Ultrasound guided hydrostatic reduction in the management of intussusception
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《美国医学杂志》
K.M.H. Memorial Hospital, Kerala, India
Abstract
Objective : A case series study was conducted for two years from 01 June 2002 to 01 June 2004 to study the efficiency of ultrasound guided hydrostatic reduction in the management of intussusception in children. Methods : A total of 25 patients who underwent the procedure were evaluated. All the patients were diagnosed by High Resolution Ultrasonography (HRUSG). Continuous monitoring of the progress of reduction during the procedure was done by HRUSG. 500-1000 ml (average 600 ml) of normal saline was used. Results : 24 out of 25 (96%) intussusceptions were successfully reduced. Average time taken was 15 minutes. All the patients were reviewed after 24 hrs for recurrence. None of them showed recurrence within 24 hrs. No complications were observed. Conclusion : The study concludes that ultrasound guided hydrostatic reduction is a safe, simple and effective method for treatment of intussusception in children.
Keywords: Intussusception; Hydrostatic reduction; High resolution ultrasonography
Intussusception is one of the common causes of intestinal obstruction in children. It is invagination of a segment of proximal bowel (intussusceptum) into the lumen of distal bowel (intussuscipiens). [1] Several types are described such as (a) ileo colic, (b) ileo ileal, (c) colo colic, (d) ileo ileo colic, (e) multiple and (f) retrograde. Ileo colic variety is the commonest.[2]
Non-operative reduction of intussusception has a long history with the use of Barium, air, Oxygen, water and water-soluble iodinated contrast medium under fluoroscopic guidance.[3],[4],[5] There are several publications on usage of air for intussusception reduction.[6],[7]
This study was conducted to evaluate the efficiency of ultrasound guided hydrostatic reduction using normal saline in the management of intussusception in children. This study included patients in whom intussusception was confirmed by HRUSG.
Materials and Methods
This is a primary case series clinical study conducted from 01 June 2002 to 01 June 2004 in the department of Radiology and Imaging of K.M.H. Memorial Hospital, Manjeri, Kerala. A total of 25 cases diagnosed with intussusception by HRUSG were evaluated.
Inclusion criteria were (1) patients with symptoms for less than 48 hrs. (2) absence of generalized toxicity, high fever and severe dehydration. (3) absence of signs of peritonitis. (4) no history of previous surgeries. (5) no radiographic evidence of free peritoneal air (in whom large amount of free fluid was seen in the peritoneum).
A linear array transducer of 7.5-10 megahertz (ESAOTE, AU3 Partner) was used for diagnozing the presence of intussusception. Both transverse and longitudinal views were used for confirming the presence of one loop within the other. Color Doppler was used in patients whenever necessary to evaluate the vascularity of involved bowel loops Figure1Figure2.
The procedure, its advantages, and probable outcome were explained to the parents or the guardian. A written informed consent was obtained from them. The surgical team was informed of the procedure and requested to be available in case of emergencies. The child was put on left lateral position. A Foley's catheter of size 16F was used. The tip of the Foley's catheter was lubricated with 2% Lignocaine gel and inserted into the rectum. The balloon of Foley's catheter was inflated by injecting up to 30 ml of normal saline, and its correct position in the rectum was confirmed by HRUSG.
The catheter was connected to an intravenous fluid line and free flow of normal saline (pre-warmed to normal body temperature) was allowed into the rectum. The saline bottle was suspended at 130 cm from the bed level. Gradual distention of colon and the retrograde movement of intussusceptum towards the cecum were monitored by real time ultrasound Figure3Figure4Figure5Figure6. Complete reduction was assumed once the edematous ileo-cecal valve Figure7 and the passage of saline through the ileo-cecal valve into the ileum were seen Figure8. Saline flow was allowed into several loops of ileum. The amount of saline required was recorded in each case. Afterwards, the saline was drained and Foley's catheter was removed. Clinical condition of the patient is closely and carefully monitored throughout the procedure.
After the procedure the patient was shifted to observation room under pediatrician's supervision. A course of antibiotic therapy was started. In each case follow-up HRUSG was done after 24 hrs.
