ORIGINAL ARTICLE
Comparison Between Small and Large Bowel
Intussusception in Children
The Experience of a Large Tertiary Care Pediatric Hospital
Hila Levinson, MD,* Tali Capua, MD,* Dennis Scolnik, MD,†‡ Ayelet Rimon, MD,*
Lotan Salomon, MD,* and Miguel Glatstein, MD*
Background: Intussusception is the most common cause of intestinal
obstruction in young children, and delayed diagnosis may lead to serious
sequelae. The objective of this study was to determine the prevalence of
ileoileal intussusception and to document and compare clinical outcomes
with ileocolic intussusception.
Methods: A retrospective cohort study of children with an abdominal ul-
trasound that diagnosed intussusception. Clinical data and diagnostic stud-
ies were retrieved, to compare ileoileal with ileocolic intussusception.
Results: A total of 488 patients were evaluated with an abdominal ultra-
sound on suspicion of intussusception; 54 (11%) had ileoileal intussusception
and 30 (6%) ileocolic intussusception. The significant features distinguishing
the 2 conditions were fever, more common in patients with ileoileal intussus-
ception, and an abdominal mass, which was papable more commonly in
ileocolic intussusception. None of the ileoileal intussusception patients re-
quired surgical intervention, and all were discharged without complication.
Conclusions: With recent advances in abdominal ultrasound, the di-
agnosis of ileoileal intussusception has become easier than before. Pa-
tients presenting with small bowel intussusception may not need any
immediate intervention. The presence of fever supports the diagnosis
of ileoileal intussusception.
Key Words: small bowel intussusception, irritability, ileocolic, ultrasound
(Pediatr Emer Care 2018;00: 00–00)
I ntussusception is the most common cause of intestinal obstruc-
tion in infants and young children,1 and the second most com-
mon cause, after appendicitis, of an acute abdominal emergency
in children.2 Delayed diagnosis can lead to bowel necrosis and
perforation, with potentially life-threatening consequences.3 An-
nual hospitalization rates for the condition declined in the United
States by 25% from 1993 to 2000, but rates have remained stable
at approximate 35 cases per 100,000 infants since then.4 The clas-
sically taught triad of intermittent colicky abdominal pain, red
currant jelly stool, vomiting, and a palpable abdominal mass3 oc-
curs in only a minority of patients,5 and diagnosis continues to de-
pend on a high level of clinical suspicion.
Abdominal ultrasound is very useful in establishing the diag-
nosis,6 but accuracy is affected by the sonographer's experience,7
and some hospitals do not have access to diagnostic ultrasound
24 hours a day. Intussusception can present with irritability or leth-
argy, nonspecific symptoms that must also be considered in
From the *Division of Pediatrics Department, Dana-Dwek Children Hospital,
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; and †Division
Department of Pediatrics, The Hospital for Sick Children, University of Toronto,
Toronto, Ontario, Canada.
Disclosure: The authors declare no conflict of interest.
Reprints: Miguel M. Glatstein, MD, Division of Pediatric Emergency Medicine,
Dana-Dwek Children Hospital, Sackler School of Medicine, Tel Aviv
University, 6 Weizman St, Tel- Aviv 64239, Israel
(e‐mail: Nopasara73@hotmail.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2018
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
infectious diseases, broadening the range of children that may
need to undergo a diagnostic ultrasound and potentially straining
ultrasound facilities.8
In contrast to ileocolic intussusceptions, ileoileal intussuscep-
tions are relatively common in children, with incidences ranging
from 1.7% to 17% of all intussusceptions.9,10 It is now known that
these ileoileal intussusceptions are without clinical import.2,11,12
The primary objective of this study was to determine the prevalence
of ileoileal intussusception and to compare the clinical presentation
and outcome of ileoileal and ileocolic intussusception among chil-
dren, in an attempt to distinguish between the 2 conditions.
METHODS
This was a retrospective chart review that included all pa-
tients evaluated between June 2010 and May 2014 with an ab-
dominal ultrasound positive for intussusception and performed
owing to clinical suspicion. Emergency department physicians or-
dered diagnostic ultrasounds when they suspected intussusception
based on history and clinical examination. Patients were excluded
if they had undergone previous abdominal surgery or had any
chronic medical condition with intestinal manifestations (eg, in-
flammatory bowel disease, intestinal polyps). Information ex-
tracted included demographic details, presenting symptoms
and signs (abdominal pain, irritability, lethargy, vomiting, bil-
ious emesis, grossly bloody stools, diarrhea, vital signs, presence
of abdominal distension, tenderness or mass), and results of radio-
graphic and ultrasound studies. Fever was defined as temperature
of greater than or equal to 38°C per rectum or above greater than
or equal to 37.5°C by mouth and was based on temperatures re-
corded during the emergency department stay or identified by
the caregiver within 24 hours before admission.
The intra-abdominal localization, diameter, and length of the
intussusception were established by ultrasound, and circulation of
the invagination by means of doppler ultrasound. Children were
classified into 2 groups based on their ultrasound findings:
Group 1: ileocolic intussusception;
Group 2: ileoileal intussusception.
Each standardized data extraction form was completed by the
primary investigator (H.L.) and reviewed by a senior physician
(M.G.) to ensure that each case of intussusception was correctly
classified. Because all ultrasound diagnoses were confirmed by
a pediatric radiologist, there was full agreement. Data were
transferred to an electronic spreadsheet (Excel 2007) and sub-
jected to descriptive analysis. Student t test was used to analyze
continuous variables and χ2 or Fisher exact test for categorical
data as appropriate.
The study was approved by the institutional ethics committee.
RESULTS
During the study period, 488 patients were assessed by ab-
dominal ultrasound for intussusception; 54 (11%) had ileoileal
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Levinson et al Pediatric Emergency Care • Volume 00, Number 00, Month 2018

