the facts at the trial will settle the matter.The plaintiff will have good reason for beingcautious about joining as defendants personsagainst whom he is not likely to succeed, inasmuchas he may have to pay their costs. The questionsof the assessment of the damages which a success-ful plaintiff is entitled to recover, and of theapportionment of damages if the plaintiff succeedsagainst more than one defendant, do not fallwithin the scope of this article.

INTUSSUSCEPTION IN CHILDRENIts Diagnosis and Treatment

By DR. JENS MUNCK NORDENTOFTPhysician in Charge of the Department of Radiology, Aalborg County Hospital, Denmark

The treatment of intussusception in children byconservative measures (enemata or manipulation)is very old. During the earlier years of thiscentury, as the safety of operative treatment in-creased, it was almost abandoned. Here andthere, however, it still had advocates. The greatadvantage of conservative treatment is obvious;laparotomy is avoided. It is, however, a blindmeasure and its greatest danger was the fact thatits success or failure was never immediately known.In a large number of cases it was not discoveredthat the reduction had been incomplete until hoursor days had passed. Precious time was thuswasted, the risks of laparotomy had increased anda high mortality resulted.To-day the non-operative treatment of in-

tussusception in children in its modern form withthe barium enema under fluoroscopic control isalmost without danger, provided always that it isadministered by an experienced radiologist. WithX-rays the diagnosis can be confirmed at once, thetopical diagnosis can often be exact, and one canwith certainty know when reduction is complete.It is, however, essential that the radiologist in

charge shall be a man of skill and experience ininterpreting the radiological findings.

The History of the Barium Enema MethodThe barium reduction method has especially

gained ground in those countries where the simpleenema and manipulation methods had never beengiven up, and where their considerable advantageswere appreciated. The fact that the bariumenema method has not been accepted in Anglo-Saxon countries is no doubt due to the fact thatthe old methods had there been quite abandonedbefore the barium method was introduced in I927.Certain series of good results of operative treat-ment from surgical departments of children'shospitals certainly contributed to this, as probablyalso did unwise and unskilled adherents of theolder conservative school.

In the writings of last century the use of acolumn of water 4 to 6 m. (I3 to 20 ft.) is recom-mended, to be applied by ' laying the child in thehallway and raising the funnel by mounting thestairs.' Mortimer tried to find out howgreat a pressure the normal colon can withstand

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June 1950 NORDENTOFT: Intussusception in Children 335

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FIGS. i and 2.-Colic intussusception in boy eight years old. The gas-distended colon ends funnel-shaped in theneck of the intussusception at the left iliac crest. After the injection (Fig. 2) a typical intussusception figure isseen, with inflow of enema about the intussusceptum. The extent of the invagination can be estimated from thepicture.

without rupture. He made post-mortem roomexperiments and found that the force should bemuch less than had generally been supposed to besafe. The writer has performed similar examina-tions which showed that, based on modern con-ceptions, the large bowel of a normal child canstand a very high pressure.

In France the enema methods seemed quiteabandoned, but the barium enema method had astrong advocate in Pouliquen. -French surgeonswere interested in the method -as a means ofdiminishing the intussusception (partial reduction)before operation. After much controversy it wasadopted also as a means of complete reduction,but in spite of the ' consecration officielle ' ofOmbredanne, it has by no means achieved generalacceptance.

In Scandinavia things were otherwise. Herethe old conservative methods had never quite beendriven from the field. In Denmark, at the QueenLouise Children's Hospital, for more than 50years the non-operative methods of treatment inthe form of water injections (Hirschsprung, Wich-mann) or taxis (Monrad) had been advocated.

There generations of young doctors have beentaught to make the diagnosis early in the disease.They have been made aware of the disease, havelearnt to listen to the mother's story and knowthe four cardinal points of colic, vomiting, blood inthe stools and an abdominal mass, combined withthe typical pallor. Moreover, articles throwinglight on the subject from all angles are constantlyappearing in Denmark, so that the problem is keptbefore their minds. These features are of thegreatest importance, because the success of everytype of conservative treatment depends on earlydiagnosis and the earliest possible institution oftreatment, a fact not at all upset by the results ofexceptionally skilled radiologists such as Hellmer(1948), who have obtained complete reductioneven in the later stages of the disease.

