• Clinical science

Intussusception

Summary

Intussusception occurs when a proximal part of the bowel invaginates into a distal part, leading to a mechanical obstruction and bowel ischemia. Infants aged 3–12 months are most commonly affected, usually with no identifiable underlying cause. Some patients may have an intraperitoneal anomaly or abnormality which initiates the process of intussusception (pathological lead point). Affected infants are typically of a healthy weight, and present with acute cyclical abdominal pain, knees drawn to the chest, and vomiting (initially nonbilious). Pallor, lethargy, and other symptoms of shock or altered mental status may be present. A late-onset symptom is “currant jelly" stool (stool with blood and mucus) passed from the ischemic bowel. A classic sign is a palpable right upper quadrant (RUQ) mass on abdominal examination, seen as a target or pseudokidney sign on abdominal ultrasound. Contrast enema (i.e., pneumatic insufflation or hydrostatic enema with normal saline or barium), is the best confirmatory diagnostic test. Intussusception is considered a surgical emergency, as it may lead to bowel necrosis and perforation if left untreated. Open surgery is indicated when nonoperative measures fail, a pathological lead point is suspected, or bowel perforation is present. If treated before complications arise, patients generally have an excellent prognosis.

Epidemiology

  • Sex: > (3:2)
  • Age [1]
    • Peak incidence: 3–12-month-old infants
    • Otherwise commonly occurs in children 3 months to 5 years of age
    • Uncommon in adults

Intussusception, alongside incarcerated hernia, is one of the most common causes of bowel obstruction in children. It is the most common cause of bowel obstruction in the first two years of life.

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1]

Pathophysiology

  • Imbalance in the bowel wall (idiopathic or via a pathological lead point) → invagination or “telescoping” of a portion of intestinal bowel (intussusceptum) into the distal adjacent bowel loop (intussuscipiens) → impaired lymphatic drainage and increasing pressure in intussusceptum bowel wall → venous impairment → mesenteric vessels congestion → ischemia of intussusceptum bowel wall → sloughing of bowel mucosa (most sensitive to bowel ischemia since it is the furthest from the arterial supply) → transmural necrosis and perforation with prolonged ischemia
  • The dysfunctional passage leads to mechanical bowel obstruction → vomiting

Classification

  • Ileocecal invagination; (most common; accounts for 85–90% of cases)
  • Ileoileal invagination
  • Ileocolic invagination
  • Colosigmoidal invagination
  • Appendicocecal invagination (very rare)

References:[1]

Clinical features

  • Child typically looks healthy.
  • Acute cyclical colicky abdominal pain (sudden screaming or crying spells), often with legs drawn up, with asymptomatic intervals; : Acute attacks occur approx. every 15–30 min.
  • Vomiting (initially nonbilious)
  • Abdominal tenderness, palpable sausage-shaped mass in the RUQ , and an “emptiness” or retraction in the RLQ (Dance sign) during palpation
  • High-pitched bowel sounds on auscultation
  • Currant jelly stool: Dark red stool (resembling “currant jelly”) may be noticed in passed stool or during digital rectal examination (usually a late sign).
  • Lethargy , pallor, and other symptoms of shock or altered mental status may be present.

Less than 15% of patients with intussusception present with the classic triad of abdominal pain, a palpable sausage-shaped abdominal mass, and blood per rectum.

References:[1][4][5]

Diagnostics

Approach [1]

  • If clinical suspicion is high : perform an enema.
  • If the diagnosis is unclear at presentation or pathological lead points are suspected : perform an ultrasound or abdominal x-ray to confirm the diagnosis.

Procedures [1]

Differential diagnoses

Differential diagnosis of lower gastrointestinal bleeding in children
Age group Condition Findings
First month of life (neonate)
  • Visualized during clinical exam of perianal area
1 month to 1 year (infant)
  • Intussusception
  • Cow's milk protein-specific IgE
  • Visualized during clinical exam of perianal area
1 year to 2 years
  • Technetium-99m pertechnetate scintiscan: gastric mucosa
> 2 years
  • Juvenile polyps
  • Visualized during colonoscopy
  • Endoscopy and biopsy: inflamed mucosa extending from the rectum

The differential diagnoses listed here are not exhaustive.

Treatment

  • Initial steps: nasogastric decompression and fluid resuscitation
  • Nonsurgical management (performed under continuous ultrasound or fluoroscopic guidance) [7]
  • Surgical reduction
    • Indications [1]
      • When a pathological lead point is suspected
      • Failed conservative management [8]
      • Suspected gangrenous or perforated bowel
      • Critically ill patient (e.g., shock)
    • Open or laparoscopic method

Urgent intervention is necessary for intussusception to prevent potentially life-threatening complications.

Complications

We list the most important complications. The selection is not exhaustive.

Prognosis

The prognosis of intussusception depends on how quickly it is treated. Most cases may be treated successfully with conservative pneumatic insufflation or hydrostatic reduction. The absence of ischemia or necrotic bowel is associated with a good prognosis.

  • Success rates for non-surgical reduction: 45–95% [9]
  • Rate of relapse in patients with non-surgical reduction: 4.5–10% [10]
  • 1. Kitagawa S, Miqdady M. Intussusception in children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/intussusception-in-children?source=search_result&search=intussusception%20in%20children&selectedTitle=1~112. Last updated March 30, 2016. Accessed January 24, 2017.
  • 2. Ong NT, Beasley SW. The leadpoint in intussusception. J Pediatr Surg. 1990; 25(6): pp. 640–643. pmid: 2359000.
  • 3. Holmes M, Murphy V, Taylor M, Denham B. Intussusception in cystic fibrosis. Arch Dis Child. 1991; 66(6): pp. 726–727. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793149/.
  • 4. Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B. Intussusception: clinical presentations and imaging characteristics. Pediatr Emerg Care. 2012; 28(9): pp. 842–844. doi: 10.1097/PEC.0b013e318267a75e.
  • 5. West KW, Stephens B, Vane DW, Grosfeld J. Intussusception: current management in infants and children. Surgery. 1987; 102(4): pp. 704–710. pmid: 3660243.
  • 6. Hryhorczuk AL, Strouse PJ. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radiol. 2009; 39(10): pp. 1075–1079. doi: 10.1007/s00247-009-1353-z.
  • 7. Del-pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in diagnosis and enema reduction. Radiographics. 1999; 19(2): pp. 299–319. doi: 10.1148/radiographics.19.2.g99mr14299.
  • 8. Bonnard A, Demarche M, Dimitriu C, et al. Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy. J Pediatr Surg. 2008; 43(7): pp. 1249–1253. doi: 10.1016/j.jpedsurg.2007.11.022.
  • 9. Khorana J, Singhavejsakul J, Ukarapol N, Laohapensang M, Siriwongmongkol J, Patumanond J. Prognostic indicators for failed nonsurgical reduction of intussusception. Therapeutics and Clinical Risk Management. 2016; Volume 12: pp. 1231–1237. doi: 10.2147/tcrm.s109785.
  • 10. Hsu W-L, Lee H-C, Yeung C-Y, et al. Recurrent Intussusception: When Should Surgical Intervention be Performed?. Pediatrics & Neonatology. 2012; 53(5): pp. 300–303. doi: 10.1016/j.pedneo.2012.07.004.
last updated 11/26/2020
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