Case Based Pediatrics For Medical Students and Residents

Department of Pediatrics, University of Hawaii John A. Burns School of Medicine

Chapter X.4. Intussusception
Lynette L. Young, MD
December 2002

An 18 month old male presents to the emergency department with six hours of stomach
pain. He awoke at 0400 crying. His mother carried him and he settled down after a few
minutes and then fell back asleep. Over the next few hours, he woke up intermittently
crying. His appetite has been poor since the onset of these symptoms. He is able to walk
but prefers to be carried by his mom this morning. He is less playful than usual. He
would sometimes bend down crying. There is no vomiting or diarrhea. His last stool
yesterday was normal. There is no fever, cough, or runny nose. There is no history of
abdominal trauma.
Exam: VS T37.6, P 118, R 24, BP 85/55, weight 11kg. He is awake, alert, and being
carried by mom. His skin is pink with good perfusion and brisk capillary refill. His oral
mucosa is pink and moist. There are no ulcers in the posterior pharynx. His tympanic
membranes are normal. Heart regular rhythm and normal rate. Lungs are clear with good
aeration. His abdomen is soft and not distended, with normoactive bowel sounds, and no
masses noted. It is difficult to determine if any abdominal tenderness is present. His
genitalia are normal (no scrotal/testicular swelling or tenderness). His distal extremities
are warm and the distal pulses are strong. He is responding to mom appropriately.
An abdominal series reveals a soft tissue density in the right lower quadrant.
Intussusception is suspected. A water-soluble contrast enema is performed. An
intussusception is identified at the hepatic flexure. The ileocolic intussusception is
successfully reduced. There was reflux of the contrast into the ileum. Admission to the
hospital is discussed with the mother, but she refuses. He is observed in the emergency
department. After a short nap, he is able to tolerate oral fluids and his behavior
normalizes. The risk of recurrence is discussed with his mother. His pediatrician is
contacted and the patient is then discharged home.

