Articles

Idiopathic intussusception in infancy and

childhood

Stanley J. Crankson, FRCS, Abdullah A. Al-Rabeeah, FRCS(C), James D. Fischer, FRCS(C), Saud A. Al-Jadaan, FRCS(C),
Mohammed A. Namshan (MBChB).

ABSTRACT
Objective: Idiopathic intussusception is an important cause
of abdominal pain, bleeding per rectum and intestinal
obstruction in infancy and childhood. This aim of this study
was to undertake a retrospective review of all children who
presented with idiopathic intussusception over a 17-year
period.
Methods: The medical records of children who presented
with idiopathic intussusception from January 1984 through
December 2000 at King Fahad National Guard Hospital,
Riyadh, Kingdom of Saudi Arabia were reviewed. The data
obtained included age, sex, clinical presentation, diagnostic
investigations, mode of treatment, length of hospital stay and
results.
Results: Thirty-three children (21 male, 12 female) presented
with 37 episodes of intussusception. Their mean age was 8.4
months (range 5 hours to 36 months). The clinical features
included rectal bleeding (81%), vomiting (78%), abdominal
colic/pain (65%) and abdominal mass (62%). All cases were
ileocolic intussusception with no leading point. Barium
enema was attempted in 36 cases with success in 20 (56%).
Laparotomy was required in 16 cases, manual reduction being
successful in 11 (30%) and 6 (16%) had bowel resection. At
surgery, after attempted barium reduction, 9 (56%) cases had
the intussusception already reduced to the cecum. Seventy
percent of the cases presented within 24 hours of onset of
symptoms. The 4 recurrences in 3 children had successful
enema reduction. There was no mortality but 3 operative
cases required late surgery for adhesive intestinal obstruction
including one requiring bowel resection.
Conclusion: Idiopathic intussusception commonly presents
as an ileo-colic type but is uncommon in our institution. The
clinical features are classical, rectal bleeding being the most
common. The majority presented within 24 hours of onset of
symptoms and barium enema reduction was successful in 20
out of 36 cases in which it was attempted. Since most
intussusceptions were already in the cecum at surgery after
failed enema reduction, a repeat or delayed enema reduction
could be considered in stable cases. Recurrent intussusception
occurred in 3 non-operated cases and adhesive intestinal
obstruction in 3 laparotomy cases.
Saudi Med J 2003; Vol. 24 Supplement 1: S18-S20

ntussusception is an important cause of intestinal postoperative complication.1,2 Primary idiopathic

I obstruction, bleeding per rectum and abdominal pain
in childhood. Although it occurs infrequently, it is one
of the most common abdominal emergencies in the
pediatric age group. It may be ileo-colic (80%),
ileoileal, cecocolic, colocolic or jejunojejunal in type.
Intussusception may also be classified as primary
idiopathic, secondary where there is a definite
pathological lead point but may also occur as
intussusception is not associated with an obvious cause
in 90% of cases except lymphoid tissue hyperplasia.
The accepted management of idiopathic intussusception
consists of adequate resuscitation, radiological
confirmation of diagnosis, and radiological reduction
(unless contraindicated) with surgical intervention as a
last resort except in special cases.3 The classical cases
of idiopathic intussusception are readily diagnosed

From the Department of Surgery, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

Received 12th November 2002. Accepted for publication in final form 21st December 2002.

Address correspondence and reprint request to: Dr. S. J. Crankson, Consultant Pediatric Surgeon, King Fahad National Guard Hospital, PO Box 22490, Riyadh
11426, Kingdom of Saudi Arabia. Tel. +966 (1) 2520088. Fax. +966 (1) 2520140. E-mail: cranksons@yahoo.com