Results
A total of 25 children, confirmed of having intussusception by HRUSG, were evaluated. The youngest patient in the study group was 4 months and the oldest was 4 yrs of age. Male patients accounted for nearly two thirds (64%) of the total number. table1 shows the age distribution.
The commonest symptom was intermittent colicky in pain abdomen, noticed in 24 out of 25 patients. The symptom distribution is listed in table2.
Complete reduction of intussusception was achieved in 24 out of 25 patients (96% success rate) in this study. No patient showed recurrence within the 24 hr. One case which could not be reduced hydrostatically underwent surgery. A large lymph node was seen obstructing the ileo-cecal valve, and adhesions were present between the involved loops. A common finding in HRUSG was presence of enlarged mesenteric lymph nodes, seen in 32% of patients in the study group. Most of the children vomited after successful reduction and went to sleep. The amount of normal saline used ranged from 500-1000 ml (average 600 ml). The average time taken from the inflow of saline into the rectum up to the reduction of intussusception was 15 minutes. No delayed attempts were necessary. One patient had recurrence of intussusception after 3months of USG guided hydrostatic reduction, which was again successfully reduced using same method.
Discussion
Intussusception is a common cause of acute intestinal obstruction in children. In most of the cases, exact cause is unknown. Swollen Peyer's patch, lymph node, polyp, submucous lipoma, Meckel's diverticulum and duplication cysts are few of the etiological causes mentioned. [1],[2],[3]
Symptomatology included sudden onset of intermittent colicky abdominal pain, drawing up of legs, vomiting, facial pallor, diarrhea, constipation, blood and mucus in the stools (the classically described red currant jelly stool).[2] Clinical examination may reveal a sausage shaped lump, with concavity towards the umbilicus and emptiness of right iliac fossa (sign of Dance).[2] Blood-stained mucus may be found in digital rectal examination, and sometimes the apex of intussusception may be felt per rectally.[1],[2] If untreated, the bowel loop may become gangrenous resulting in sloughing, perforation, peritonitis and may eventually lead to death.[2],[8] Occasionally, intussusceptions can reduce spontaneously.[9]
USG is a very useful examination for diagnosing intussusception with high sensitivity (98-100%) and specificity (88-100%).[6] The 'target sign' described in literature is very useful and can be easily picked up by HRUSG transducer (7.5-10 MHZ).[10]
Plain radiographs of those patients who showed more than usual amount of free fluid in the peritoneum were taken to check perforation.[4],[6],[7] A small amount of free fluid in the peritoneum is common in most cases of intussusception.[11] None of these patients showed radiographic evidence of pneumoperitoneum. Although peritonitis is a contra indication for non-surgical reduction, it is quite unlikely to be confirmed by plain radiographs prior to enema therapy.
Absence of blood flow in color Doppler study in the intussusception correlates significantly with irreducibility.[6],[7],[12] We used color Doppler assessment in majority of the patients and none of these patients showed absence of blood flow in the intussusception. Patients who presented very early (< 6-8 hrs) did not undergo color Doppler study.[10],[13] No patient suffered from perforation during hydrostatic reduction in this study. Large lymph nodes (the cause for failure in one of the patients), trapped peritoneal fluid in the intussusception, and thick (>10 mm) hypoechoic rim are the other predictors of irreducibility.[6],[14],[15] In the presence of predictors of irreducibility, enema therapy can be tried, before resorting to surgery, if the clinical condition is favourable.[15] The attempt should be very gentle and careful.
One child, who had recurrence after 3 months, was 9 months of age during the second episode. There was no clinical suspicion of probable lead point in this patient. USG did not pick up any direct or indirect evidence of lead points.[6],[11] USG can characterize lead points and the choice of other imaging modalities should be tailored as required.[6],[11],[16] Hydrostatic reduction has been attempted in cases with lead points.[16],[17] Those patients who will ultimately undergo surgery will be benefited, even by partial reduction. The time taken for surgical procedure and manipulation of the bowel during surgery was reduced.[16],[17]
Foley's catheter is used in the technique. This provided a relatively closed system for effective transmission of hydrostatic pressure, increasing the success rate. None of the patients suffered from rectal trauma due to inflated retention balloon.
