Intussusception

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Background

  • Most common cause of intestinal obstruction in 6mo-6yr
    • Usually occurs in 6-36 months
  • Due to telescoping of one part of intestine into another
    • Mesentery involvement > ischemia, bloody/mucous stool

Pediatrics

  • Typically no pathological lesions
    • If > 6 years old, more likely to have a lead point
      • Lead points: Meckel diverticulum, duplication cyst, polyp, tumor, hematoma, vascular malformation, parasite (eg Ascaris), Henoch-Schonlein purpura
  • Slight male predominance - 3:2

Adults

  • Rare
  • 80% involve small bowel
  • 70% risk of malignancy

Clinical Features

Intermittent episodes of pain are often present and may be associated with other symptoms such as:

  • Vomiting
  • Child pulls up knees to chest
  • Asymptomatic periods between episodes where patient has no pain
    • May be completely benign, smiling, playful
    • Suspect intussusception if there are recurrent brief pain episodes, especially if wake child from sleep
    • Later stages may be associated with lethargy
  • May have vomiting (non-bilious, late stages bilious)
  • May present as lethargy alone (Neurologic intussusception), without any of the classic triad
  • Neurologic intussusception has also been described as presenting with an isolated seizure and abdominal pain[1]

Classic Triad

The classic triad may only be present in up to 21% of cases[2]

  1. Sudden colicky pain
  2. Palpable sausage shaped mass on right
  3. Currant jelly stool (only 50% of cases; late manifestation of the disease)

Adults

  • Typically have partial/SBO symptoms
  • Vomiting, rectal bleeding, constipation
  • Distended
  • Late Stage: sepsis

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Evaluation

  • Classic Triad not always present
    • Maintain high index of suspicion
  • All labs nonspecific
  • Guaiac-positive stool (~50%)

Imaging

Ultrasound

Intussusception in both short axis and longitudinal view[3]
    • Sensitivity and specificity approach 100%, but operator dependent
      • Some emergency departments have successfully implemented bedside point-of-care ultrasound
  • Scanning technique involves using a linear probe and applying graded compression serially over all 4 quadrants of the abdomen, looking for a "bullseye lesion" in the short axis view and a "pseudokidney sign" in the longitudinal view
  • Ultrasound can diagnose ileo-ileal intussusception, whereas contrast enema cannot
  • Negative ultrasound = may still be intermittent intussusception

Air contrast enema

  • Diagnostic and frequently curative
  • Prior to procedure, IV hydration, NG tube decompression, surgery consult
  • Hydrostatic (saline or water-soluble contrast) enema also may be used

CT Abdodmen

  • For adults (air contrast or barium enemas not sufficient)[4]
    • Up to 20% of cases do not have lead point

Management

  • Stable children with a high clinical suspicion and/or radiographic evidence of intussusception and no evidence of bowel perforation should be treated with nonoperative reduction
    • NPO
    • Consider NG tube as indicated
    • Air-contrast enema (reduces 80%)
    • Hydrostatic (saline or water-soluble contrast) may also be used
  • Surgery consult
    • Surgery is indicated when nonoperative reduction is incomplete, or patient is toxic, or has perforation or peritonitis.
    • In stable, asymptomatic patient with ileo-ileal intussusception, short length of intussusception <2.3 cm, expectant management is reasonable as many of these cases will resolve spontaneously
    • In all adults with intussusception due to high incidence of malignancy

Disposition

  • Consider discharge if good follow-up, reasonable distance to hospital, parents that can watch
    • Recurrence occurs 5-12% of cases[5][6]
    • Majority of recurrence does not occur within 24-48 hours
  • Admission also acceptable in appropriate patient population

See Also

References

  1. Kleizen KJ et al. Acta Paediatr. 2009 Nov;98(11):1822-4
  2. Bruce J, Huh YS, Cooney DR, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr 1987;6:663-674.
  3. http://www.thepocusatlas.com/pediatrics/
  4. Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009 Jan 28; 15(4): 407–411.
  5. Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.
  6. Beres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg. 2014 May;49(5):750-2.