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 Idiopathic intussusception ... Crankson et al

clinically but intussusception may mimic other Table 1 - Clinical features (N=37).
conditions. Radiological investigations should therefore
be undertaken promptly in suspected cases. Barium
Features n (%)
enema has been the imaging study of choice for the
diagnosis and treatment in the absence of any
contraindications such as peritonitis, septicemia or Rectal bleeding 30 (81)
advanced intestinal obstruction. Pneumoperitoneum on Vomiting 39 (78)
abdominal radiograph would indicate a perforation an
absolute contraindication.4 The alternative of gas Abdominal pain/colic 24 (65)
(air/oxygen) enema is reported to be quicker, less messy, Abdominal mass 23 (62)
delivers less radiation to patients and has increased
Diarrhea 13 (35)
reduction rate.4,5 Ultrasonography (US) is a helpful
diagnostic tool for those children whose clinical Triad (abdominal pain, 16 (43)
presentation or plain abdominal film is suspicious but abdominal mass, rectal
bleeding)
not diagnostic for intussusception. Ultrasonography has
characteristic findings of doughnut or target sign on
transverse section and pseudo-kidney or sandwich on Table 2 - Plain abdominal radiograph findings (n=37).
longitudinal section.1,2 Therapeutic saline enema under
US guidance has been reported with a success rate of
83-95.5% but the procedure takes a long time for the Findings n (%)
inexperienced and is more operator dependent.5,6 The
advantages of this procedure are the avoidance of Normal 11 (29.7)
radiation and detailed evaluation of intussusception. The
incidence of pediatric intussusception in the Kingdom of Abdominal mass 8 (21.6)
Saudi Arabia (KSA) is unknown. A retrospective review Meniscus sign 2 (5.4)
of idiopathic intussusception over a 17-year period at
Absence of cecal gas and 2 (5.4)
King Fahad National Guard Hospital, Riyadh, KSA is stool in RIF
herein presented.
Small bowel obstruction 14 (37.9)

Methods. Thirty-one children with idiopathic

intussusception were managed at King Fahad National
Guard Hospital, Riyadh, KSA from January 1984
through December 2000. The medical records of these
children were reviewed with regards to age, sex, clinical
presentation, investigations, mode of treatment, length of
hospital stay, and results. Barium enema was used for
diagnosis and reduction of intussusception. Successful
reduction was proven by adequate reflux of contrast into
the distal ileum: If unsuccessful, laparotomy was
performed.
Results. Thirty-three children, 21 males and 12
females were treated for ileocolic intussusception. There
were 4 recurrences in 3 children. The mean age was 8.4
months (range 5 hours to 36 months). Thirty-one (94%)
children were under 12 months of age and 23 (70%)
were between 5-9 months old. The clinical features
included rectal bleeding (81%), vomiting (78%),
abdominal pain/colic (65%) and abdominal mass (62%)
(Table 1). The classic clinical triad of abdominal pain,
abdominal mass and rectal bleeding occurred in 16
(43%) children. After initial resuscitation, the child had
a plain abdominal radiograph and the findings are as per
Table 2. Barium enema and recently water-soluble
contrast enema was used in all cases except one of
peritonitis to confirm the diagnosis and for enema
reduction. Successful reduction was possible in 20
(56%) cases, the apex of intussusception was in the
transverse colon in 23 (70%) cases, descending
RIF - right iliac fossa
colon/sigmoid in 12 (37%) and ascending colon in one
(3%). Laparotomy was performed in 17 cases, operative
reduction in 6, operative reduction and appendicectomy
in 5 and bowel resection in 6. At surgery, 9 (56%)
children had the intussusception already reduced to the
cecum after prior enema. Bowel resection was required
for gangrenous ileum and cecum in 3 cases, perforated
cecum during reduction at operation in one, and
gangrenous ileum in 2 cases. The mean duration of
symptoms of all children was 33 hours (range 5-96
hours). Twenty-six (70%) cases presented within 24
hours of onset of symptoms and for the series for
successful enema cases, the mean duration was 30 hours
(range 5-72 hours) and 41 hours (range 8-46 hours) for
laparotomy cases (P value = 0.0048). The mean length
of stay was 2.4 days (range 1-5 days) and 6 days (range
1-23 days) for successful enema reduction and
laparotomy cases respectively (P value = 0.00023).
These P values are statistically significant. All 4 cases
of recurrent intussusception were from the enema
reduction group and were successfully reduced by repeat
enema. Adhesive small bowel obstruction occurred in 3
children who had previous laparotomies. One child
required laparotomy and release of adhesions and
another required bowel resection and the third responded
to non-operative management.

