Pediatr Radiol (2001) 31: 184186 Springer-Verlag 2001

Stuart A. Royal

Hypovolemic shock after air reduction of intussusception

Received: 20 January 2000 Accepted: 22 September 2000

S. Royal ( ) The University of Alabama Hospitals, Department of Radiology, 1600 7th Avenue S., Birmingham, AL 35233, USA S. Royal The Childrens' Hospital of Alabama, Department of Radiology, Birmingham, Alabama, USA

Abstract A 7-month-old white baby girl developed hypovolemic shock requiring resuscitation secondary to an air enema reduction of intussusception. The implications of this case for standardization of the management techniques in this setting are emphasized.

Introduction
Enema reduction of intussusception has been used for at least 120 years, but the methodology for this technique continues to evolve even today [1]. This technique has been the subject of an American College of Radiology Practice Standard [2] in an effort to provide guidelines for the safe practice of this treatment method. We report a patient who developed hypovolemic shock secondary to the air enema reduction for intussusception and discuss the importance of detecting this complication in the clinical management of such patients.

Case report
A 7-month-old white baby girl who had previously been healthy presented with a 2-day history of diarrhea, followed by nausea and progressive bilious vomiting. One day prior to evaluation, there was blood streaking in the stools. The patient was seen at a regional hospital and treated with IV fluids. Conventional radiographs suggested small bowel obstruction, and the patient was sent to the Children's Hospital the next day. On arrival at the Children's Hospital Emergency Department, the patient was noted to have a 99 F rectal temperature, HR 140,

RR 40, BP 107/56, with good pulses, a distended tense abdomen without palpable mass, and heme-positive rectal stool. The patient had a nasogastric tube placed, IV hydration started with D5 normal saline at 20 cc per hour, and abdominal radiographs demonstrated small bowel obstruction (Fig. 1 a). The patient was transferred to the Departement of Radiology for an air enema procedure. The air enema procedure was accomplished, with the intussusceptum being encountered in the transverse colon, reduced to the cecum (Fig. 1 b), and subsequently air refluxed freely into the small bowel. The patient was then sent back to the Emergency Department. At that time the patient's temperature was 101.9 F rectal, HR 106, RR 40, BP 112/54. The patient was then admitted to a floor bed in a clinically stable state. About an hour later the Surgical House officer was called because the patient was now lethargic, showed decreased responsiveness, and had shaking chills, a rectal temperature of 104 F, systolic BP 50 palpable, with the abdomen less distended. HR was 220 and RR 70. The patient was transferred to the Pediatric Intensive Care Unit and was treated with aggressive fluid management and triple antibiotics. Overnight in the ICU, the patient returned to a clinically stable state, became afebrile, alert and active with a soft abdomen, warm extremities and normal electrolytes. All blood cultures were negative. The patient began to eat the next day and was discharged with a diagnosis of hypovolemic shock with secondary fever responding to IV fluids.

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Fig. 1 a Upright abdominal radiograph demonstrates small bowel obstruction with moderate fluid and air within small bowel. b Spot film from air enema reduction demonstrates intussusceptum in the cecum before complete reduction was accomplished

b
had been given IV fluids both at a regional hospital and in our Emergency Department prior to enema reduction and was felt to be clinically stable for the procedure. Air was used as the contrast agent, so that questions of third-spacing related to using water-based contrast agents was not of consideration. We presume this patient had third spacing within the bowel lumen that was intrinsically related to this patient's intussusception with small bowel obstruction or undocumented release of humoral agents such as cytokines or endotoxins, and not otherwise related to a complication while performing the technique. Current guidelines from the American College of Radiology do not give specific recommendations as to the type of fluid resuscitation that should be given prior to enema reductions of intussusception, although it is stated that the patient should be rehydrated prior to the procedure. Based on our experience, more data should be gathered on the fluid status of patients with intussusception prior to the reduction technique in order to decide the safest and most effective fluid management pre-enema and post-enema in these patients. There should be an appropriate observation period of the patient following the enema reduction so that the delayed complication of hypovolemic shock, as we experienced in our patient, can be diagnosed and treated effectively.

Discussion
Enema reduction of intussusception is an important pediatric interventional radiology procedure. By today's standards, complete recovery is expected for children with intussusception treated at children's hospitals in North America, with mortality being rare. An experience in Nigeria showed that mortality was 18 %, largely related to delays in diagnosis, with seven out of nine deaths being related to nonviable bowel [3]. Morbidity and mortality from intussusception may be surgically related (anesthesia/preoperative/intraoperative/postoperative complications) and general complications (hypovolemia, sepsis, endotoxinemia) [4]. Complications related to radiology procedures have largely focused on the potential for perforation/extravasation with air and positive contrast material. One article has addressed the subject of the risk of bacteremia related to air enema reduction of intussusception [5]. In this study, 27 children with air enema for intussusception had serial blood cultures pre-enema, immediate post enema, and 1 h post enema. Six of 81 cultures were positive, although 5/6 were contaminants, and 1/6 was Staphylococcus aureus of questionable significance. All of these patients recovered without antibiotic treatment. Five patients had rectal temperatures greater than 38 F, although all of these had negative cultures. It was concluded that patients may develop fever from air enema reduction of intussusception, but the risk of bacteremia and sepsis of clinical significance was felt to be extremely low. Our patient was treated according to current ACR standards for intussusception reduction. The patient

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References
1. McAlister WH (1998) Intussusception: even Hippocrates did not standardize his technique of enema reduction. Radiology 206: 595598 2. American College of Radiology, 1998 Standards (1998) ACR Standards for the Performance of Pediatric Contrast Enema Examinations, pp 8388 3. Meier DE, Coln CD, Rescorla FJ, et al (1996) Intussuception in children: international perspective. World J Surg 20: 10351040 4. Ein SH, Alton D, Palder SB, et al (1997) Intussusception in the 1990's: has 25 years made a difference? Ped Surg Int 12: 374376 5. Somekh E, Serour F, Goncalves D, et al (1996) Air enema for reduction of intussusception in children: risk of bacteremia. Radiology 200: 217218