One episode of vomiting was observed in most children, after successful reduction. Saline flow into several loops of ileum was allowed to look for any ileo-ileal component. This sudden reverse flow of saline into the small bowel loops and transient increase in total fluid volume in the bowel loops might have caused vomiting in these patients. There was no incidence of vomiting after draining the saline from the bowel.
There is a risk of bacteremia and sepsis after nonsurgical reduction of intussusception.[19] Most patients showed minimal free fluid in the peritoneum, which can become easily infected. A course of antibiotic was administered post-reduction as a precaution.
There are several advantages in employing HRUSG in the diagnosis and management of intussusception in children. (1) It is simple, effective, economical and less time-consuming. (2) Less complications (very low perforation rate, 0.26%).[6] (3) Minimal hospital stay is required. (4) No radiation hazard. (5) Less morbidity (No incidence of pseudo-reduction as seen in fluoroscopic guided procedures. No fluctuation in intra-colonic pressure as in air enema. If perforation occurs, no chance for chemical peritonitis as with Barium enema, no tension pneumo-peritoneum as with air enema, no chance for fluid shifts as with hypertonic contrast medium solutions or tap water) and no mortality (no reported case of death as with air enema) are in volved[6],[17] (5) Recurrence can also be treated by the same method.[16],[17],[18]
Though this technique is very useful in recent onset intussusceptions presenting within 48 hrs, longer time lapses in presentation should not be a contraindication in trying this method in the absence of abdominal or systemic complications.[16],[17] Plain radiograph of the abdomen should be obtained for the presence of pneumoperitoneum in delayed cases, whenever clinically indicated and where clinical or sonographic findings are equivocal. Color Doppler assessment of the involved bowel loops for vascularity is an added advantage in these patients.[6],[12] Consultation with the pediatrician and the surgeon is very essential during the whole procedure.
Conclusion
USG-guided hydrostatic reduction of intussusception in children using normal saline is a simple and effective technique. It is less time consuming, cost effective, has no radiation hazard, almost no complications and minimal hospital stay. The procedure has high success rate in properly selected patients. It is strongly advised to advocate this procedure in selected patients for avoiding harmful radiation and unwarranted surgeries with associated complications.
References
1. Vanessa MW, Intussususception. In Lewis S, Arnold GC, eds. Rob & Smith's Operative Surgery, Pediatric Surgery, 4th ed, London; Chapman & Hall Medical, 1994: 396-397.
2. Marc CW. Intestinal Obstruction. In RG Russel, NS Williams, & CJK Bulstrode, eds. Bailey & Love's Short Practice of Surgery, 23rd ed, London; Arnold Publishers, 2000: 1067-106.
3. Hadidi AT, El Shal N. Childhood intussusception: A comparative study of nonsurgical management. J Pediatr Surg 1999; 34 (2): 304-307.
4. Riebel TW, Nasir R, Weber K. US-guided hydrostatic reduction of intussusception in children. Radiology 1993; 188: 513- 516.
5. Choi SO, Park WH, Woo JK. Ultrasound guided water enema: An alternative method of nonoperative treatment for childhood intussusception. J Pediatr Surg 1994; 29(4): 498-500.
6. Del-Pozo G, Albillos JC, Tejedor D et al. Intussusception in children: Current concepts in diagnosis and enema reduction. Radiographics 1999; 19 : 299-319.
7. Daneman A, Alton DJ. Intussusception : Issues and controversies related to diagnosis and reduction. Radiol Clin North Am 1996; 34(4): 743-756.
8. Ugwu BT, Legbo JN, Dakum NK et al. Child hood intussusception: 9 year review. Ann Trop Paediatr 2000, 20(2): 131-135.
9. Swischunk LE, John SD, Swischunk PN. Spontaneous reduction of intussusception: Verification with ultrasound. Radiology 1994; 192 : 269-271.
