Intussusception Clinical Presentation

  • Author: Felix C Blanco, MD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Jan 13, 2012
 

History

The constellation of signs and symptoms of intussusception represents one of the most classic presentations of any pediatric illness; however, the classic triad of vomiting, abdominal pain, and passage of blood per rectum occurs in only one third of patients. The patient is usually an infant who presents with vomiting, abdominal pain, passage of blood and mucus, lethargy, and a palpable abdominal mass. These symptoms are often preceded by an upper respiratory infection.

In rare circumstances, the parents report 1 or more previous attacks of abdominal pain within 10 days to 6 months prior to the current episode. These patients are more likely to have a surgical lead point causing recurrent attacks of intussusception with spontaneous reduction.

Pain in intussusception is colicky, severe, and intermittent. The parents or caregivers describe the child as drawing the legs up to the abdomen and kicking the legs in the air. In between attacks, the child appears calm and relieved.

Initially, vomiting is nonbilious and reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious. Any child with bilious vomiting is assumed to have a condition that must be treated surgically until proven otherwise.

Parents also report the passage of stools that look like currant jelly. This is a mixture of mucus, sloughed mucosa, and shed blood. Diarrhea can also be an early sign of intussusception.

Lethargy is a relatively common presenting symptom with intussusception. The reason lethargy occurs is unknown, because lethargy has not been described with other forms of intestinal obstruction. Lethargy can be the sole presenting symptom, which makes the diagnosis challenging. Patients are found to have an intestinal process late, after initiation of a septic workup.

In a prospective observational study, Weihmiller et al evaluated several clinical criteria to risk-stratify children with possible intussusception. This study identified that age older than 5 months, male sex, and lethargy were 3 important clinical predictors of intussusception.[12]

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Physical Examination

Upon physical examination, the patient is usually chubby and in good health. Intussusception is uncommon in children who are malnourished. The child is found to have periods of lethargy alternating with crying spells, and this cycle repeats every 15-30 minutes. The infant can be pale, diaphoretic, and hypotensive if shock has occurred.

The hallmark physical findings in intussusception are a right hypochondrium sausage-shaped mass and emptiness in the right lower quadrant (Dance sign). This mass is hard to detect and is best palpated between spasms of colic, when the infant is quiet. Abdominal distention frequently is found if obstruction is complete.

If intestinal gangrene and infarction have occurred, peritonitis can be suggested on the basis of rigidity and involuntary guarding.

Early in the disease process, occult blood in the stools is the first sign of impaired mucosal blood supply. Later on, frank hematochezia and the classic currant jelly stools appear. Fever and leukocytosis are late signs and can indicate transmural gangrene and infarction.

Patients with intussusception often have no classic signs and symptoms, which can lead to an unfortunate delay in diagnosis and disastrous consequences.

Maintaining a high index of suspicion for intussusception is essential when evaluating a child younger than 5 years who presents with abdominal pain or when evaluating a child with HSP or hematologic dyscrasias.

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Contributor Information and Disclosures
Author

Felix C Blanco, MD  Research Fellow, Department of Surgery, Children's National Medical Center

Felix C Blanco, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

A Alfred Chahine, MD  Associate Professor of Surgery and Pediatrics, George Washington University School of Medicine and Health Sciences; Chief of Pediatric Surgery, Georgetown University Medical Center; Attending Surgeon, Children's National Medical Center

A Alfred Chahine, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Lonnie King, MD  Consulting Staff, Department of Emergency Medicine, Children's Healthcare of Atlanta at Scottish Rite

Lonnie King, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Garry Wilkes  MBBS, FACEM, Director of Emergency Medicine, Calvary Hospital, Canberra, ACT; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia

Disclosure: Nothing to disclose.

Specialty Editor Board

Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H  Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Bushnaq Medical Centre, University of Jordan Faculty of Medicine, Jordan

Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H is a member of the following medical societies: Royal College of Paediatrics and Child Health, Royal College of Physicians, Royal College of Surgeons in Ireland, Royal College of Surgeons of Edinburgh, and Royal Society of Tropical Medicine and Hygiene

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

B UK Li, MD  Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Grace M Young, MD  Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References

  1. Milbrandt K, Sigalet D. Intussusception associated with a Meckel's diverticulum and a duplication cyst. J Pediatr Surg. Dec 2008;43(12):e21-3. [Medline].

  2. Soccorso G, Puls F, Richards C, Pringle H, Nour S. A ganglioneuroma of the sigmoid colon presenting as leading point of intussusception in a child: a case report. J Pediatr Surg. Jan 2009;44(1):e17-20. [Medline].

  3. Sanni RB, Nandiolo R, Coulibaly Diaoudia MT, Vodi L, Mobiot ML. Acute intussusception due to intestinal Kaposi's sarcoma in an infant. Afr J Paediatr Surg. Jul-Dec 2009;6(2):131. [Medline].

