Introduction
Background
Intussusception is a common cause of childhood intestinal obstruction. Some patients experience a seasonal form of intussusception, in which the disease occurs with a higher incidence in fall and spring; however, seasonal occurrence is not characteristic. Infants with intussusception often are well nourished, and the specific cause of the disease is unknown. Intussusception occurs more frequently in males than in females.1,2
Upright and supine anteroposterior abdominal radiographs in an infant with crying and bloody diarrhea for 12 hours show a small bowel obstruction pattern and little gas in the cecal region.
This vomiting 10-month-old infant has a palpable abdominal mass. Note the obstruction pattern on plain radiograph and the intussusceptum in the sigmoid colon on contrast enema.
Longitudinal ultrasound of a patient with suspected intussusception shows the layered bowel walls of the outer and inner loop, the intussuscipiens, and the intussusceptum.
CT is not indicated for intussusception; however, this infant was thought to have an abdominal mass. Note the dilated bowel with an internal loop shown on the single section from an abdominal CT.
Pathophysiology
Invagination of a bowel segment (usually, the small bowel) into the lumen of the more distal bowel (usually, the colon) occurs. The invaginated segment (intussusceptum) is carried distally by peristalsis. Mesentery and vessels become involved with the intraluminal loop and are squeezed within the engulfing segment (intussuscipiens). Almost all occurrences are acute. Venous congestion is a major factor both in symptomatology and in the characteristic presence of blood in the stool.
Intussusception is known to occur with greater frequency in children who have undergone recent abdominal surgery, either intraperitoneal or retroperitoneal operations. It is thought that early adhesions or focal edema of the bowel wall create a lead point for the intussusception. Children with postoperative intussusception may present with unexplained bowel obstruction within a time frame that is unusual for the development of bowel obstruction in postoperative patients.
Frequency
United States
In infants aged 6 months to 2 years, intussusception is not unusual and often follows an upper respiratory tract illness; however, inciting factors may be absent.
Mortality/Morbidity
- Bowel obstruction is often the presenting sign of intussusception (see Image below and Image 1 in Multimedia).
Upright and supine anteroposterior abdominal radiographs in an infant with crying and bloody diarrhea for 12 hours show a small bowel obstruction pattern and little gas in the cecal region.
- Infants have cramping abdominal pain, vomiting, and blood in the stool (currant-jelly stool).
- With prompt reduction, bowel necrosis is avoided.
- Prolonged intussusception may result in bowel necrosis and/or perforation.
- Spontaneous reduction has been reported, but surgery is advised when radiologic reduction is unsuccessful.
- Mortality from intussusception is unusual. Morbidity is increased by a delay in diagnosis; such delay increases the possibility of bowel wall necrosis and perforation. Prolonged bowel obstruction with vomiting results in dehydration and electrolyte imbalance as the patient loses chloride.
Race
- Intussusception occurs in all ethnic groups, although it is more common in white infants.
Sex
- The male-to-female ratio of intussusception is 3:1-2.
Age
- Intussusception typically occurs in children aged 6 months to 2 years.
- In neonates and in children older than 2 years, there is a high incidence of associated bowel abnormality that serves as an initiating lead point for intussusception.
- Approximately 5% of patients are found to have a lead point.
Anatomy
A loop of bowel infolds (and inverts) more distally into the lumen of the bowel and is then carried distally by peristalsis. Approximately 90% of intussusceptions are ileocolic. In ileocolic intussusception, the terminal ileum is carried through the ileocecal valve into the colon; it may reach the rectum. Idiopathic intussusceptions usually lack an identifiable lead point; they occur in children aged 6 months to 2 years. Lymphoid hyperplasia or hypertrophic lymph nodes have been postulated but not proven. Lead points in nonidiopathic intussusception may include the following:
- Meckel diverticulum
- Lymphoma of bowel
- Leukemia involving bowel
- Henoch-Schönlein purpura with intramural hemorrhage
- Hemolytic uremic syndrome
- Cystic fibrosis with inspissated bowel content
- Postoperative complication following retroperitoneal surgery
- Post abdominal trauma
- Inflammatory bowel disease
- Polyp
- Peutz-Jeghers syndrome appendix (normal or appendicitis)
- Recent rotavirus immunization3
Presentation
Most intussusceptions are acute. The clinical picture is of a well-nourished infant with the following signs and symptoms of bowel obstruction:
- Cramping abdominal pain
- Poor feeding
- Vomiting
The infant usually has one or more episodes of diarrhea mixed with blood and mucus (ie, currant-jelly stool), which is related to venous congestion. A palpable, slightly tender, sausage-shaped mass in the abdomen is characteristic. Although usually acute, chronic or recurrent intussusception may occur, with typical symptoms. In some patients, intussusception is painless; the infant may appear pale, diaphoretic, or lethargic. The physician may not suspect intussusception if unusual symptoms are present or if symptoms mask an upper respiratory infection (see Images below and Images 6-7 in Multimedia).4
Surgical specimen of an intussusception. Note the dilated intussuscipiens.
Note the internal inverted loop of bowel in the specimen.
Preferred Examination
In some countries, history and physical findings are sufficient criteria for undertaking reduction procedures for intussusception.
