Authors' Response

Abstract

To the Editor: We would like to thank Dr Scholz et al for their commentary regarding our Image of the Month in March 2010 (1), which highlights the use of ultrasound in the diagnosis of intussusception. We agree that abdominal ultrasound is useful for diagnosis in cases of suspected intussusception, specifically ileocolic variations. Dr Scholz and colleagues also describe limitations of other imaging modalities (eg, computed tomography [CT]), as well as therapeutic options for reduction. We applaud the German approach of broad training in ultrasound for pediatric residents and gastroenterology fellows. However, we also note several logistical issues that may limit the feasibility of ultrasound training as a requirement in the United States. Our case focused on intussusception as a presenting feature of celiac disease. Our patient's initial presentation was a distended and tender abdomen with bilious emesis and an abdominal film suggestive of obstruction. We agree that if a standard ileocolic intussusception was suspected from the presentation, CT scan and laparoscopy would not have been performed initially. In a 4-year-old patient such as ours, appendicitis is more common than ileocolic intussusception, and in the setting of obstruction, this diagnosis was pursued. In our case, the multiple intussusceptions were not identified on CT imaging. We submit that even if they had been visualized, the presentation of bilious emesis and small bowel obstruction would have prompted exploratory laparoscopy. There was no clinical indication that the intussusceptions were transient in nature. Although we agree that typical ileocolic intussusception can be generally reduced by contrast enema, the 6 multiple ileoileal intussuceptions seen in our patient would not have been reduced in this manner as effectively. Instead, intussusceptions caused by pathological lead points often require operative reduction. The majority of the literature in this area is directed at ileocolic intussusception rather than small bowel intussusceptions (SBI), but subsets of data related to ileoileal intussusception can be extracted. Saxena and Höllwarth (2) reported 25.2% of patients with intussusception were SBI, and 14.3% had surgery, with 10.7% requiring bowel resections. Compared with ileocolic intussusceptions, pneumatic reduction was less successful in SBI (85.7% vs 91%). Harrington et al (3) propose that plain film suggestive of small bowel obstruction is a relative contraindication for enema reduction. They report that >50% of children older than age 2 years experienced a failed attempt at hydrostatic reduction, and 5 of 6 with bowel obstruction had proximal lesions (3). There is a paucity of data on the management of multiple simultaneous SBI, as in our case. In a series of 112 positive ultrasound examinations for ileocolic intussusceptions, 8 of 15 were falsely positive and later diagnosed with ileoileal intussusception (4). These data may suggest that even if ultrasound is positive, management may be altered in a significant number of patients (5). In conclusion, we maintain that a variety of diagnostic options are available in the diagnosis and treatment of SBI, and clinical information and initial imaging are likely to direct subsequent steps in diagnosis and treatment. Our case primarily suggests the importance of evaluating for potential underlying celiac disease in cases of SBI in which pathological lead points, such as polyps or lymphoma, are not identified as the cause of intussusception, regardless of the means by which reduction is achieved.