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Intussusception
From WikEM
Contents
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
- If > 6 years old, more likely to have a lead point
- 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]
- Sudden colicky pain
- Palpable sausage shaped mass on right
- 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
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Intussusception
- Testicular Torsion
- Trauma
- Volvulus
- Appendicitis
- Toxic megacolon
- Vaso-occlusive crisis
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
- Classic Triad not always present
- Maintain high index of suspicion
- All labs nonspecific
- Guaiac-positive stool (~50%)
Imaging
- Sensitivity and specificity approach 100%, but operator dependent
- Some emergency departments have successfully implemented bedside point-of-care ultrasound
- Sensitivity and specificity approach 100%, but operator dependent
- 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)[3]
- 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
- Admission also acceptable in appropriate patient population
See Also
References
- ↑ Kleizen KJ et al. Acta Paediatr. 2009 Nov;98(11):1822-4
- ↑ Bruce J, Huh YS, Cooney DR, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr 1987;6:663-674.
- ↑ Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009 Jan 28; 15(4): 407–411.
- ↑ Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.
- ↑ 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.