Intussusception is a common abdominal emergency in children. Intussusception is best
described as a portion of the intestine which telescopes into a more distal intestinal
segment. It is one of the most common causes of abdominal obstruction in infants.
Intussusception occurs most often in patients between 3 to 12 months of age. There is a
male to female predominance of 2:1. It is often difficult to diagnose because of the
variable presentation of symptoms in a young infant.
The most common type of intussusception is ileocolic (also known as ileocecal) (90%). A
portion of terminal ileum intussuscepts through the ileocecal valve into the colon. The
intussusception may sometimes extend all the way to the rectum. Other types of
intussusception that are rarer include ileoileal, colocolic, and ileoileocolic. The majority
of intussusceptions are idiopathic. An anatomic lead point (a piece of intestinal tissue
which protrudes into the bowel lumen such as a polyp) occurs in approximately 10% of
intussusceptions. This is most often found in children older than 2 years. Possible lead
points include Meckel's diverticulum (most common), polyps, an inflamed appendix,
neoplasm (lymphoma), and ileal duplications. Intussusceptions with lead points are more
common in patients with Henoch-Schonlein purpura (intestinal wall hematoma) and
cystic fibrosis (hypertrophied mucosal glands). In infants it is hypothesized that
hypertrophied Peyer's patches, following a respiratory infection or gastroenteritis, may
serve as the lead point.
The mesentery is pulled along with the intussusceptum (leading invaginating segment)
into the intussuscipiens (receiving segment). The intussusceptum is propelled distally
through peristalsis. The mesenteric vessels are compressed leading to venous obstruction.
The intussusceptum becomes engorged causing bleeding from the mucosa (bloody
mucusy stools, sometimes known as currant jelly stool since extreme amounts of blood in
the stool will loosely resemble the red jelly of currant berries). However, it should be
noted that any blood in the stool may be caused by an intussusception. With a prolonged
intussusception, perfusion to the intestine may be compromised, which can then lead to
bowel necrosis, perforation, and shock.
The classic triad of intussusception include crampy (intermittent, also known as colicky)
abdominal pain, vomiting, and bloody stools. The classic triad was found in only 21% of
cases and two symptoms were found in 70% of cases in one series of patients with
intussusception (1). The colicky abdominal pain usually appears first and is the most
common symptom. The pain is intermittent lasting for 4 to 5 minutes. It may return in 5
to 30 minute intervals. The patient may pull up his knees with crying. In between the
episodes the patient may be asymptomatic. The patient may develop vomiting (90% of
cases). The emesis may become bilious because of the obstruction. Bloody stools, found
in 50% of cases, can be a late sign of intussusception. The absence of blood (even occult
blood) does not rule-out intussusception. Patients with an intussusception may also
present with lethargy/altered level of consciousness and pallor. The etiology of this
lethargic presentation is not known, but it tends to occur in younger infants. Some
hypothesize that this is due to release of endogenous opioids or endotoxins released from
ischemic bowel. Intussusception in a child presenting with lethargy is often difficult to
diagnose since other causes of lethargy such as dehydration, hypoglycemia, sepsis, toxic
ingestion, post-ictal state, etc., must also be considered.
The physical examination of a patient with an intussusception may be unremarkable. If
the patient is between attacks of the crampy abdominal pain, he may appear normal and
the abdominal examination may be unrevealing. Also, examining the abdomen of an
active or crying child can often be difficult. Lethargic or tired infants with very soft
abdomens are the easiest to examine. In some patients, a mass may be palpable in the
right upper quadrant. It is often described as sausage-shaped. A sausage-like mass in the
right upper quadrant and emptiness (the absence of bowel) in the right lower quadrant is
clinically indicative of an intussusception. Blood may be found on rectal examination. If
the intussusception has been present for a longer period of time, the abdomen may be
distended and there may be findings of peritonitis.
There are several findings described on plain film abdominal radiographs of patients with
intussusception. There may be evidence of a soft tissue mass or signs of bowel
obstruction (air fluid levels and distended loops of bowel). The absence of gas in the right
lower quadrant or flank may be seen with an intussusception. A target sign, crescent sign
or indistinct liver margin sign may be present. A target sign is viewing the
intussusception on cross-section which appears as two concentric circles (created by
bowel fat density differences) usually in the right upper quadrant. The crescent sign is
formed by the leading edge of the intussusception outlined by gas in the colon forming a
crescent (intussusceptum protruding into a gas filled pocket). The absent liver margin
sign can be seen if the soft tissue mass of the intussusception is resting at the hepatic
flexure of the colon or there is absence of gas in the right upper quadrant making the
lower edge of the liver indistinct. Free air may be visible on the radiograph if there has
been intestinal perforation. An abdominal series may be normal especially early on. More
recently, ultrasound has been advocated as it is highly specific (100%) and sensitive
(98%) in making the diagnosis of intussusception, but only when interpreted by highly
skilled radiologists. It may be helpful with confirming the diagnosis if an enema is
contraindicated. The major problem with utilizing ultrasound is that it must be able to
definitively rule out intussusception, since if diagnostic uncertainty still exists following
the ultrasound, a contrast enema must still be performed. Additionally, if the ultrasound
does identify an intussusception, a contrast enema must still be performed to reduce the
intussusception. Thus, before considering an ultrasound, the diagnostic ultrasonography
skills of the available radiologist must be determined. The high specificity and sensitivity
percentages are published from studies done in ultrasound pediatric super centers and
thus, these numbers are not necessarily applicable to general radiologists.
A barium enema has been the gold standard in the past for confirming the diagnosis and
nonsurgical reduction of an intussusception. Water-soluble contrast has been used and
more recently air enema reduction has been introduced. There are several reasons why
radiologists have different preferences for which type of contrast they choose to use for
the procedure. After the radiologist reduces the intussusception, they look for the contrast
to reflux into the ileum. This is necessary to eliminate the possibility of an ileoileal
intussusception. This is more difficult to see with an air contrast enema compared to a
barium or water-soluble contrast enema. Air leaking into the peritoneal cavity because of
intestinal perforation may also be difficult to see. Those in favor of using the air contrast
enema technique argue that with perforation, the sudden loss of pressure would signal to
the radiologist to stop the procedure. If a tension pneumoperitoneum results, this should
be decompressed immediately with an 18-gauge needle. Barium leaking into the
peritoneal cavity may cause a chemical peritonitis. Using a water-soluble contrast may
decrease this complication. An air contrast enema is advocated as the preferred method
by many pediatric radiologists (2), but since there is no clear consensus among
radiologists of the best contrast enema option, this decision is best left to the radiologist
performing the contrast enema procedure. The success rate of nonsurgical reduction is
about 60% to 80%. Several factors are associated with a contrast enema being
unsuccessful in reducing the intussusception. These include ileo-ileocolic
intussusception, longer duration of symptoms (>12 hours), dehydration, small bowel
obstruction, and age greater than 2 years or less than 3 months. The intussusception being
present for 24 hours or more, is no longer a contraindication for attempting contrast
enema reduction. The rate of intestinal perforation with nonsurgical reduction of an
intussusception is 1% to 3%. A contrast enema is contraindicated in patients who have a
bowel perforation, shock, or peritonitis. Ultrasound has also been used to monitor
reduction of the intussusception using saline rather than contrast under fluoroscopy. The
advantage of using ultrasound is that there is no radiation exposure. This is not
commonly used in the United States. Computed tomography can also identify an
intussusception. This usually occurs incidentally when the patient is having a CT scan for
the evaluation of abdominal pain and intussusception was not initially suspected. If the
intussusception is not reduced by an enema, or if there is intestinal perforation, shock, or
peritonitis present, the patient is sent for surgical reduction. An intravenous line, a
nasogastric tube, and consultation with a surgeon should be considered. If the patient is
dehydrated, a fluid bolus with NS or LR should be given.
If the intussusception is reduced successfully by enema, some may discharge the patient
home from the emergency department after observing the patient. However, most feel
that the patient should be observed in the hospital for 24 hours. The risk of recurrence is
about 4%. Intussusception recurs in up to 5% to 10% of the cases reduced by contrast
enema and about 1 to 5% of those reduced by surgery, though most recurrences are late
recurrences (after the patient has been discharged).

