INTUSSUSCEPTION

Expected learning outcomes:

[Presumed prior knowledge: physiological triggers of vomiting e.g. via central nervous system,
neurohormonal etc.; embryological, histological and anatomical features of normal gastrointestinal
tract]

Describe the above acquired cause of gastrointestinal obstruction with respect to: basic
pathophysiology, presenting features, key diagnostic radiological features, principles of pre-surgical
stabilization, description of corrective surgical procedure in layman’s terms and long-term outcome.

A) DEFINITION:

Intussusception:
When proximal bowel invaginates/ telescopes into a distal part of the bowel

Intussuscipiens:
The distal bowel that the proximal bowel telescopes into (the “recipients” of the bowel)

Intussusceptum:
The proximal bowel that telescopes (like a sock) into the distal bowel
B) PATHOPHYSIOLOGY:

Incidence:
The majority occur in infants between 3 months and 3 years
 ~50% occur between 6 - 12 months of age
 ~85% occur < two years of age

Natural history:
 The telescoping of one part of the bowel into another results in obstruction of the
venous and lymphatic return which in turn leads to oedema and increasing intra-
luminal pressure. Intestinal obstruction occurs and proximal bowel dilates
 Usually ileocolic but may be colo-colic/ ileo-ileal
 A massive third space fluid loss occurs.
 Strangulation and bowel infarction then occurs

Cause:
Not fully understood
 Idiopathic
 commonest form
 classically 3months -3 years of age (peak ~6-9 months)
 lymphoid hyperplasia - due to an increase in the lymphoid tissue mass ("Peyers
patches") in the bowel wall of the terminal ileum is thought to be the most
likely cause

 Other possible causes:

o ? viral association
usually occurs about 10 days after a respiratory infection or
gastroenteritis
o the change from breast to bottle feeds may play a role
o there is a seasonal variation (higher in spring and summer)
o association with rotavirus vaccination (slightly increased risk within first
week)
 Ileo-colic (ileum into colon) intussusception is usually found

 Lead point
 Much less common
 Usually seen in the older child and adults (must be ruled out in older children)
 May initiate intussusception on a mechanical basis
 e.g. of a lead point includes
o Meckel’s diverticulum
o Enlarged lymph nodes including lymphoma
o Intestinal polyps

 Postoperative
 May occur 2 -5 days postoperatively especially after retroperitoneal surgery e.g.
Wilms tumour resection
 Generally painless
 May present with signs of bowel obstruction (increasing nasogastric aspirates,
abdominal distension, inappropriately sick child)
 Usually small bowel intussusception e.g. ileo-ileal
C) CLINICAL PRESENTATION:

Symptoms:
1. Sudden onset of colicky abdominal pain
 The attacks of pain are severe enough to wake the child, who then screams with
pain and rolls around. The pain is colicky and intermittent and may then go away
only to return every half hour or so , lasting 20 to 30 seconds The child lies very still
in between attacks vomiting occurs in association with the attacks of pain (reflex)
2. Associated with vomiting
 Vomiting (~90%) may initially be milk feeds but becomes bilious
3. The passage of blood and mucus per rectum ("RED CURRANT JELLY" stools)
4. Abdomen becomes progressively more distended

Signs:
 Usually well nourished or even fat child (who perhaps mount a more robust immune
response to precipitating viral infection if enlarged Peyers patches are indeed the
initiating lead point in idiopathic intussusception)
 Child is restless and irritable during attacks of pain
 Child is apathetic and looks ill in between attacks
 Cries severely with attacks and pulls up legs to the abdomen.
 The child is dehydrated and may be shocked
 Mass palpable in the right so the abdomen in most cases. The
masses typically “sausage” or “cylindrically” shaped – usually it is
non-tender unless presentation is delayed and ischaemia is present
 On rectal examination the bloody stool may be identified and a
mass may be palpated in the rectum
 Intussusceptum may prolapse out of the rectum
Differentiate from rectal mucosal prolapse by bowel veering to the
side/spiralling due to mesenteric tethering, as well as ability to
pass finger between side of rectal wall and the prolapsed bowel in intussusception