Before passing on to the subject of diagnosis andtherapy by the barium enema method, the writerwould like to stress the importance of:-

(a) Educational campaigns aiming at earlierreference of patients for diagnosis and treatment;

(b) Provision of facilities for immediate ex-

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336 POSTGRADUATE MEDICAL JOURNAL June 1950

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FIG. 3.-Typical ileocaecal intussusception (ascendingcolon, detail).

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FIG. 5.-Ring-formed intussusception figure in theright flexure, where the intussusception is seen incross-section.

amination and treatment by experienced radi-ologists; and

(c) A friendly attitude towards the non-opera-tive treatment of intussusception on the part ofall those concerned.The writer hastens to add that cases of in-

tussusception should by all means remain underthe care of the surgeons, on the surgical side, butshould be referred to the radiologist for attemptedreduction with the barium enema. In Denmarkthis is the normal practice, the surgeon oftencoming to the radiological department to be presentduring the procedure.

Radiological Diagnosisi. Straight films in recumbent position before

injection of barium suspension should never beomitted, as it is possible from them to form. anestimate of the gas-distension of the bowel and togain information not only about the presence ofan ileus, but also abcut the type of the intussuscep-

tion (Fig. i). It is helpful in diagnosing whetherlarge or small bowel is involved, thus giving someguidance as to the manner in which the enema isto be given.

In X-rays taken with the patient standing,sitting or suspended, fluid levels with dome-shaFedgas accumulations above may be present.

2. A diagnostic barium enema is then given, pro-vided that it is not contraindicated by a possibilityof appendicitis.

The intussusception figure is the picture thatappears when the apex of the intussusceptum issurrounded by barium. Commonly it takes theform of a cup or crescent-shaped rarefaction in thebarium shadow, usually with a sharply outlinedmargin (Fig. 3), often like a ' fork-figure' or' earwig-pincers' (Fig. 4). If the barium hasadvanced for some distance about the intussuscep-tum a negative picture of the latter may be obtainedin the form of a filling-defect enclosed by twohorn-like projections or arms. If the intussuscep-tion is seen in cross-section the figure may become

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Courtesy: Jacob Nordentoft, Surgeon-in-chief

FIG. 4.-Typical fork-figure resembling earwig pincers in a boyaged five months. Note tip of metal obturator in the anus.

ovoid or annular (Fig. 5), and if the intussusceptumconsists of small bowel, broad lines of bariumshadow may demonstrate that the intussusceptionis one that has passed into the colon through theileocaecal junction (Edberg's sign of ileocolic in-tussusception; Figs. 6 and 9). Another frequentpicture is a series of rings, due to a concertina-likecontraction of the intussuscipiens about the in-vaginated portion. This is especially seen duringthe evacuation of the enema, where an intussuscep-tum that has been very much reduced by the fluidpressure draws the sheath with it when it againmoves forward (Figs. 7 and io).

Demonstration with a barium enema of afigure resembling an intussusception is not, how-ever, conclusive proof of the diagnosis. Only ina child with symptoms of obstruction, where thefigure is movable, and where it disappears onlywhen it has been reduced to the ileocaecal regiondoes the diagnosis become certain. It is there-fore justifiable to speak of the intussusceptionfigure as the fifth cardinal sign of inlussusception inchildren.

3. Topical diagnosis (see diagrams, Figs. 8 andI2).Pure colonic intussusception may be diagnosed

from the straight film (Fig. i). With the bariumenema the distance from the funnel-shaped ter-mination of the gas figure to the cup-shaped caputoutlined by the fluid may indicate the length of theintussusceptum (Fig. 2).

Pure ileal intussusception can be recognizedwhen the enema flows into the small bowel, hereproducing the typical figure near the ileocaecaljunction (Figs. 8a and ii). Figs. 9 to ii demon-strate three stages in the reduction of an ileo-colic intussusception, the last figure showing theremaining pure ileal intussusception from whichthe complicated invagination has started (compareFig. 8, where c, b and a correspond to Figs. 9,io and ii respectively).

