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Retroperiton

 

Goubaa Mohamed MD Djerba Tunisia

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--- Arabic
This is a 5-month-old male with 2-day history of blood in his stools and vomiting.
An abdominal ultrasound examination was performed.
C'est un nourrisson âgé de 5 mois avec à l'anamnèse, et depuis deux jours, une émission de selles sanglante accompagnées de vomissements.
Un examen échographique a été pratiqué.


intussusception ultrasonography

invagination intesinale échographie


ulrasound doppler intestine


colon grele invagination echographie




bowel intussusception

 

ileocolic intussusception with target sign is clearly shown in this patient : classical appearance of a pseudokidney or donut sign.
Short-axis view of a loop of intestine shows multiple con-centric rings of increased and decreased echogenicity and thickening of the outer intestine layer typical of an intussusception (scans : 1, 2 and 3). Longitudinal sonography reveals a sandwichlike appearance of the alternating loops of bowel with a loop-within-loop appearance (scan 4).
From the multiple images, it can be appreciated that the structure changes with time. At real-time, peristaltic motion was seen.
Color Doppler view shows detectable internal vascularity, which indicates a low likelihood of bowel wall necrosis (scan 5). Indeed :
Evolution : Mass was successfully reduced during preliminary barium enemaexamination, without surgery.

L'invagination iléo-colique avec l'aspect en cible est clairement visible chez ce patient : aspect classique d'un signe de pseudo-rein ou de beignet. Transversalement on voit une anse intestinale interne avec des anneaux concentriques multiples faites d'alternances de couches hyperechogènes et hypoéchogènes et un épaississement de la boucle intestinale externe qui enveloppe le tout et ceci est évocateur d' invagination(clichés : 1, 2 et 3). La coupe longitudinale montre un aspect semblable au " sandwich " avec un aspect " d'une anse dans l'anse (cliché 4).
Sur les multiples images, on peut constater que la structure change avec le temps. Le suivie en en temps réel a montré des mouvements péristaltiques.
Le Doppler couleur montre une vascularisation de l'anse interne, indiquant une faible probabilité de nécrose de la paroi intestinale (cliché 5). En effet :
Évolution : La masse a été réduite avec succès au cours de l'examen préliminaire par un lavement baryté, sans recours à la chirurgie.



 

 

 

 

 

 

 

Intussusception, Child Invagination, Enfant

 


Intussusception

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Arabic

Intussusception is the invagination of a segment of bowel into the lumen of the adjacent bowel. It is a common pediatric emergency, especially in younger children aged 3 months to 3 years, and tends to affect the ileocaecal region.
The most common triad of clinical symptoms in patients with intussusception includes crampy abdominal pain, vomiting, and bloody stools. The child presents some-times with a palpable mass. Intussusception can result in bowel necrosis and subsequently perforation requiring surgery.

SONOGRAPHY :
The sensitivity of sonography in the diagnosis of intussusception is almost 100 %.
The ultrasound appearances of bowel within bowel are characteristic and the classic sonographic appearance of intussusception includes the "doughnut" or target, sign and the "pseudokidney" or "sandwich" sign. A doughnut sign, a hypoechoic rim of homogenous thickness and contour with a central hyperechoic core, is seen in a transverse view of intussusception. A hyperechoic tubular center is seen longitudinally covered by a hypoechoic ring, resembling a pseudokidney. Longitudinal sonography reveals a sandwichlike appearance of the alternating loops of bowel with a loop-within-loop appearance.
Free peritoneal fluid or ascites is not an uncommon finding with intussusception. Also, dilated loops of fluid-filled obstructed bowel may be demonstrated proximal to the intussusception.
Color flow Doppler can be used to help determine whether the involved bowel should be reduced (cured with barium enema or fluid or air pressure) or surgically resected. Inability to detect blood flow in the intussusception increases the likelihood of necrosis and predicts the need for surgery. Absent blood flow in the bowel walls means that the bowel bas probably necrosed and will need surgical resection. Detection of blood flow is reassuring and if adequate color flow is seen to ail areas of the telescoping bowel, the chances are better for a reduction.

Differential :
Intussusception is a common cause of childhood intestinal obstruction and in children, intussusceptions are usually idiopathic.
In adults, approximately 90% are associated with a lead mass of some sort (polyp, lipoma, hamartoma, stromal tumor, lymphoma, metastasis, cancer,). Other causes in adults include Meckel's diverticulum and sprue.
Bowel usually bas a ring-like or target appearance. 'Abnormal target' appearance because of asymmetric bowel thickening can be caused by the following conditions :
- Intussusception.
- Appendicitis.
- Crohn's disease.
- diverticular disease.
- tuberculoses.
- Tumors (adenocarcinoma, benign bowel wall tumors, lymphoma, carcinoid, leiomyosarcoma, implants).
- Pancreatitis.
- Amyloidosis.
- Whipple's disease.
- intramural hematoma.
- duplication cyst.
- pneumatosis coli or intestinal.
- radiation enteritis.

