Intussusception

Background

Schematic of intussusception.
  • 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

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

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

  1. ↑ Kleizen KJ et al. Acta Paediatr. 2009;98(11):1822-4. PMID 19664012
  2. ↑ Bruce J, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr. 1987;6:663-674. PMID 3430268
  3. ↑ http://www.thepocusatlas.com/pediatrics/
  4. ↑ Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009;15(4):407-411. PMID 19152443
  5. ↑ Gray MP, et al. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014;134(1):110-9. PMID 24935999
  6. ↑ 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
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