 Signs of intestinal obstruction may be present

 Abdominal distension in ~90%
 Bilious/ small bowel contents draining from nasogastric tube
 Visible bowel loops (corrugated abdomen) in late presentation
 Leucocytosis ( ± 20 x 106/L) often present

D) DIFERENTIAL DIAGNOSIS
 Bloody stools: (Vitamin C)
 Vascular: Intestinal haemangioma; Dielafoy lesion
 Infectious: dysentery, septicaemia causing thrombocytopaenia; intestinal parasite
 Trauma: Anal fissure (constipation); blunt abdominal trauma
 Autoimmune: -
 Metabolic:-
 Idiopathic:-Juvenile rectal polyp
 Neoplastic:-
 Congenital: Bleeding dyscrasia e.g. Haemophilia, Juvenile polyposis

Vomiting:
 Vascular: -
 Infectious: ascariasis (worm bolus obstruction); any infection esp. urinary tract
infection, meningitis, middle ear infection
 Trauma: blunt abdominal trauma
 Autoimmune: -
 Metabolic:-various
 Idiopathic:-gastro-oesophageal reflux disease
 Neoplastic:-abdominal mass e.g. lymphoma, solid organ tumour (compression)
 Congenital: incarcerated inguinal hernia; infantile hypertrophic pyloric stenosis

E) SPECIAL INVESTIGATIONS:

Abdominal x-ray
 Signs of intestinal obstruction: tubular Low intestinal
dilated loops of bowel; gasless rectum; obstruction:
air-fluid levels at different levels multiple air-fluid levels,
 Mass may be seen distended bowel, gasless
 May be normal early in presentation rectum

Abdominal ultrasound
Gold Standard to make dx
 99% sensitivity
 “ target” lesion on transverse view or
“pseudo kidney” on longitudinal view Target sign

Contrast enema
Is useful if diagnosis in doubt; see notes
under management

Coiled spring and

lobster claw
appearance- contrast
enema
 F) MANAGEMENT:

Initial Management:

Prior to special investigations & reduction of intussusception:

1. Management of bowel obstruction:
a. Nasogastric tube on free drainage (± intermittent aspiration of both swallowed air and
gastrointestinal secretions) and nil by mouth
 Prevents further abdominal distension (overstretching of the bowel wall can lead to
perforation; splinting of the diaphragm impairs breathing)
 Prevents vomiting of accumulated GIT contents and aspiration pneumonia
 Allows measurement and replacement of GIT losses, preventing dehydration and
electrolyte disturbances.
b. Intravenous fluids (“3 R’s”)
 Resuscitation fluid: 10-20ml/kg of 0.9% NaCl bolus may be given and repeated as
necessary for dehydration ± hypovolaemic shock due to vomiting and fluid sequestration
in obstructed bowel wall and lumen.
o Fluid losses may be significant in intussusception
o Repeat as necessary until improving tachycardia, adequate urine output
(1ml/kg/hr), improved metabolic acidosis (on blood gas monitoring), wet
mucosa & normal capillary refill etc.
o Must be well-resuscitated prior to special investigations or pneumatic/ surgical
reduction of intussusception
 Regular ongoing maintenance fluid: 5% dextrose containing e.g. [0.45% NaCl & 5%
dextrose] + 20mmol KCl/L
 Replacement of ongoing fluid losses. Replace small intestinal losses with isotonic
crystalloid containing potassium e.g. Balsol/ Plasmalyte B/ Ringers’ lactate/ [0.9% NaCl +
20mmol KCl/L]
c. Correct electrolyte abnormalities
 Blood tests: Check serum urea & serum electrolytes
o Concurrent FBC, BC, glucose, XM as per below
2. Prevention/ treatment of septicaemia
a. Broad spectrum intravenous antibiotics
 e.g. stat dose of ceftriaxone to prevent translocation during pneumatic reduction OR
 treatment course (e.g. ampicillin, gentamycin & metronidazole/ amoxicillin-clavulanate/
cefuroxime & metronidazole) if tender abdomen ± bowel necrosis found at surgery)
b. If abnormal vital signs esp. pyrexia:
 Full blood count (FBC) , blood culture (BC) , serum glucose
 Blood grouping and cross-match (XM) if pneumatic reduction unsuccessful/ contra-
indicated
Reduction of intussusception:
Once patient has been fluid resuscitated and are stable enough