Treatment :
The diagnostic BE is therapeutic in approximately 80% of cases because of the retrograde flow of barium through the large intestine. As the barium fills and expands the colon, the pressure can spontaneously reduce the intussusception.
An air enema is also used to reduce the intussusception using inflation pressures of up to 120 mmHg.
The main contraindications to attempting a non-surgical reduction are peritonitis and free intraperi-toneal air. A number of sonographic features have been reported to be associated with a decreased success rate of non-surgical reduction, including a hypoechoic rim greater than 1 cm, absent blood flow on color flow Doppler sonography, or a large amount of fluid trapped within the intussusception, but these findings are not contraindications to a careful attempt at non-surgical reduction. Approximately 10% of cases recur whether the initial intussuception was treated surgically or non-surgically. The overall mortality rate of intussusception is less than 1%.
Without treatment, the patient may have complications, such as bowel obstruction, perforation, peritonitis, and vascular compromise, which could lead to edema or gangrene of the bowel.

Reference :
1 : Patsikas MN, Papazoglou LG, Jakovljevic S, Dessiris AK. Color Doppler ultrasonography in prediction of the reducibility of intussuscepted bowel in 15 young dogs.
2 : Ozguner IF, Savas C, Baykal B. Ileoileal invagination without obstruction in a four-year-old boy. J Pediatr Surg. 2004 Oct;39(10):1595-6.
3 : Grant RL, Piotto L. Benefits of sonographic-guided hydrostatic reduction opposed to air reduction in a case of intussusception due to lymphoma. Australas Radiol. 2004 Jun;48(2):264-6.
4 : Sorantin E, Lindbichler F. Management of intussusception. Eur Radiol. 2004 Mar;14 Suppl 4:L146-54. Review.
5 : Tellado MG, Liras J, Mendez R, Somoza I, Sanchez A, Mate A, Requejo I, Rios J, Vela D. [Ultrasound-guided hydrostatic reduction for the treatment of idiopathic intestinal invagination] Cir Pediatr. 2003 Oct;16(4):166-8. Spanish.
6 : Henrikson S, Blane CE, Koujok K, Strouse PJ, DiPietro MA, Goodsitt MM. The effect of screening sonography on the positive rate of enemas for intussusception. Pediatr Radiol. 2003 Mar;33(3):190-3. Epub 2002 Dec 12.
7 : Rubi I, Vera R, Rubi SC, Torres EE, Luna A, Arcos J, Paredes R, Rodriguez J, Velasco B, Garcia M. Air reduction of intussusception. Eur J Pediatr Surg. 2002 Dec;12(6):387-90.
8 : Crystal P, Hertzanu Y, Farber B, Shabshin N, Barki Y. Sonographically guided hydrostatic reduction of intussusception in children. J Clin Ultrasound. 2002 Jul-Aug;30(6):343-8. Review.
9 : 124: Mirilas P, Koumanidou C, Vakaki M, Skandalakis P, Antypas S, Kakavakis K. Sonographic features indicative of hydrostatic reducibility of intestinal intussusception in infancy and early childhood. Eur Radiol. 2001;11(12):2576-80. Epub 2001 Aug 2.
10 : Sofia S, Casali A, Bolondi L. Sonographic diagnosis of adult intussusception. Abdom Imaging. 2001 Sep-Oct;26(5):483-6.
11 : Tiao MM, Wan YL, Ng SH, Ko SF, Lee TY, Chen MC, Shieh CS, Chuang JH. Sonographic features of small-bowel intussusception in pediatric patients. Acad Emerg Med. 2001 Apr;8(4):368-73.
12: Yoon CH, Kim HJ, Goo HW. Related Articles, Links Intussusception in children: US-guided pneumatic reduction--initial experience. Radiology. 2001 Jan;218(1):85-8.
13 : Smoljanic Z, Zivic G, Krstic Z, Milanovic D, Vukanic D, Lukac R. [Intestinal intussusception in children. Ultrasonic diagnosis] Srp Arh Celok Lek. 2000 Jul-Aug;128(7-8):259-61. Serbian.
14 : Shehata S, El Kholi N, Sultan A, El Sahwi E. Hydrostatic reduction of intussusception: barium, air, or saline? Pediatr Surg Int. 2000;16(5-6):380-2.
15: Cerro P, Magrini L, Porcari P, De Angelis O. Sonographic diagnosis of intussusceptions in adults. Abdom Imaging. 2000 Jan-Feb;25(1):45-7. Erratum in: Abdom Imaging 2000 Jul-Aug;25(4):453. Macrini, L
16: Britton I, Wilkinson AG. Ultrasound features of intussusception predicting outcome of air enema. Pediatr Radiol. 1999 Sep;29(9):705-10.
17 : Hanquinet S, Anooshiravani M, Vunda A, Le Coultre C, Bugmann P. Reliability of color Doppler and power Doppler sonography in the evaluation of intussuscepted bowel viability. Pediatr Surg Int. 1998 Jul;13(5-6):360-2. Review.
18 : Stanley A, Logan H, Bate TW, Nicholson AJ. Ultrasound in the diagnosis and exclusion of intussusception. Ir Med J. 1997 Mar;90(2):64-5.
19 : Jequier S, Argyropoulou M, Bugmann P. Ultrasonography of jejunal intussusception in children. Can Assoc Radiol J. 1995 Aug;46(4):285-90.



 
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