Enterocolic intussusceptions form up to 8o percent. of the total. They are subdivided into ileo-caecal, and the various ileocolic types. In theformer the apex is formed either by the caputcaeci or by the ileocaccal valve (Fig. I2). Edberg's

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FIG. 6.-Ileocolic intussusception I2 hours old in girlaged nine months. The plain film had showedsmall fluid levels. There is positive Edberg'ssign: caecum and appendix filled, but the intus-susceptum is distinctly seen in the ascending colon.At operation no invagination was found. Theappendix lay free; there was some oedema of thecaecum, especially the valve; i 0-I2 cm. of theadjoining ileum were dark red with subseroushaemorrhages.

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FIG. 7.-Post-evacuation picture of compound ileo-colic intussusception in a girl aged I6 months.Considerable gas in the small bowel. Numerousannular figures surround the intussusceptum, whichdistends the ascending colon. (Detail.)

1. Ileal. | 2. Ileo-IeOCOiC.

4. Compound ileocolic3. Ileocolic.(ileocolic-ileocaecal).

FIG. 8.-Diagrams to show the development of anileocolic intussusception; (3), (2) and (I) corres-pond to the figures 9, io and ii respectively.

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FIG. 9 FIG. 10

FIG. I I

FIGS. 9 to I I.-Three phases in the partial reduction of an ileo-ileocolic intussusception in a girl aged five months.(Details.) FIG. 9: Large intussusceptum in the caecum and ascending colon. Only ileocolic invagination can bediagnosed. FIG. io: Partial reduction. The caecum is filled, but a small filling defect is still to be seen in theascending colon. The enema has passed Bauhin's valve and surrounds the intussusceptum in the terminal ileum.FIG. I I: Caecum and ascending colon are well filled, but there remains a pure ileal intussusception. The patientwas operated upon and did well.

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POSTGRADUATE MEDICAL JOURNAL June 1950

sign, mentioned above, is pathognomonic of anileocolic intussusception. Hellmer, in the majorityof cases, succeeded in pushing such an intussuscep-tion back through the dilated orifice of theileocaecal (Bauhin's) valve into the ileum, and hebelieves that ileocaecal intussusceptions in the truesense are exceptional.

The Therapeutic Barium EnemaIt is evident from what has been said that

diagnosis and therapy to a certain extent go handin hand. The diagnostic injection must always bemade under a low pressure and under constantfluoroscopic control, otherwise the diagnosis maybe missed as loose invaginations can be reducedwith a minimum pressure.

If an intussusception is found, the enema iscontinued by allowing the fluid to enter for someminutes under a pressure of 3 to 4 ft. In cases ofless than 24 hours' duration the pressure may beincreased to 4 ft. 6 in. or more, but it is neverallowed to exceed 6 ft. The anus of the childshould be occluded either by means of a metal orebonite obturator (Fig. 4), or by using a thickrubber tube and pinching the buttocks togetheraround it. Hellmer is right when he says:' Attach the greatest importance to the nurse whoassists ad anum. . . . This assistance is . . . quiteas important for a successful result as the work ofthe roentgenologist. Place the untrained helper

at the instrument table and the trained nurse atthe enema can.' Rouliquen has constructed avery useful rubber tube with a water-distensibleballoon for occlusion of the anus.When the reduction is almost complete, the

caecum, particularly on its medial side in theregion of the ileocaecal valve, is the key-point.Complete filling of the caecum and satisfactory refluxinto the ileum are the two important radiologicalsigns of reduction.

After the examination, the enema is evacuatedand further X-rays are taken. These post-evacuation pictures are important because thecondition can best be studied after the colon hascollapsed. If reduction is not certain the in-jection is repeated under pressure and again thecaecum and lower ileum are examined for filling(Figs. I 3 and 14).According to Hellmer it is possible, without

anaesthesia, to obtain inflow into the small bowelin all cases in which the intussusception has beenreduced. This is the result, probably, of repeatedenemata. With one injection only reflux into theileum is obtained in about 50 per cent. of cases.

