RADIOLOGY IN THE ED
Intussusception
Edematous Ileocecal Valve Mimicking Incomplete Reduction
Mary T. Kitazono, MD and Avrum N. Pollock, MD, FRCPC
From the Department of Radiology, Children’s Hospital of Philadelphia,
Philadelphia, PA.
Disclosure: The authors declare no conflict of interest.
Reprints: Avrum N. Pollock, MD, FRCPC, Department of Radiology,
Children’s Hospital of Philadelphia, 34th and Civic Center Blvd,
Philadelphia, PA 19104 (e-mail: POLLOCKA@email.chop.edu).
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 0749-5161
PRESENTATION
A 3-year-old boy presents with intermittent colic, emesis,
and bloody diarrhea for 1 day.
RADIOLOGY FINDINGS
An abdominal ultrasound reveals a characteristic target sign
in the transverse plane (concentric rings formed by multiple
layers of bowel wall) in the right lower quadrant compatible
with an ileocolic intussusception (Fig. 1). The patient subsequently underwent single-contrast water-soluble reduction
enema, which revealed an intraluminal filling defect (M) in
the proximal ascending colon (Fig. 2A) compatible with an
intussusceptum, which was successfully reduced by the contrast column to the level of the cecum, allowing reflux of
contrast into the small bowel. However, a masslike filling defect (asterisk) persisted along the medial aspect of the cecum
FIGURE 1. Ultrasound demonstrating the classic
bowel-within-bowel appearance of intussusception on ultrasound,
composed of multiple concentric rings of bowel wall, often
referred to as a target sign.
(Fig. 2B). A targeted ultrasound performed after the reduction
enema confirmed successful reduction of the intussusception,
with fluid seen traversing a thickened, edematous ileocecal
valve (arrows; Fig. 3), which accounts for persistence of a
FIGURE 2. A, Water-soluble contrast enema demonstrating an intraluminal filling defect in the ascending colon compatible with
the intussusceptum. B, Postreduction fluoroscopy revealing a persistent masslike filling defect on the medial aspect of the cecum, in the
expected region of the ileocecal valve. This may represent an edematous ileocecal valve, a persistent intussusceptum in the setting of
an incomplete reduction, or a pathologic lead point.
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FIGURE 3. Postreduction ultrasound showing an edematous
ileocecal valve, accounting for the filling defect seen on
fluoroscopy, and confirming complete reduction of the
intussusception.
masslike filling defect in the cecum on the postreduction fluoroscopic image.
DISCUSSION
Ileocolic intussusception is a common pediatric abdominal emergency, for which reduction enema (air- or water-soluble
contrast) is the initial treatment of choice. Approximately 80%
to 95% of intussusceptions can be successfully reduced nonoperatively, with higher success rates seen in patients presenting
with a shorter duration of symptoms (G24 hours), in the typical
age group ranging from 6 months to 3 years, and in the absence
of a visible lead point or trapped intraperitoneal fluid seen within
the intussusception.1Y3 Patients with signs concerning for perforation, peritonitis, or shock, or who fail multiple reduction
attempts, require operative reduction.2,3
Although ultrasound-guided enema reduction is a reliable
and safe alternative in the hands of an experienced operator,
fluoroscopically guided reduction enemas are more commonly
performed in North America, primarily owing to the training
and experience of the radiologist. One of the disadvantages of
fluoroscopic guidance over sonographic guidance is the occasional dilemma when there are equivocal signs regarding the
success of the procedure.
Criteria for a successful hydrostatic reduction enema include disappearance of the intussusceptum as well as reflux of
contrast from the cecum into the ileum. Fulfillment of both
criteria is necessary, as rarely contrast may be seen to reflux into
the small bowel by flowing through or around a persistent ileoileocolic intussusception; this finding usually indicates the need
* 2012 Lippincott Williams & Wilkins
Intussusception
for surgical intervention.4 An edematous ileocecal valve can occasionally mimic a persistent intussusceptum or a pathological
lead point on the postreduction fluoroscopic images, appearing
as a residual filling defect along the medial wall of the cecum.
A postprocedure targeted ultrasound can help confirm
complete reduction of the intussusceptum and exclude a pathologic lead point when a masslike filling defect remains in the
cecum. The sonographic appearance of an edematous ileocecal
valve has been likened to an aperistaltic ‘‘donut,’’ consisting of
an echogenic center surrounded by a broad, hypoechoic rim.5
The postreduction ‘‘donut’’ is smaller in diameter compared
with the prereduction target lesion and lacks the typical concentric rings and invaginated mesentery. In addition to grayscale
images, visualization of a continuous movement of air bubbles
floating from the cecum into the ileum is another helpful sign
that confirms patency.6 Color Doppler sonography may also
be useful in demonstrating the continuous flow of fluid through
the ileocecal valve, similar to the jet phenomenon utilized to
depict the unobstructed flow of urine at the ureterovesicular
junction.7
In summary, a persistent intraluminal filling defect seen in
the cecum on fluoroscopy-attempted reduction of an ileocolic
intussusception may pose a diagnostic dilemma in differentiating an edematous ileocecal valve from residual/recurrent intussusception or a pathologic lead point. This dilemma can be
easily solved with postreduction sonography.
REFERENCES
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evolution of management. Pediatr Radiol. 2004;34:97Y108.
2. Navarro OM, Daneman A, Chae A. Intussusception: the use of
delayed repeated reduction attempts and the management of
intussusceptions due to pathologic lead points in pediatric patients.
AJR Am J Roentgenol. 2004;182:1169Y1176.
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management of intussusception in children. Eur Radiol.
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4. Koplewitz BZ, Simanovsky N, Lebensart PD, et al. Air encircling the
intussusceptum on air enema for intussusception reduction: an
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reduction of intussusception to differentiate edematous ileocecal
valve and residual intussusception. AJR Am J Roentgenol.
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