1. Non-operative reduction:
Pneumatic (air enema) reduction under fluoroscopic guidance
 also known as “Forced Air Reduction Technique”
 >80-90% successful reduction world wide and is the preferred method of reduction .
 hydrostatic (saline enema) reduction under ultrasound guidance done in centres with
sonographic expertise
 Barium hydrostatic reduction under fluoroscopic guidance was done historically (hung
from height of 1m above table for 3 minutes at a time) but stopped due to risk of barium
peritonitis from leaking into peritoneal cavity in case of perforation

Contra-Indication:
Absolute:
 Small bowel intussusception
 Shock/ incompletely resuscitated
 Signs of peritonitis e.g.
tenderness
 Perforation (pneumoperitoneum)
on AXR or fluoroscopic scout film
Relative:
 Long-standing history >3-4 days
 Grossly dilated loops of bowel on
AXR
 Bowel >1cm thick with impaired
blood flow on Doppler sonar

Technique:
 Child is resuscitated and stable
 10 -20 ml/kg N/Saline bolus just before reduction
 Broad-spectrum antibiotics if not yet given
 Ketamine sedation with vital sign monitoring
 Surgeon and radiologist should be present
 Fluorsocpic (x-ray) screening is employed
 Air is pumped into the rectum through a rubber or silastic tube while monitoring the
pressure used and observing the movement of the bowel fluoroscopically
 The air gives a black rather than white contrast of the bowel lumen
 Systolic blood pressure should not be exceeded for any length of time
o Protocol currently used at TBCH
 80 mg for 3 min, rest for 1 min
 100 mg for 3 min, rest for 1 min
 120 mg for 3 min, rest for 1 min
 Air should flow into the ileum in a successful reduction
 If unsuccessful but movement was seen – second attempt 15 min – 6 hours later

Complications:
 Unsuccessful reduction in 20-50% (requires surgical reduction)
Higher success in developed countries with early presentation
 Perforation
Should perforation occur with air enema urgent surgery is required and urgent
decompression of the pneumoperitoneum with a needle may be necessary as
respiratory arrest may occur due to the sudden high pressures in the abdominal
cavity
 Recurrence
5% compared to 2% following surgical reduction
 2. Operative reduction:

Indications:
 Unsuccessful reduction
 Peritonitis
 Lead point intussusception
 Small bowel intussusception
 Perforation post reduction or free air on initial XR

Technique (READ ONLY):

 Approach is usually via a right upper transverse laparotomy is carried out.

 Laparoscopy (minimal access approach) may be utilized in selected cases without
longstanding obstruction.
 The intussusception is reduced by starting at the top and milking it downwards. Gentle
compression of the oedematous bowel may fascilitate successful reduction. (See bruised but
viable bowel in picture below post-reduction)
 Should this not be possible or necrotic bowel be present, a bowel resection and primary
anastomosis must be carried out
 Lead point may be resected and sent for histology if found e.g. lymphomatous lymph node,
Meckel’s diverticulum

Post-operative care:
 Intravenous fluids & analgesia
 Restart oral feeds once post-operative ileus has resolved (normal bowel sounds, abdominal
distension improved, passing flatus, nasogastric aspirates no longer bilious, child hungry)

Outcome:
 2% risk of recurrence of intussusception (usually during first 10 days post-reduction) after
surgery (5% after pneumatic reduction)
 10% mortality in developing world due to late presentation; fluid resuscitation and
antibiotics essential to treat septic shock in these patients and improve outcome