If there is doubt about the reduction, a charcoaltablet dissolved in water may be given by mouth.If an enema given five hours later is returned withparticles of charcoal, it proves fairly reliably thatthe obstruction has been relieved.

I and 3. Ileocaecal. 2 and 4. Caecocolic.The ileocaecal junction The caput caeci in-forms the apex. X verted forms the apex.

FIG. 12.-Diagram showing ileocaecal intussusceptions; in thoseto the left the apex is constituted by the ileocaecal junction,in those to the right by the fundus of the caecum.

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If there is doubt about the reduction-whichthere will always be if the enema does not pass intothe small bowel-intervention is indicated. Inearly cases a brief delay, not exceeding a few hours,may be allowed.

It is essential that the caecum be completelyfilled (Figs. I3 and I4). If it contains a filling de-fect (Figs. I5, i6 and I7), and particularly ifthere is no reflux into the ileum, operation isindicated. If the procedure here indicated isclosely followed, it will rarely be necessary tooperate merely for the purpose of exploration.

In almost all cases it will be possible to obtainat least a partial reduction of the intussusceptionby means of the barium enema. This is of ad-vantage in planning the most suitable incision forthe subsequent laparotomy.

Post-Examination CareThe after-care is extremely important. If colic

or vomiting recur, further X-ray examination oroperative intervention is indicated. In the writer'sexperience the child's condition is often improvedeven when reduction is incomplete. The fact thatthe child seems to be improved, begins to drink orfalls asleep does not, in fact, necessarily mean thatthe intussusception has been reduced. Clinicalimprovement is therefore a dangerous sign uponwhich to rely. The radiological signs of complete re-duction are ofparamount importance.

Elements of DangerThe principal criticism of the barium enema

method is the risk of thinking that reduction iscomplete when it is, in fact, incomplete. It ishere shown that proof of reduction can be obtainedin a high percentage of cases.As regards organic changes these are of less im-

portance, at least in small children. In this bookHellmer shows how useful the barium enema canbe in the diagnosis of polypi, of Meckel's diverti-culum, etc. The risk of ruptuire of the bowel hasbeen mentioned, but by careful technique thisdisaster should not occur. The writer has notseen it in his series of 200 cases. A diagnosis ofappendicitis has been mentioned as a contra-indication to a barium enema.The objection that precious time is wasted can

hardly be taken seriously-the barium enema canbe given while the surgeon washes his hands! Inthe.writer's experience the whole X-ray procedurehas seldom lasted more than one hour. Thechildren are not exhausted, probably because ofthe resorption of water, and possibly on account ofthe removal of toxic products; for the same reason,in fact, which makes it unwise to rely on clinicalimprovement which may be seen where reductionis still incomplete.

*.

FIG. I3.-Intussusception three hours old, in boy agedthree years, reduced by high barium enema pressure.The last loop of the ileum points almost verticallydownwards, toward the medially directed ileocaecaljunction. Caecum well filled, good inflow into thesmall intestine.

Results of the TreatmentIn comparison with the results which can be

obtained by primary surgical treatment, the resultsof the barium enema treatment are able to com-pete. In the years 1934-1939 Monrad (Copen-hagen) treated 39 cases with the barium enemamethod; none died; seven had to be operatedupon secondarily.

In 1943 Hellmer published a series of I I0 cases,8o per cent. of which were reduced by bariumenema without operation (no deaths); 22 had to beoperated upon secondarily, of these eight died.In his book, published shortly before his death, hismaterial had risen to I62 cases, of which 130 werereduced by barium enema without a death. Of 30cases in which reduction with the barium enemawas unsuccessful and laparotomy was sub-sequently performed, nine died. This correspondsto a 5.6 per cent. mortality for the whole series.None of his cases from the university clinic ofLund were operated upon primarily.

Further information about these cases and thewriter's own material appears in Table i.

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FIG. 14.-Ileocaecal intussusception seven hours old in a girl aged nine months; reduced with barium enema. Thecaecum well filled. Good inflow into the small bowel.