10. Mirilas P, Koumanidou C, Vakaki M et al. Sonographic features indicative of hydrostatic reducibility of intestinal intussusception in infancy and early childhood. Eur Radiol 2001; 11(12) : 2576-2580.
11. Susan DJ,Leonard ES. Pediatric gastrointestinal tract-Intussusception. In : Carol MR, Stephanie RW, Charboneau JW, eds. Diagnostic Ultrasound Vol. II, 2nd ed. St. Louis: Mosby-Year book Inc., 1998: 1729-1731.
12. Lim HK, Bae SH, Lee KH et al. Assessment of reducibility of ileo-colic intussusception in children: Usefulness of color Doppler sonography. Radiology 1994; 191 : 781-785.
13. Katz M, Phelan E, Carlin JB, Beasly SW.Gas enema for the reduction of intussusception: Relationship between clinical signs and symptoms and outcome. AJR 1993; 160 : 363-366.
14. Koumanidou C, Vakaki M, Pitroouiakis G et al. Sonographic detection of lymph nodes in the intussusception of infants and young children. AJR 2002; 178 : 444-450.
15. Crystal P, Hertzanu Y, Farber B et al. Sonographically guided hydrostatic reduction of Intussusception in children. J Clin Ultrasound 2002; 30 (6): 343-348.
16. Navarro OM, Daneman A, Chae A. Intussusception: The use of delayed, repeated reduction attempts and the management of intussusception due to pathologic lead points in pediatric patients. AJR 2004; 182 : 1169-1176.
17. Daneman A, Navarro O. Intussusception, Part 2: An Update on the evolution of management. Pediatr Radiol 2004: 34 : 97-108.
18. Fecteau A, Flageole H, Nguyen LT et al. Recurrent intussusception: safe use of hydrostatic enema. J Pediatr Surg 1996; 31(6) : 859-861.
19. Chan K, Chan J, Peh W et al. Endotoxemia associated with intussusception and its diagnostic and surgical interventions. Pediatr Surg Int 2002; 18(8): 685-688.(Krishnakumar, Hameed Shah)
Abstract
Objective : A case series study was conducted for two years from 01 June 2002 to 01 June 2004 to study the efficiency of ultrasound guided hydrostatic reduction in the management of intussusception in children. Methods : A total of 25 patients who underwent the procedure were evaluated. All the patients were diagnosed by High Resolution Ultrasonography (HRUSG). Continuous monitoring of the progress of reduction during the procedure was done by HRUSG. 500-1000 ml (average 600 ml) of normal saline was used. Results : 24 out of 25 (96%) intussusceptions were successfully reduced. Average time taken was 15 minutes. All the patients were reviewed after 24 hrs for recurrence. None of them showed recurrence within 24 hrs. No complications were observed. Conclusion : The study concludes that ultrasound guided hydrostatic reduction is a safe, simple and effective method for treatment of intussusception in children.
Keywords: Intussusception; Hydrostatic reduction; High resolution ultrasonography
Intussusception is one of the common causes of intestinal obstruction in children. It is invagination of a segment of proximal bowel (intussusceptum) into the lumen of distal bowel (intussuscipiens). [1] Several types are described such as (a) ileo colic, (b) ileo ileal, (c) colo colic, (d) ileo ileo colic, (e) multiple and (f) retrograde. Ileo colic variety is the commonest.[2]
Non-operative reduction of intussusception has a long history with the use of Barium, air, Oxygen, water and water-soluble iodinated contrast medium under fluoroscopic guidance.[3],[4],[5] There are several publications on usage of air for intussusception reduction.[6],[7]
This study was conducted to evaluate the efficiency of ultrasound guided hydrostatic reduction using normal saline in the management of intussusception in children. This study included patients in whom intussusception was confirmed by HRUSG.
Materials and Methods
This is a primary case series clinical study conducted from 01 June 2002 to 01 June 2004 in the department of Radiology and Imaging of K.M.H. Memorial Hospital, Manjeri, Kerala. A total of 25 cases diagnosed with intussusception by HRUSG were evaluated.
