Intussusception
Background
- Most common cause of intestinal obstruction in 6 months to 6 years
- Peak incidence at 6-36 months
- Telescoping of proximal bowel segment (intussusceptum) into distal segment (intussuscipiens)
- Ileocolic type is most common in children
- Mesenteric involvement leads to venous congestion → ischemia → bloody/mucous stool
Pediatrics
- Typically no pathologic lead point (idiopathic in ~90% of cases <3 years)
- If > 6 years old, more likely to have a lead point:
- Meckel diverticulum, duplication cyst, polyp, lymphoma, Henoch-Schonlein purpura (HSP) hematoma, Peyer patch hypertrophy
- Often preceded by viral URI or gastroenteritis (lymphoid hyperplasia)
- Slight male predominance (3:2)
- Rotavirus vaccine associated with slightly increased risk in first week after dose
Adults
- Rare; accounts for 1-5% of bowel obstruction in adults
- 80% involve small bowel
- 70% associated with pathologic lead point (malignancy in up to 50% of colonic cases)
Clinical Features
Pediatrics
- Intermittent, colicky abdominal pain with episodes every 15-20 minutes
- Child draws knees to chest during episodes
- Asymptomatic intervals between episodes (child may appear well and playful)
- Vomiting (initially non-bilious; bilious in late stages)
- Lethargy may be sole presentation ("neurologic intussusception")
- May present with isolated seizure and abdominal pain[1]
- Classic triad present in only ~21% of cases[2]:
- Sudden colicky abdominal pain
- Palpable sausage-shaped mass (right upper quadrant/epigastric)
- Currant jelly stool (only ~50%; late finding indicating mucosal ischemia)
- Dance sign: emptiness in RLQ (cecum displaced superiorly)
- Late: peritonitis, shock, sepsis
Adults
- Typically partial/small bowel obstruction symptoms
- Vomiting, abdominal distension, constipation, rectal bleeding
- Late: sepsis, perforation
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
- Classic triad not always present — maintain high index of suspicion
- Labs are nonspecific; obtain if concerned for complications:
- CBC, BMP, lactate (if concern for bowel ischemia)
- Guaiac-positive stool (~50%)
Imaging
Ultrasound (Test of Choice in Pediatrics)
File:Ultrasound intussusception.jpg
Ultrasound showing characteristic target sign for intussusception.
File:Intussusception long and short axis.jpg
Intussusception in both short axis and longitudinal view[3]
- Sensitivity and specificity approach 100% (operator dependent)
- Target/doughnut sign (short axis): concentric rings of bowel wall
- Pseudokidney sign (long axis): layered appearance
- Can identify ileo-ileal intussusception (contrast enema cannot)
- Successfully implemented as bedside POCUS in many EDs
- Technique: linear probe, graded compression over all 4 abdominal quadrants
- Negative US does not completely exclude intermittent intussusception
Other Imaging
- Air-contrast enema: both diagnostic and therapeutic (see Management)
- CT abdomen: preferred in adults[4]
- Target sign, sausage-shaped mass, lead point identification
- Up to 20% of adult cases lack identifiable lead point
Management
Pediatric
- NPO and IV access
- IV fluid resuscitation prior to reduction
- NG tube if bilious vomiting or significant distension
- Surgery consult prior to attempted reduction
Nonoperative Reduction (First-line for Stable Patients)
- Indicated if no evidence of perforation, peritonitis, or hemodynamic instability
- Air-contrast enema (preferred at most centers):
- Success rate: 80-95%
- Performed by radiology with surgery on standby
- Contraindicated if perforation, peritonitis, or shock
- Hydrostatic enema (saline or water-soluble contrast): alternative method
- Rule of 3s: maximum 3 attempts of reduction, each lasting 3 minutes, with 3 minutes rest between
Surgical
- Indicated when:
- Nonoperative reduction incomplete or unsuccessful
- Patient is hemodynamically unstable, toxic, or has perforation/peritonitis
- Pathologic lead point identified
- Recurrent intussusception (relative indication)
Special Situations
- Ileo-ileal intussusception (small bowel only, often incidental):
- If stable, asymptomatic, and length <2.3 cm → expectant management reasonable (many resolve spontaneously)
- Post-reduction observation: monitor for recurrence and complications for minimum 12-24 hours
Adults
- Surgical management is standard due to high incidence of malignancy
- CT for preoperative planning and lead point identification
Disposition
- Admit after successful reduction for observation (minimum 12-24 hours)
- Consider discharge only if:
- Successful reduction confirmed
- Good follow-up available
- Reliable parents with understanding of recurrence signs
- Reasonable distance to hospital
- Recurrence rate: 5-12%[5][6]
- Majority of recurrences do NOT occur within first 24-48 hours
See Also
References
- ↑ Kleizen KJ et al. Acta Paediatr. 2009;98(11):1822-4. PMID 19664012
- ↑ Bruce J, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr. 1987;6:663-674. PMID 3430268
- ↑ http://www.thepocusatlas.com/pediatrics/
- ↑ Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009;15(4):407-411. PMID 19152443
- ↑ Gray MP, et al. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014;134(1):110-9. PMID 24935999
- ↑ Beres AL, et al. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg. 2014;49(5):750-2. PMID 24851761
- Waseem M, Rosenberg HK. Intussusception. Pediatr Emerg Care. 2008;24(11):793-800. PMID 19018227
- Gluckman S, et al. Management for intussusception in children. Cochrane Database Syst Rev. 2017;6:CD006476. PMID 28617038