Concluding RemarksIn Denmark the barium enema method has been

almost universally adopted. During the years1928 to I935 the use of the opaque enema rosefrom io to 90 per cent. of all intussusception casesin children (statistics from all Danish surgical de-partments and the Queen Louise Children'sHospital).The experience of the writer seems to an in-

creasing degree to show that in all early cases(within the first 24 hours of the disease) anenergetic attempt at reduction should be made,all clinical and roentgenologic diagnostic criteriaand the condition of the child being taken intoconsideration. In this respect the writer agrees

with Wichmann, who in I893 said of the con-servative treatment of intussusception:-

' The time is simply wasted if these attempts atreduction are not carried out energetically; for itwill then be a mere matter of chance whether thereduction is effected or not, and the result willoften be that attempts are abandoned which mighthave succeeded if they had been better con-ducted.'The either-or of earlier years in Denmark has

disappeared. We now use the method routinely.This is due to the fact that diagnostic accuracy hasincreased very much both with regard to makingthe diagnosis, and with regard to verifying thereduction.

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Courtesy: Jacob Nordentoft, Surgeon-in-chief

FIG. 15.-Non-reduction: incomplete filling of themedial side of the caecum. (Detail.) Boy agedsix months.

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FIG. i6.-Non-reduction: ileocolic intussusception fourdays old in boy aged four years. The rarefactionin the caecum was supposed to be due to faeces ortumour. The following day there was a copiousdischarge from the bowel, but six days later opera-tion had to be performed and an ileocolic intussus-ception and a Meckel's diverticulum were found.The patient died the same day.

.........

FIG. I7.-Invagination of a haustrum caeci in a boyaged three years-verified by operation the follow-ing day. Roundish regular indentation on thelateral side of the large intestine. (Detail.)

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344 POSTGRADUATE MEDICAL JOURNAL June I950

TABLE I

CONSERVATIVE TREATMENT OF INTUSSUSCEPTION IN CHILDREN

Total Reduced Not Point of OriginNum- Con- Reduced Uncer- Commentber servatively Ileum Colon tain

Hellmer 110 88 22 51 7 52 1933-42. Personal material. In(Sweden, 1943) (8o%) all cases barium reduction

attempted. Eight deaths (alloperated upon).

Nordentoft 440 1341 2992 I 28 3I2 All surgical departments and(Denrnark, 1943) (31%) Queen Louise Hospital,

1928-35. Many of the enemasgiven for diagnostic purposes.Seven patients not treated.I6 cases certainly purelycolonic.

Monrad 207 15I 56 ? I906-39. Personal material;(Denmark, 1944) (73%) Queen Louise Hospital for

I_ Children, Copenhagen.97 barium examinations only, two deaths; 37 conservatively only (without X-ray diagnosis), three deaths.

2 I00 operations after barium examination, 23 deaths; 14 after conservative treatment (without X-ray examination),six deaths; I85 primary operation, 4I deaths.

332 barium examination only (I934-39), no deaths; II9 taxis only, 13 deaths.4 Seven operations after barium examination, no deaths; 24 after taxis, IS deaths.

To sum up, therefore, intussusception stillcomes under the care of the surgeons but theyrefer the cases primarily for reduction by theopaque enema method. Only if this fails or re-duction is uncertain is operation necessary.

BIBLIOGRAPHY

HELLMER, H. (I943), Acta Radiol., 24, 235.

HELLMER, H. (I948), ' Intussusception in Children, Diagnosisand Therapy with Barium Enema,' Acta Radiol., supplementum65.

MONRAD, SV. (I944), Ugesk. Laeger., Io6, x85.NORDENTOFT, J. MUNCK (I293), 'The Value of the Barium

Enema in the Diagnosis and Treatment of Intussusception inChildren,' illustrated by about 500 Danish cases, Acta Radiol.,supplementum 5I.

NORDENTOFT, J. MUNCK (1948), 'Modern Trends inDiagnostic Radiology,' London, p. 225.

NYBORG, S. (943),W Intussusception in Children, a study based onIo8 cases,' Actn Chirurgica Scandinavica, supplementum 8o,Stockholm.

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