eMedicine Specialties > Radiology > Pediatrics

Intussusception, Child

Beverly P Wood, MD, PhD, Professor Emerita, Departments of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California; Professor of Clinical Radiology, Loma Linda University School of Medicine

Updated: Jul 2, 2008

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

Appendicitis
Cecal Volvulus

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

Radiography

Findings

In this x-ray of a patient being treated with contrast enema, the convex-shaped filling defect of the intussusceptum should be noted; the intussusceptum is reduced to the level of the cecum.

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.

A contrast-reduced intussusception shows backward flow of barium into the small bowel.

Usually, a pattern of small bowel obstruction with absence of gas in the right colon is visible.

An intraluminal colonic filling defect may indicate intussusceptum.

Intraluminal blood may create a speckled pattern of gas and colonic material.

A careful search should be made for intraperitoneal free air; the presence of free air is a contraindication for reduction by enema because the presence of free air indicates that the bowel is already perforated (see Images above and Images 2, 4, 10 in Multimedia).

Degree of Confidence

The appearance of small bowel obstruction in conjunction with characteristic clinical findings almost always indicates intussusception, as does the appearance of a gasless cecum and/or an intraluminal bowel mass. Unless otherwise indicated, the diagnosis should be confirmed with an air or barium enema.

False Positives/Negatives

Appendicitis may have an "empty cecum" appearance that looks like intussusception.

Inflammatory bowel disease may involve the cecum and appear like intussusception.

Any abnormality that has an appearance like that of small bowel obstruction mimics intussusception, because findings often are nonspecific.

Severe edema of the bowel wall as found in shigellosis, Salmonella infection, or enterohemorrhagic Escherichia coli infection may appear like intussusception.

Computed Tomography

Findings

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.

False Positives/Negatives

Volvulus and some intraperitoneal masses (eg, cystic teratoma) mimic intussusception.

Ultrasonography

Findings

Longitudinal ultrasound of a patient with suspected intussusception shows the layered bowel walls of the outer and inner loop, the intussuscipiens, and the intussusceptum.

• Transverse sonography of the mass reveals a swirled pattern of alternating hyperechogenicity and hypoechogenicity, representing the alternating layers of mucosa, muscularis, and serosa.
• On longitudinal sonography, alternating loops of bowel and a loop-within-loop have a sandwichlike appearance.
• Some centers use US to monitor reduction of the intussusception with fluid introduced via the rectum.

Degree of Confidence

On sonography, intussusception has a characteristic appearance; it is usually not mistaken for other bowel abnormalities.^7,8

Intervention

Air reduction

In the current method of air reduction, room air is introduced through a rectal catheter and is taped well in place. A manometer is attached to a Y-connector to monitor pressure in the colon. Pressure should never exceed 110 mm Hg. The air pressure on the intussusception usually forces the inverted bowel back through the ileocecal valve and into its proper position. When reduction occurs, the observed pressure falls precipitously.

Contrast reduction

Contrast reduction was widely used until the current decade. A large rectal tube is taped firmly in place, and dilute water-soluble contrast is introduced slowly by gravity drip into the rectum; hydrostatic pressure is used to reduce the intussusception. The fluid is placed a maximum of 3 feet above the level of the radiography table. No more than 3 attempts at reduction are undertaken, and the column is pressed against the intussusception mass no longer than 3 minutes at each attempt. Visualization of the small bowel usually indicates that intussusception has been reduced. The following rules need to be observed:

• The fluid level should be maintained at no more than 3 feet above the patient.
• Palpation of the abdomen should be avoided during reduction.
• Pressure should be maintained no longer than 3 minutes against a nonmoving intussusception.

Reduction may proceed at an uneven rate, and it may slow at various locations; this is particularly true at the ileocecal valve, which is swollen and often resists passage of the intussusception (see Images below and Images 11-13 in Multimedia). To ensure reduction, contrast should be observed entering the ileum. Once contrast enters the ileum, it often proceeds quickly through the ileum. Vomiting is a frequent side effect of reduction.

Reduction of an intussusceptum through the ileocecal valve is the most difficult part of the reduction. The mass is seen in the cecum (A).

On the second attempt at reduction, the intussusceptum still extends through the ileocecal valve (B). Reduction was unsuccessful.

The ileocecal valve is usually quite edematous after an intussusception has occurred; it may remain large for several days. In this patient, the ileocecal valve was mistaken for an intussusception, although barium had entered the ileum.

The appearance of the ileocecal valve at resection is edematous and enlarged (B).

Recurrences

Intussusception recurs in approximately 10% of children. Intussusception can recur at any time and is not a contraindication to repeat reduction. Sedation to assist reduction does not greatly affect the reduction rate. Glucagon has been advocated, but its efficacy has not been established.

