Intussusception

The most common abdominal emergency of early childhood

The telescoping of 1 part of the bowel into itself or adjacent bowel, causing abdominal pain, vomiting, and
eventually bloody stools and lethargy

Telescoping of the bowel causes diminished venous blood flow and bowel wall edema, which can result in
ischemia and obstruction. Eventually, arterial blood flow is inhibited and infarction of the bowel wall occurs, which
results in hemorrhage and, if untreated, possible perforation.

Strangulation of the bowel rarely occurs in the 1st 24 hours but evolves afterward.

Ileocolic type accounts for 8090% of intussusceptions; ileoileal and colocolic types also occur.

Typical triad of acute onset of colicky abdominal pain, right upper quadrant (RUQ) mass, and currant jelly stools,
although clinical presentation can vary

Increased incidence in children who received the Rotashield rotavirus vaccine. The currently available vaccine
(Rota Teq) has not been shown to increase the risk.
EPIDEMIOLOGY

Male/Female ratio: 3:2

Generally occurs in 6 months to 3 years

Peak age from 612 months

Incidence

14/1,000 live births

ETIOLOGY

Children <3 years: Usually idiopathic or enlarged Peyer patch from viral infection

Children 3 years or older: Often a pathologic lead point: Meckel diverticulum, hematoma from Henoch-Schnlein
purpura or bleeding diatheses, tumors (polyps, lymphoma, sarcoma, lipoma, neurofibroma), adhesions, duplication,
postsurgical anastomotic sutures or staples, cystic fibrosis

Diagnosis
SIGNS AND SYMPTOMS
History

The typical presentation is the sudden onset of severe intermittent (colicky) abdominal pain, with the child often
drawing the legs up to the abdomen and crying. Can be asymptomatic between paroxysms of pain

Lethargy out of proportion to the severity of dehydration

Nonbilious emesis initially, becomes bilious with progressive obstruction

Currant-jelly stools (sloughed mucosa, blood, and mucous) appear in 50% of cases: A sign of longer course

Physical Exam

Lethargic with colicky pattern of abdominal pain

Mass in the RUQ may be palpated (RUQ sausage)

Absence of bowel contents in right lower quadrant (Dance sign)

Abdominal distention

Rectal exam: Blood-tinged mucous or currant jelly stool; occasionally the intussusception can be felt

Peritoneal signs if intestinal perforation has occurred

TESTS

LABORATORY
CBC, electrolytes
IMAGING

Abdominal x-ray: Not sensitive or specific. Normal in early stages, later can have absence of gas in right lower
quadrant (RLQ) and RUQ as well as RUQ soft tissue mass; with obstruction, will have airfluid levels, paucity of
distal gas

Abdominal ultrasound: If performed by experienced radiologist, highly sensitive and specific. Doughnut sign
with presence of several concentric rings

Contrast enema: Diagnostic and therapeutic with reduction often achieved. Air enema preferred because less
perforation risk than barium. Can miss a lead point
CLINICAL:

Only 30% present with the classical triad of abdominal pain, palpable abdominal mass, and currant-jelly stool, so
high clinical suspicion is necessary

Clinical status of hypovolemic patients may worsen with high-osmotic contrast agents.
DIFFERENTIAL DIAGNOSIS

Infection: Gastroenteritis, enterocolitis, parasites

Immunologic: Henoch-Schnlein purpura

Miscellaneous:
1. Appendicitis
2. Meckel diverticulum: May act as a lead point in the absence of bleeding
3. Incarcerated hernia
4. Hemolytic uremic syndrome
5. Obstruction: Adhesions, hernia, volvulus, stricture, bezoar, foreign body, polyp, tumor

Treatment

INITIAL STABILIZATION

Nasogastric tube placement: Bowel decompression

IV line placement: Correction of fluid and electrolyte losses

GENERAL MEASURES

Prompt reduction is imperative.

Spontaneous reduction occurs in 5%

Obtain surgical consultation before contrast enema reduction attempt secondary to risk of perforation; failed
reduction requires surgical correction.

Absolute contraindications to reduction by enema: Peritonitis, shock, and perforation

Relative contraindications to reduction by enema: Symptoms >24 hours, evidence of obstruction (i.e., air fluid
levels), sonographic evidence of ischemia

Perforation during reduction occurs in 1% of cases, mostly in the transverse colon.

SURGERY

If perforation/peritonitis exists, patient is unstable, nonoperative reduction is unsuccessful, or lead point is identified,
proceed to surgical reduction.
Follow-up Recommendations
Recurrence after nonoperative reduction has been reported in up to 10% of cases and usually is seen within 24 hours of the
reduction.
EXPECTED COURSE/PROGNOSIS

Timely diagnosis results in a highly favorable prognosis.

Hydrostatic reduction by contrast enema is therapeutic in 5090% of cases.

Risk of recurrence is ~10% after contrast enema reduction, 1% after manual reduction, and not reported after
intestinal resection; the greatest risk is in the 2472 hours after reduction.
POSSIBLE COMPLICATIONS

Bowel necrosis secondary to local ischemia

GI bleeding

Bowel perforation

Sepsis, shock

Q: Can my child have a recurrent intussusception?

A: Yes, the risk is very low, probably <10% if the child has had a nonsurgical reduction or removal of the lead
point. The greatest risk is in the 1st 72 hours after reduction.

Q: What are the common ages for presentation?

A: 6 months to 3 years is the age range associated with the greatest risk of intussusception, but it may occur at any
age. The prevalence of pathologic conditions rises with the age of a child diagnosed with intussusception.