Inclusion criteria were (1) patients with symptoms for less than 48 hrs. (2) absence of generalized toxicity, high fever and severe dehydration. (3) absence of signs of peritonitis. (4) no history of previous surgeries. (5) no radiographic evidence of free peritoneal air (in whom large amount of free fluid was seen in the peritoneum).
A linear array transducer of 7.5-10 megahertz (ESAOTE, AU3 Partner) was used for diagnozing the presence of intussusception. Both transverse and longitudinal views were used for confirming the presence of one loop within the other. Color Doppler was used in patients whenever necessary to evaluate the vascularity of involved bowel loops Figure1Figure2.
The procedure, its advantages, and probable outcome were explained to the parents or the guardian. A written informed consent was obtained from them. The surgical team was informed of the procedure and requested to be available in case of emergencies. The child was put on left lateral position. A Foley's catheter of size 16F was used. The tip of the Foley's catheter was lubricated with 2% Lignocaine gel and inserted into the rectum. The balloon of Foley's catheter was inflated by injecting up to 30 ml of normal saline, and its correct position in the rectum was confirmed by HRUSG.
The catheter was connected to an intravenous fluid line and free flow of normal saline (pre-warmed to normal body temperature) was allowed into the rectum. The saline bottle was suspended at 130 cm from the bed level. Gradual distention of colon and the retrograde movement of intussusceptum towards the cecum were monitored by real time ultrasound Figure3Figure4Figure5Figure6. Complete reduction was assumed once the edematous ileo-cecal valve Figure7 and the passage of saline through the ileo-cecal valve into the ileum were seen Figure8. Saline flow was allowed into several loops of ileum. The amount of saline required was recorded in each case. Afterwards, the saline was drained and Foley's catheter was removed. Clinical condition of the patient is closely and carefully monitored throughout the procedure.
After the procedure the patient was shifted to observation room under pediatrician's supervision. A course of antibiotic therapy was started. In each case follow-up HRUSG was done after 24 hrs.
Results
A total of 25 children, confirmed of having intussusception by HRUSG, were evaluated. The youngest patient in the study group was 4 months and the oldest was 4 yrs of age. Male patients accounted for nearly two thirds (64%) of the total number. table1 shows the age distribution.
The commonest symptom was intermittent colicky in pain abdomen, noticed in 24 out of 25 patients. The symptom distribution is listed in table2.
Complete reduction of intussusception was achieved in 24 out of 25 patients (96% success rate) in this study. No patient showed recurrence within the 24 hr. One case which could not be reduced hydrostatically underwent surgery. A large lymph node was seen obstructing the ileo-cecal valve, and adhesions were present between the involved loops. A common finding in HRUSG was presence of enlarged mesenteric lymph nodes, seen in 32% of patients in the study group. Most of the children vomited after successful reduction and went to sleep. The amount of normal saline used ranged from 500-1000 ml (average 600 ml). The average time taken from the inflow of saline into the rectum up to the reduction of intussusception was 15 minutes. No delayed attempts were necessary. One patient had recurrence of intussusception after 3months of USG guided hydrostatic reduction, which was again successfully reduced using same method.
Discussion
Intussusception is a common cause of acute intestinal obstruction in children. In most of the cases, exact cause is unknown. Swollen Peyer's patch, lymph node, polyp, submucous lipoma, Meckel's diverticulum and duplication cysts are few of the etiological causes mentioned. [1],[2],[3]
Symptomatology included sudden onset of intermittent colicky abdominal pain, drawing up of legs, vomiting, facial pallor, diarrhea, constipation, blood and mucus in the stools (the classically described red currant jelly stool).[2] Clinical examination may reveal a sausage shaped lump, with concavity towards the umbilicus and emptiness of right iliac fossa (sign of Dance).[2] Blood-stained mucus may be found in digital rectal examination, and sometimes the apex of intussusception may be felt per rectally.[1],[2] If untreated, the bowel loop may become gangrenous resulting in sloughing, perforation, peritonitis and may eventually lead to death.[2],[8] Occasionally, intussusceptions can reduce spontaneously.[9]
USG is a very useful examination for diagnosing intussusception with high sensitivity (98-100%) and specificity (88-100%).[6] The 'target sign' described in literature is very useful and can be easily picked up by HRUSG transducer (7.5-10 MHZ).[10]
Plain radiographs of those patients who showed more than usual amount of free fluid in the peritoneum were taken to check perforation.[4],[6],[7] A small amount of free fluid in the peritoneum is common in most cases of intussusception.[11] None of these patients showed radiographic evidence of pneumoperitoneum. Although peritonitis is a contra indication for non-surgical reduction, it is quite unlikely to be confirmed by plain radiographs prior to enema therapy.