Medicolegal Pitfalls

• Failure to make the diagnosis in a timely manner is a pitfall. In subtle or unsuspected occurrences of intussusception, delay in the diagnosis may allow the condition to progress to bowel infarction and bowel perforation. Thus, awareness of the possible diagnosis is important in a young patient with any of the symptoms or signs of intussusception, even when they are not characteristic.

Special Concerns

• One should be aware of conditions that lead to intussusception and that also are predictive of perforation (eg, Henoch-Schönlein purpura). Contrast enema procedures should be avoided in patients with these conditions.

Multimedia

Media file 1: 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.

Media file 2: In this x-ray of a patient being treated with contrast enema, the convex-shaped filling defect of the intussusceptum should be noted; the intussusceptum is reduced to the level of the cecum.

Media file 3: Longitudinal ultrasound of a patient with suspected intussusception shows the layered bowel walls of the outer and inner loop, the intussuscipiens, and the intussusceptum.

Media file 4: 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.

Media file 5: 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.

Media file 6: Surgical specimen of an intussusception. Note the dilated intussuscipiens.

Media file 7: Note the internal inverted loop of bowel in the specimen.

Media file 8: 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.

Media file 9: Note the typical mass creates a curved density to the air in the transverse colon.

Media file 10: A contrast-reduced intussusception shows backward flow of barium into the small bowel.

Media file 11: Reduction of an intussusceptum through the ileocecal valve is the most difficult part of the reduction. The mass is seen in the cecum (A).

Media file 12: On the second attempt at reduction, the intussusceptum still extends through the ileocecal valve (B). Reduction was unsuccessful.

Media file 13: The ileocecal valve is usually quite edematous after an intussusception has occurred; it may remain large for several days. In this patient, the ileocecal valve was mistaken for an intussusception, although barium had entered the ileum.

Media file 14: The appearance of the ileocecal valve at resection is edematous and enlarged (B).

References

1. DiFiore JW. Intussusception. Semin Pediatr Surg. Nov 1999;8(4):214-20. [Medline].

2. Simpson T, Ivey J, Borkowski S. Pediatric management problems. Intussusception. Pediatr Nurs. Jul-Aug 2004;30(4):326-7. [Medline].

3. Rennels MB. The rotavirus vaccine story: a clinical investigator''s view. Pediatrics. Jul 2000;106(1 Pt 1):123-5. [Medline].

4. 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].

5. 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].

6. 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].

7. 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].

8. Holt S, Samuel E. Multiple concentric ring sign in the ultrasonographic diagnosis of intussusception. Gastrointest Radiol. Aug 31 1978;3(3):307-9. [Medline].

9. 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].

10. 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].

11. 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].

12. Conners GP, Weber CE, Emmens RW. Intussusception following a baby walker injury. J Emerg Med. Mar-Apr 1999;17(2):269-71. [Medline].

13. 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

Contributor Information and Disclosures

Author

Beverly P Wood, MD, PhD, Professor Emerita, Departments of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California; Professor of Clinical Radiology, Loma Linda University School of Medicine
Beverly P Wood, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Medical Editor

Lori Lee Barr, MD, FACR, FAIUM, Clinical Associate Professor of Radiology, University of Texas Health Science Center in San Antonio; Clinical Assistant Professor of Radiology, University of Texas Medical Branch at Galveston; Member, Board of Directors, Austin Radiological Association; Consulting Staff, Seton Health Network, Columbia/St David's Healthcare System, Healthsouth Rehabilitation Hospital of Austin, Georgetown Hospital, St Mark's Medical Center, Cedar Park Regional Medical Center
Lori Lee Barr, MD, FACR, FAIUM is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, American Society of Pediatric Neuroradiology, Association of University Radiologists, Radiological Society of North America, Society for Pediatric Radiology, Society of Radiologists in Ultrasound, Southern Medical Association, Texas Radiological Society, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

David A Stringer, BSc, MBBS, FRCR, FRCPC, Professor, National University of Singapore; Head, Diagnostic Imaging, KK Women's and Children's Hospital, Singapore
David A Stringer, BSc, MBBS, FRCR, FRCPC is a member of the following medical societies: British Columbia Medical Association, Canadian Association of Radiologists, European Society of Paediatric Radiology, Ontario Medical Association, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, and Society for Pediatric Radiology
Disclosure: Sirius d'innovation None Board membership

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Clinical Director of Radiology and Consultant Radiologist, Department of Radiology, King's College Hospital, London
John Karani, MBBS, FRCR is a member of the following medical societies: British Institute of Radiology, British Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, European Society of Gastrointestinal and Abdominal Radiology, European Society of Radiology, Radiological Society of North America, and Royal College of Radiologists
Disclosure: Nothing to disclose.

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Intussusception
Pediatrics, Intussusception

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