intussusception and 30 (6%) ileocolic intussusception. Of the 84
positive for intussusception, median age was 19 months (range,
1.5–60 months) and 52 (61.9%) were male. Although there was
no difference in the incidence of the presenting symptoms such
as abdominal pain, vomiting, diarrhea, bloody diarrhea, lethargy,
and restlessness between the 2 groups, the ileoileal intussuscep-
tion group presented more frequently with a history of fever than
the ileocolic group (33.3% vs 6.7%; P = 0.0068 [see Table 1]).
Furthermore, an abdominal mass was palpated in a third of the
cases of ileocolic intussusceptions versus 1.8% of ileoileal intus-
susceptions (P < 0.0001). Abdominal radiographs were obtained
in 83.3% of patients with ileocolic versus 44.4% of ileoileal in-
tussusceptions (P = 0.005). All patients with ileocolic intussus-
ception, except 1 (a case of spontaneous reduction), had an air
enema reduction. Spontaneous reduction was observed in all
cases of ileoileal intussusception. No surgical reductions were
necessary in our patients. Per institution protocol, all patients
with ileocolic intussusception were admitted for at least 24 hours
to verify hemodynamic stability and the ability to tolerate oral
feedings before discharge. All patients with ileoileal intussus-
ception were discharged after a few hours of observation in the
emergency department.
DISCUSSION
In our cohort of children with a positive abdominal ultra-
sound for intussusception, approximately a third (35.7%) were
diagnosed with ileocolic intussusception and 2 (64.3%) of 3
ileoileal intussusception, with the latter being characterized by
decreased incidence of palpable abdominal mass and decreased
incidence of fever. The prevalence of ileoileal intussusception
among children evaluated by abdominal ultrasound for intussus-
ception was 11%.
Ultrasonography has a sensitivity of 98.5% and a specificity
of 100% in the diagnosis of intussusception, and it is a quick, sim-
ple, accurate, noninvasive method of diagnosis.13 The test charac-
teristics for point of care ultrasound are also highly encouraging.14
The uptake of point of care ultrasound makes it increasingly prob-
able that clinicians will be called upon more frequently to decide
how to manage children found to have ileoileal intussusception.
The increasing use of abdominal ultrasound allows demon-
stration of mesenteric lymphoid hyperplasia (one of the pathologic
cause of small bowel intussusception),15 intestinal peristalsis, in-
testinal obstruction, and the location of the ileocecal valve, in ad-
dition to the appreciation of bowel wall edema. Patients with
ileoileal intussusception usually have less wall edema, and an in-
tact bloody supply to the intussusceptum,16 giving a physiological
basis to our finding of a palpable abdominal mass significantly
more often in patients with ileocolic than ileoileal intussusception.
Our finding of fever being statistically more common in pa-
tients with ileoileal intussusception could be clinically useful. Fe-
ver is relatively common in patients with intussusception in
developing countries compared with developed countries.17 This
might be because of the higher frequency of infections, specifi-
cally rotavirus, which is known to be associated with intussuscep-
tion, in these developing areas.18 In contrast, a study from Europe
assessing fever in intussusception patients found no difference be-
tween ileoileal intussusception and ileocolic intussusception.4
None of the cases of ileoileal intussusception in our study
required any intervention, and they were all discharged with