  4. Earl TM, Wellen JR, Anderson CD, et al. Small bowel obstruction after pediatric liver transplantation: the unusual is the usual. J Am Coll Surg. Jan 2011;212(1):62-7. [Medline].

  5. Bai YZ, Chen H, Wang WL. A special type of postoperative intussusception: ileoileal intussusception after surgical reduction of ileocolic intussusception in infants and children. J Pediatr Surg. Apr 2009;44(4):755-8. [Medline].

  6. Turkyilmaz Z, Karabulut R, Gulen S, et al. Role of nitric oxide and cyclooxygenase pathway in lipopolysaccharide-induced intussusception. Pediatr Surg Int. Aug 2004;20(8):598-601. [Medline].

  7. Zanardi LR, Haber P, Mootrey GT, et al. Intussusception among recipients of rotavirus vaccine: reports to the vaccine adverse event reporting system. Pediatrics. Jun 2001;107(6):E97. [Medline].

  8. Christie CD, Duncan ND, Thame KA, et al. Pentavalent rotavirus vaccine in developing countries: safety and health care resource utilization. Pediatrics. Dec 2010;126(6):e1499-506. [Medline].

  9. [Best Evidence] Ruiz-Palacios GM, Pérez-Schael I, Velázquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [Medline].

  10. Zickafoose JS, Benneyworth BD, Riebschleger MP, Espinosa CM, Davis MM. Hospitalizations for Intussusception Before and After the Reintroduction of Rotavirus Vaccine in the United States. Arch Pediatr Adolesc Med. Jan 2 2012;[Medline].

  11. Niramis R, Watanatittan S, Kruatrachue A, et al. Management of recurrent intussusception: nonoperative or operative reduction?. J Pediatr Surg. Nov 2010;45(11):2175-80. [Medline].

  12. Weihmiller SN, Buonomo C, Bachur R. Risk stratification of children being evaluated for intussusception. Pediatrics. Feb 2011;127(2):e296-303. [Medline].

  13. [Best Evidence] Morrison J, Lucas N, Gravel J. The role of abdominal radiography in the diagnosis of intussusception when interpreted by pediatric emergency physicians. J Pediatr. Oct 2009;155(4):556-9. [Medline].

  14. Hooker RL, Hernanz-Schulman M, Yu C, Kan JH. Radiographic evaluation of intussusception: utility of left-side-down decubitus view. Radiology. Sep 2008;248(3):987-94. [Medline]. [Full Text].

  15. Hryhorczuk AL, Strouse PJ. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radiol. Oct 2009;39(10):1075-9. [Medline].

  16. Munden MM, Bruzzi JF, Coley BD, Munden RF. Sonography of pediatric small-bowel intussusception: differentiating surgical from nonsurgical cases. AJR Am J Roentgenol. Jan 2007;188(1):275-9. [Medline].

  17. Shekherdimian S, Lee SL, Sydorak RM, Applebaum H. Contrast enema for pediatric intussusception: is reflux into the terminal ileum necessary for complete reduction?. J Pediatr Surg. Jan 2009;44(1):247-9; discussion 249-50. [Medline].

  18. Jen HC, Shew SB. The impact of hospital type and experience on the operative utilization in pediatric intussusception: a nationwide study. J Pediatr Surg. Jan 2009;44(1):241-6. [Medline].

  19. Sandler AD, Ein SH, Connolly B, Daneman A, Filler RM. Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile?. Pediatr Surg Int. 1999;15(3-4):214-6. [Medline].

  20. 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 (GECI). J Pediatr Surg. Jul 2008;43(7):1249-53. [Medline].

  21. Fraser JD, Aguayo P, Ho B, et al. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A. Aug 2009;19(4):563-5. [Medline].

  22. Herwig K, Brenkert T, Losek JD. Enema-reduced intussusception management: is hospitalization necessary?. Pediatr Emerg Care. Feb 2009;25(2):74-7. [Medline].

  23. Gilmore AW, Reed M, Tenenbein M. Management of childhood intussusception after reduction by enema. Am J Emerg Med. Oct 25 2010;[Medline].

 
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Abdominal radiograph shows small bowel dilatation and paucity of gas in the right lower and upper quadrants.
Air contrast enema shows intussusception in the cecum.
Barium enema shows intussusception in the descending colon.
CT scan reveals the classic ying-yang sign of an intussusceptum inside an intussuscipiens.
Abdominal ultrasonography reveals the classic target sign of an intussusceptum inside an intussuscipiens.
Laparoscopic view of a jejuno-jejunal intussusception
Note intussusception in the left upper quadrant on this plain film of an infant with pain vomiting. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite.
Intussusception evident during air contrast enema prior to reduction. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite.
 
 
 
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