Questions
1. The most common type of intussusception is:
. . . . . a. ileoileal
. . . . . b. colocolic
. . . . . c. ileocolic
. . . . . d. ileo-ileocolic
2. Contraindications for non-surgical reduction of an intussusception include all of the
following except:
. . . . . a. symptoms for longer than 24 hours
. . . . . b. shock
. . . . . c. intestinal perforation
. . . . . d. peritonitis
3. Which is the most common pathological lead point found with intussusception?
. . . . . a. neoplasm
. . . . . b. appendicitis
. . . . . c. polyps
. . . . . d. intestinal duplication
. . . . . e. Meckel's diverticulum
4. A pathologic lead point can be identified in approximately what percentage of patients
with intussusception?
. . . . . a. 1%
. . . . . b. 5%
. . . . . c. 10%
. . . . . d. 15%
. . . . . e. 25%
5. The "classical triad" of symptoms of intussusception include:
. . . . . a. diarrhea
. . . . . b. vomiting
. . . . . c. fever
. . . . . d. bloody stools
. . . . . e. abdominal pain
6. Which element of the "classical triad" usually appears first?
. . . . . a. diarrhea
. . . . . b. vomiting
. . . . . c. fever
. . . . . d. bloody stools
. . . . . e. abdominal pain
7. All three of the "classical triad" of symptoms is found in what percentage of patients
with intussusception?
. . . . . a. 9%
. . . . . b. 21%
. . . . . c. 50%
. . . . . d. 70%
. . . . . e. 90%
8. True/False: A normal abdominal series rules-out intussusception.
9. If a mass is palpable on physical examination, it is most often found in the:
. . . . . a. right upper quadrant
. . . . . b. right lower quadrant
. . . . . c. left upper quadrant
. . . . . d. left lower quadrant

Answers to questions
1. c
2. a
3. e
4. c
5. b, d, e
6. e
7. b
8. false
9. a
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