Can use air or water soluble contrast—peds rads usually start with air, unless abd film shows so much air that it may be hard to tell
If using water soluble contrast, can use Cystoconray or Hypaque
The seal is the name of the game—use a Foley catheter that is big enough, so it will give you the best seal (usually 24-28 French in kids >12 months)
Inflate balloon under fluoro, then pull to snug and tape well with foam tape
Inflate air until you confidently see air reflux into the small bowel (it’s “bubbly”)
Sustained pressure shouldn’t be higher than 120 mmHg
Give it 3 tries to try and reduce—in general, if making progress, keep going
If using water soluble contrast, elevate bag approximately 3 feet above table, to get a good pressure head
Image capture multiple spots as you go—it can be helpful if trying to convince yourself that you are in fact in the small bowel to go back and look at the spots as you progress.
Consent for the procedure should include risk of perforation necessitating surgery and risk of being unable to reduce intussusception thus necessitating surgery.
The only true emergent indication is rule out malrotation, or bilious emesis, which implies malrotation with midgut volvulus.
Place baby on octostop.
I do all emergent studies using a feeding tube in the stomach as it gives you more control and usually speeds things up such as if the stomach isn’t emptying which may be the case with midgut volvulus or the incidental pyloric stenosis ( I use air to push contrast out of the stomach with child right decub position), and if study is positive, it is desirable to decompress the stomach as much as possible.
Inject water soluble contrast (Omnipaque 300 or similar) in the left side down position—after fundus of stomach fills, turn baby right side down, in order to empty the stomach. When you see contrast in the duodenal bulb/second portion of the duodenum, turn baby to supine position and watch the contrast cross over the midline to the ligament of Treitz.
Key image is documenting the position of the ligament of Treitz, which is to the left of the spine and at the level of the duodenal bulb in normal kids. If the ligament is not in correct position, then there is malrotation. If there is a tight twist in the duodenum, or frank obstruction, then there is midgut volvulus (it can be difficult to see the “corkscrew” of the volvulized small bowel). This is a true surgical emergency and needs to be reduced in the OR immediately.
Indication: rule out septic hip
Technique: Single longitudinal (parasagittal) image of each hip (both the symptomatic and asymptomatic side) from the anterior position. Use linear array transducer. If there is ANY fluid in the joint, then the hip must be tapped. This is an orthopedic emergency, as a septic joint can rapidly destroy cartilage.
ABNORMAL LEFT SIDE
NORMAL RIGHT SIDE FOR COMPARISON
Aside from r/o intussuseption, most pediatric enemas can be deferred until morning