Absence of blood flow in color Doppler study in the intussusception correlates significantly with irreducibility.[6],[7],[12] We used color Doppler assessment in majority of the patients and none of these patients showed absence of blood flow in the intussusception. Patients who presented very early (< 6-8 hrs) did not undergo color Doppler study.[10],[13] No patient suffered from perforation during hydrostatic reduction in this study. Large lymph nodes (the cause for failure in one of the patients), trapped peritoneal fluid in the intussusception, and thick (>10 mm) hypoechoic rim are the other predictors of irreducibility.[6],[14],[15] In the presence of predictors of irreducibility, enema therapy can be tried, before resorting to surgery, if the clinical condition is favourable.[15] The attempt should be very gentle and careful.
One child, who had recurrence after 3 months, was 9 months of age during the second episode. There was no clinical suspicion of probable lead point in this patient. USG did not pick up any direct or indirect evidence of lead points.[6],[11] USG can characterize lead points and the choice of other imaging modalities should be tailored as required.[6],[11],[16] Hydrostatic reduction has been attempted in cases with lead points.[16],[17] Those patients who will ultimately undergo surgery will be benefited, even by partial reduction. The time taken for surgical procedure and manipulation of the bowel during surgery was reduced.[16],[17]
Foley's catheter is used in the technique. This provided a relatively closed system for effective transmission of hydrostatic pressure, increasing the success rate. None of the patients suffered from rectal trauma due to inflated retention balloon.
One episode of vomiting was observed in most children, after successful reduction. Saline flow into several loops of ileum was allowed to look for any ileo-ileal component. This sudden reverse flow of saline into the small bowel loops and transient increase in total fluid volume in the bowel loops might have caused vomiting in these patients. There was no incidence of vomiting after draining the saline from the bowel.
There is a risk of bacteremia and sepsis after nonsurgical reduction of intussusception.[19] Most patients showed minimal free fluid in the peritoneum, which can become easily infected. A course of antibiotic was administered post-reduction as a precaution.
There are several advantages in employing HRUSG in the diagnosis and management of intussusception in children. (1) It is simple, effective, economical and less time-consuming. (2) Less complications (very low perforation rate, 0.26%).[6] (3) Minimal hospital stay is required. (4) No radiation hazard. (5) Less morbidity (No incidence of pseudo-reduction as seen in fluoroscopic guided procedures. No fluctuation in intra-colonic pressure as in air enema. If perforation occurs, no chance for chemical peritonitis as with Barium enema, no tension pneumo-peritoneum as with air enema, no chance for fluid shifts as with hypertonic contrast medium solutions or tap water) and no mortality (no reported case of death as with air enema) are in volved[6],[17] (5) Recurrence can also be treated by the same method.[16],[17],[18]
Though this technique is very useful in recent onset intussusceptions presenting within 48 hrs, longer time lapses in presentation should not be a contraindication in trying this method in the absence of abdominal or systemic complications.[16],[17] Plain radiograph of the abdomen should be obtained for the presence of pneumoperitoneum in delayed cases, whenever clinically indicated and where clinical or sonographic findings are equivocal. Color Doppler assessment of the involved bowel loops for vascularity is an added advantage in these patients.[6],[12] Consultation with the pediatrician and the surgeon is very essential during the whole procedure.