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 Idiopathic intussusception ... Crankson et al
Discussion. The peak incidence of intussusception
is between the 5th and 9th month of life and in this
review 70% of the children were within this age group.
Ninety-four percent of our patients were within the first
year of life, the youngest being only 5 hours old.
Intussusception in the prenatal and neonatal period is
however, considered extremely uncommon. The
incidence of intussusception in KSA is unknown with 60
cases reported over 2.5 years in one institution.7 This
report however, included secondary intussusception. In
our review of idiopathic intussusception over 17 years,
we encountered an average of only 2 cases per year,
therefore making it a very uncommon condition at our
institution. Male preponderance has been our experience
and of others, although not validated by Al-Bassam and
Orfale.1,7 The classic triad of abdominal pain, abdominal
mass, and red currant jelly stool which was encountered
in 43% of our cases is also the experience of others.5
The most common features are vomiting in infants and
colicky abdominal pain in older children.1 Rectal
bleeding which is considered to be a sign of mucosal
sloughing or intestinal ischemia was found in 81%
which was surprising considering that 70% of children
presented early in the first 24 hours.
The role of the abdominal radiograph in children with
suspected intussusception is uncertain. In our study, the
abdominal radiograph was not suggestive of
intussusception in 29.7% of patients. However, signs
suggestive of intussusception included meniscus sign
(5.4%), absence of cecal gas (5.4%), abdominal mass
(21.6%) and small bowel obstruction (39.7%). In a
retrospective review of abdominal radiographs in
children with suspected intussusception by Sargent et al,6
intussusception was identified in only 27 of 60 (45%)
children. We think that the abdominal radiograph may
be omitted in most children in whom there is a high
clinical index of suspicion for intussusception,
particularly if barium enema is used diagnostically.
The current reduction techniques, the spontaneous
reduction of intussusception at surgery, and easy
operative reduction have led to the adoption of repeat
enemas in stable patients. In 9 patients in our study,
intussusception had been reduced to the cecum and
probably a repeat enema would have achieved successful
reduction. Saxton et al,8 reported over 50% success rate
in 22 patients who had delayed enema following an
unsuccessful first attempt and confirmed by others.1,9
We believe that this should be considered in all stable
patients before surgery.
Operative reduction has been necessary in cases in
whom radiological techniques are contraindicated or
have failed; when a pathological lead point is suspected;
or in the case of multiple recurrences.1 Laparotomy is
associated with an invasiveness, morbidity and increased
length of stay as apparent in our review. Laparoscopy
has been used for diagnosis of failed reduction, for
laparoscopic-assisted pneumatic reduction and
hydrostatic saline enema during the procedure.10,11
Poddoubnyi et al,10 reported a success of 65.3% in the
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use of laparoscopic-assisted treatment with a conversion
to open procedure of 34.7%. In a report by Hay et al,11
14 (70%) of 20 patients were saved from unnecessary
laparotomy using laparoscopy for diagnosis of failure
and for hydrostatic saline enema. Operative reduction
was required in 11 (65%) of 17 patients, resection being
necessary in 6 (35%) in our study. Resection usually
reflects either delay in presentation or diagnosis and the
experience of the surgeon. Perhaps in our study this
reflects delay in presentation since only one patient
required resection as a result of perforation during the
manual reduction.
In conclusion, idiopathic intussusception is an
uncommon condition in our institution. Although most
children present within 24 hours of onset of symptoms
rectal bleeding is the most common clinical feature.
After resuscitation, abdominal radiograph is necessary to
exclude perforation and other intraabdominal causes.
Contrast enema is still used at our institution for both
diagnosis and enema reduction, despite the recent use of
gas pneumatic reduction, US with hydrostatic saline
enema and laparoscopic-assisted pneumatic or saline
enema reduction. Repeat enema or laparoscopy should
be considered for failed reduction before laparotomy.
Of course, for patients with peritonitis or when a
pathological lead point is suspected, laparotomy is
indicated.
Acknowledgment. We wish to express our sincere gratitude to
Ms. Mel Rabago for her secretarial help and Dr. Saeed Ahmed for his
review of the manuscript.
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