- Abdominal radiograph: A search should be made for dilated small bowel and an absence of gas in the region of the cecum (see Image below and Image 5 in Multimedia). In some cases, a mass impression within the colonic gas indicates an intraluminal mass created by the intussuscepting loop.
Radiograph of a 14-month-old boy who has been experiencing blood in the stool for 3 days. An absence of cecal air and an obstruction pattern are seen. Next, a spot radiograph during an air reduction shows the intussusceptum. Finally, the reduced intussusception with air in the small bowel is seen.
- Ultrasound
- Transverse: Ultrasound (US) shows a mass with a swirled appearance of alternating sonolucent and hyperechoic bowel wall of the loop-within-a-loop.
- Longitudinal: On US, the intussuscipiens and the intussusceptum have the appearance of a submarine sandwich. There appear to be multiple layers, which represent the walls of the intussuscepted bowel loops (see Image below and Image 3 in Multimedia).
Longitudinal ultrasound of a patient with suspected intussusception shows the layered bowel walls of the outer and inner loop, the intussuscipiens, and the intussusceptum.
- In some institutions, reduction of the intussusception takes place under US guidance with fluid or air.
Once the patient is stabilized, reduction procedures should be initiated immediately; radiographic examination and physical examination should be performed to ensure that neither free air nor peritonitis is present. It should be ascertained by physical examination that no peritonitis is present. Spontaneous reduction has been reported, but it is unusual (see Intervention).
Surgical consultation should be sought early when intussusception is suspected. Despite positive results from reduction through the use of imaging techniques, reduction or re-intussusception may be unsuccessful, necessitating surgery. Surgeons should be made aware of the possible need for surgery. Rarely, complications from reduction with imaging techniques (perforation) require emergency surgery. Thus, alerting the surgical consultant is a prudent measure. The use of air, gas, or water-soluble contrast to reduce the intussusception decreases potential complications.5,6
Limitations of Techniques
Intussusception may not be apparent on plain-film abdominal radiography. Radiographs may appear indeterminate or normal; therefore, the presence of an unremarkable abdominal radiograph should not be the basis for excluding a diagnosis of intussusception.
US examination is almost always positive, although overlying loops of air-containing bowel may obscure intussusception (see Image below and Image 9 in Multimedia).
Note the typical mass creates a curved density to the air in the transverse colon.
Differential Diagnoses
Other Problems to Be Considered
Inflammatory bowel disease
Appendicitis with or without perforation
Incarcerated inguinal hernia
Internal hernia
Appendicitis
Henoch-Schönlein purpura
Hemolytic uremic syndrome
Small bowel obstruction
Inflammatory bowel disease
Cecal/sigmoid volvulus
Abdominal wall hernia
More on Intussusception, Child |
 Overview: Intussusception, Child |
| Imaging: Intussusception, Child |
| Follow-up: Intussusception, Child |
| Multimedia: Intussusception, Child |
| References |
| Further Reading |
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References
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Simpson T, Ivey J, Borkowski S. Pediatric management problems. Intussusception. Pediatr Nurs. Jul-Aug 2004;30(4):326-7. [Medline].
Rennels MB. The rotavirus vaccine story: a clinical investigator''s view. Pediatrics. Jul 2000;106(1 Pt 1):123-5. [Medline].
Lai WP, Yang YJ, Cheng CN, Chen JS. Clinico-pathological features of intussusception in children beyond five years old. Acta Paediatr Taiwan. Sep-Oct 2007;48(5):267-71. [Medline].
Heller RM, Hernanz-Schulman M. Applications of new imaging modalities to the evaluation of common pediatric conditions. J Pediatr. Nov 1999;135(5):632-9. [Medline].
Peh WC, Khong PL, Lam C, et al. Reduction of intussusception in children using sonographic guidance. AJR Am J Roentgenol. Oct 1999;173(4):985-8. [Medline].
Gu L, Zhu H, Wang S, et al. Sonographic guidance of air enema for intussusception reduction in children. Pediatr Radiol. May 2000;30(5):339-42. [Medline].
Holt S, Samuel E. Multiple concentric ring sign in the ultrasonographic diagnosis of intussusception. Gastrointest Radiol. Aug 31 1978;3(3):307-9. [Medline].
Navarro OM, Daneman A, Chae A. Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathologic lead points in pediatric patients. AJR Am J Roentgenol. May 2004;182(5):1169-76. [Medline].
Chang YT, Lee JY, Wang JY, Chiou CS, Lin JY. Early laparoscopy for ileocolic intussusception with multiple recurrences in children. Surg Endosc. Jun 5 2008;[Medline].
Ramachandran P, Gupta A, Vincent P, Sridharan S. Air enema for intussusception: is predicting the outcome important?. Pediatr Surg Int. Mar 2008;24(3):311-3. [Medline].
Conners GP, Weber CE, Emmens RW. Intussusception following a baby walker injury. J Emerg Med. Mar-Apr 1999;17(2):269-71. [Medline].
Vestergaard H, Westergaard T, Wohlfahrt J, Pipper C, Melbye M. Association between intussusception and tonsil disease in childhood. Epidemiology. Jan 2008;19(1):71-4. [Medline].
Keywords
child intussusception, pediatric intussusception, ileocolic intussusception, ileoileal intussusception, colocolic intussusception