Conclusion
USG-guided hydrostatic reduction of intussusception in children using normal saline is a simple and effective technique. It is less time consuming, cost effective, has no radiation hazard, almost no complications and minimal hospital stay. The procedure has high success rate in properly selected patients. It is strongly advised to advocate this procedure in selected patients for avoiding harmful radiation and unwarranted surgeries with associated complications.
References
1. Vanessa MW, Intussususception. In Lewis S, Arnold GC, eds. Rob & Smith's Operative Surgery, Pediatric Surgery, 4th ed, London; Chapman & Hall Medical, 1994: 396-397.
2. Marc CW. Intestinal Obstruction. In RG Russel, NS Williams, & CJK Bulstrode, eds. Bailey & Love's Short Practice of Surgery, 23rd ed, London; Arnold Publishers, 2000: 1067-106.
3. Hadidi AT, El Shal N. Childhood intussusception: A comparative study of nonsurgical management. J Pediatr Surg 1999; 34 (2): 304-307.
4. Riebel TW, Nasir R, Weber K. US-guided hydrostatic reduction of intussusception in children. Radiology 1993; 188: 513- 516.
5. Choi SO, Park WH, Woo JK. Ultrasound guided water enema: An alternative method of nonoperative treatment for childhood intussusception. J Pediatr Surg 1994; 29(4): 498-500.
6. Del-Pozo G, Albillos JC, Tejedor D et al. Intussusception in children: Current concepts in diagnosis and enema reduction. Radiographics 1999; 19 : 299-319.
7. Daneman A, Alton DJ. Intussusception : Issues and controversies related to diagnosis and reduction. Radiol Clin North Am 1996; 34(4): 743-756.
8. Ugwu BT, Legbo JN, Dakum NK et al. Child hood intussusception: 9 year review. Ann Trop Paediatr 2000, 20(2): 131-135.
9. Swischunk LE, John SD, Swischunk PN. Spontaneous reduction of intussusception: Verification with ultrasound. Radiology 1994; 192 : 269-271.
10. Mirilas P, Koumanidou C, Vakaki M et al. Sonographic features indicative of hydrostatic reducibility of intestinal intussusception in infancy and early childhood. Eur Radiol 2001; 11(12) : 2576-2580.
11. Susan DJ,Leonard ES. Pediatric gastrointestinal tract-Intussusception. In : Carol MR, Stephanie RW, Charboneau JW, eds. Diagnostic Ultrasound Vol. II, 2nd ed. St. Louis: Mosby-Year book Inc., 1998: 1729-1731.
12. Lim HK, Bae SH, Lee KH et al. Assessment of reducibility of ileo-colic intussusception in children: Usefulness of color Doppler sonography. Radiology 1994; 191 : 781-785.
13. Katz M, Phelan E, Carlin JB, Beasly SW.Gas enema for the reduction of intussusception: Relationship between clinical signs and symptoms and outcome. AJR 1993; 160 : 363-366.
14. Koumanidou C, Vakaki M, Pitroouiakis G et al. Sonographic detection of lymph nodes in the intussusception of infants and young children. AJR 2002; 178 : 444-450.
15. Crystal P, Hertzanu Y, Farber B et al. Sonographically guided hydrostatic reduction of Intussusception in children. J Clin Ultrasound 2002; 30 (6): 343-348.
16. Navarro OM, Daneman A, Chae A. Intussusception: The use of delayed, repeated reduction attempts and the management of intussusception due to pathologic lead points in pediatric patients. AJR 2004; 182 : 1169-1176.
17. Daneman A, Navarro O. Intussusception, Part 2: An Update on the evolution of management. Pediatr Radiol 2004: 34 : 97-108.
18. Fecteau A, Flageole H, Nguyen LT et al. Recurrent intussusception: safe use of hydrostatic enema. J Pediatr Surg 1996; 31(6) : 859-861.
19. Chan K, Chan J, Peh W et al. Endotoxemia associated with intussusception and its diagnostic and surgical interventions. Pediatr Surg Int 2002; 18(8): 685-688.(Krishnakumar, Hameed Shah)