TABLE 1. Ileoileal Versus Ileocolic Intussusception

Ultrasound Proven Intussusception, Ileocolic Intussusception, Ileoileal Intussusception,

n = 84 n = 30 n = 54 P (Univariate)
Age, median (range), 19 (1.5–60) 16.5 (1–66) 20 (1.5–60) 0.24
Male, n (%) 52 (61.9) 18 (60) 34 (63) 0.81
History, n (%)
Fever 20 (23.8) 2 (6.7) 18 (33.3) 0.0068
Abdominal pain 38 (45.2) 17 (56.7) 21 (38.9) 0.1696
Vomiting 45 (53.6) 13 (43.3) 32 (59.3) 0.1783
Bilious vomiting 3 (3.6) 2 (2.7) 1 (1.8) 0.2891
Diarrhea 22 (26.2) 6 (20) 16 (29.6) 0.440
Bloody diarrhea 8 (9.5) 3 (10) 5 (9.3) 1.000
Lethargy 34 (40.5) 16 (53.3) 18 (33.3) 0.104
Irritability 50 (59.5) 21 (70) 29 (53.7) 0.1696
Physical examination, n (%)
Apathy 15 (17.9) 8 (26.7) 7 (13) 0.1424
Abdominal distension 5 (6) 3 (10) 2 (3.7) 0.3432
Abdominal tenderness 40 (47.6) 18 (60) 22 (40.7) 0.1128
Abdominal mass 11 (13.1) 10 (33.3) 1 (1.8) <0.0001
Rectal examination, n (%) 4 (4.7) 1 (3.3) 3 (5.6) 1.000
Fecal occult blood positive 1 1 N/A
Imaging, n (%)
Abdominal ultrasound 84 (100) 30 (100) 54 (100) 1.0
Abdominal radiograph 49 (58.3) 25 (83.3) 24 (44.4) 0.0005
Air enema, n (%) 29 (34.5) 29 (96.7) 0 (0) <0.0001
Disposition, n (%)
Admitted 29 (34.5) 29 (96.7) 0 (0) <0.0001
Operating room 0 (0) 0 (0) 0 (0)

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Pediatric Emergency Care • Volume 00, Number 00, Month 2018
instructions to follow up with the primary care physician. Our cen-
ter is a large urban tertiary care pediatric hospital, and most patients
return for medical care to our emergency department in any case of
clinical worsening. Our findings suggest that ileoileal intussus-
ception reduced spontaneously, indirectly implying that ischemic
changes are generally mild or absent. Possible cases of small
bowel intussusception are treated as gastroenteritis and/or upper
respiratory infection without any suspicion of intussusception.19
Our study is limited by being a retrospective case-control
study in a single center and by the fact that entry into the study
was restricted to children undergoing diagnostic ultrasound. The
number of patients in our study is too small to draw final conclu-
sions about the complete self-resolution of ileoileal intussuscep-
tion, and we are unable to prove conclusively that all cases of
small bowel intussusception resolved fully.
Ileoileal intussusception was observed in two thirds of chil-
dren diagnosed with intussusception. All our patients with an
ileoileal intussusception had a benign and uneventful clinical
course, requiring no intervention. The absence of fever and the
presence of an abdominal mass best distinguished ileocolic from
ileoileal intussusception in our cohort of patients. Our findings
are important owing to the increase in the number of ultrasound
examinations being performed in emergency departments, which
may lead to an increase in diagnosis of ileoileal intussusception.
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