
 acute intussusception is one of the most common causes of acute abdomen in infants .
management includes both surgical and non - surgical methods , with gradually increasing importance recently being accorded to the latter .
conservative measures , including hydrostatic reduction , are the methods of choice for initial management . though widely accepted , the expertise is still not widely available , especially in developing countries .

 a six - month - old child presented with complaints of repeated episodes of vomiting that contained only ingested milk .
this was associated with three episodes of loose stools , initially watery and later with fresh red blood per rectum with jelly - like consistency .
there was no history of fever , decreased urine output , lethargy , abnormal body movements , or difficulty in breathing .
her immunizations were fully up to date with no history of rota virus immunization . 
 
 on admission
abdominal examination was remarkable for an ill - defined mass that could be felt in the right hypochondrium .
she was initially kept nil per oral and started on conservative measures , including antibiotics .
an urgent abdominal ultrasonography was done , which showed a round mass - like lesion giving a target appearance in the right hypochondrium ( suggestive of ileocolic intussusception ) .
she was taken for immediate intervention , and as per surgical opinion , a hydrostatic reduction under radiological guidance was started . 
 

the child was first stabilized using intravenous fluids to treat dehydration , and a pre - procedure x - ray abdomen was performed to rule out intestinal perforation .
the procedure was done in the ultrasonography room in the presence of a treating physician and a pediatric surgeon . without using any sedation ,
a 16 f foley catheter was inserted into the rectum in the supine position and the balloon was gently inflated while maintaining a tight anal seal . 
 

the patient s vitals , which included abdominal girth and distension , were monitored throughout the procedure .
lactate solution , warmed to body temperature , was then slowly introduced into the catheter through a bag hanging at a height of approximately 100 cm . during reduction ,
the intussusceptum was observed under continuous ultrasound guidance as it proceeded to the cecum and then reduced across the ileocecal valve ( figures 1 - 4 ) . 
 

ileal loop ( star ) within ascending colon ( arrow ) , longitudinal view . 
 

this was associated with the patient s improved condition , which included less crying and irritability .
the parents were told about the possibility of recurrence and asked to pay close attention for the onset of symptoms . 


 acute intussusception is defined as the telescoping of the proximal bowel ( intussusceptum ) into the distal bowel ( intussuscipiens ) .
the usual locations include the ileocolic region and ileocecal junction , which comprise the majority of cases .
intussusception mostly presents between four months and two years , while the peak incidence is found around middle infancy . 
 

diagnosis usually needs a high suspicion on the part of the treating physician , as presentation can be quite varied , including irritability , vomiting , and poor feeding .
characteristic manifestations include crying episodes , fresh red blood in stools ( hematochezia ) , and a mass in the abdomen .
differential diagnoses include acute gastroenteritis , dysentery , sepsis syndrome , and volvulus , amongst others .
the diagnosis is usually confirmed sonographically , which is highly accurate and has a reported sensitivity that exceeds 90% .
various signs have been described in the literature , depicting intussusception as an abdominal mass with a target sign on the transverse section , a pseudokidney ( or sandwich sign ) on the longitudinal section , and a crescent - in - doughnut sign on axial images . 
 

the management of intussusception has seen a paradigm shift in recent years . in the past , the preferred non - surgical method involved use of a barium enema for reduction , followed by the air insufflation method . 
 

hydrostatic reduction using ultrasound - guided saline reduction has recently gained acceptance as the procedure of choice for initial nonsurgical management of intussusceptions in children .
this popularity can be attributed to the avoidance of radiation exposure to the child and the treating team , as well as to the high success rates that have been achieved . 
 

there is still some controversy regarding the exact method of the procedure , which can be attributed to the poor training of physicians and to the general belief that intussusception is entirely a surgical problem , especially in developing countries .
this procedure should be undertaken with a close liaison between pediatrics , pediatric surgery , and radiology teams to obtain the best results .
the surgeon and physician should always be present at the time of reduction for clinical monitoring . 
 

after adequate optimization , including temperature controlled settings , the procedure should ideally be undertaken without any sedation .
this is helpful for assessing a successful reduction using clinical criteria , as described later . 
 

we used ringer s lactate due to its near physiological constitution , avoiding the risk of chemical peritonitis due to a barium enema or tension pneumoperitoneum due to an air enema , as seen in cases of intestinal perforation .
the risk of intestinal perforation following such a procedure is rarely encountered due to less hydrostatic pressure exerted and an even amount of pressure exerted on the bowel walls as compared to air insufflations . even if intestinal perforation occurs
we chose 100 cm h2o pressure to lessen the risk of perforation , though different studies have used a wide range of pressures ( 75 to 125 cm h2o).6 , 
 9 
 
 the main ultrasonographical criteria of successful reduction is the flow of the fluid from the cecum into the terminal ileum .
general improvement in the clinical profile of the patient including relief from crying , stable vitals , increasing abdominal distension during the procedure ( which indicates filling of the small bowel ) , and the disappearance of the abdominal mass , should also be given due consideration when deciding to terminate the procedure . 
 

a repeat ultrasound should always be done after the procedure as the chances of recurrence is high , especially in the immediate post - procedure period .
, this method should be undertaken as teamwork , and not considered the work of a single specialty , which is the best way of treating the patients according to the standards of today . 

 we present a case of infantile intussusception treated successfully using hydrostatic reduction , highlighting the importance of non - surgical techniques as the first line of management for this entity . 
 physicians should strive for mastery over such techniques by extensive training to prevent unwanted surgical procedures in such cases . 

INTRODUCTION


CASE REPORT


DISCUSSION


CONFLICT OF INTEREST
