eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Intussusception: Differential Diagnoses & Workup

Author: Felix C Blanco, MD, Research Fellow, Department of Surgery, Children's National Medical Center
Coauthor(s): A Alfred Chahine, MD, Associate Professor of Surgery and Pediatrics, The George Washington University School of Medicine; Chief of Pediatric Surgery, Georgetown University Medical Center; Attending Surgeon, Children's National Medical Center
Contributor Information and Disclosures

Updated: Feb 4, 2010

Differential Diagnoses

Appendicitis
Colic
Cyclic Vomiting Syndrome
Gastroenteritis
Volvulus

Other Problems to Be Considered

Milk allergy
Incarcerated hernia
Internal hernia
Other rare causes of intestinal obstruction

Workup

Laboratory Studies

  • Laboratory investigation is usually not helpful in the evaluation of patients with intussusception.
  • Leukocytosis can be an indication of gangrene if the process is advanced.
  • Dehydration is depicted by electrolyte imbalances.

Imaging Studies

  • After obtaining a thorough history and performing a careful physical examination, obtain plain radiographs of the abdomen with the patient in the supine and upright positions.
    • Plain abdominal radiography reveals signs that suggest intussusception in only 60% of the cases.
    • Plain radiograph findings may be normal early in the course of intussusception.6
    • As the disease progresses, earliest radiographic evidence includes an absence of air in the right lower and upper quadrants and a right upper quadrant soft tissue density present in 25-60% of patients.
    • These findings are followed by an obvious pattern of small bowel obstruction, with dilatation and air-fluid levels in the small bowel only. If the distention is generalized and the air-fluid levels are also present in the colon, the findings more likely represent acute gastroenteritis than intussusception.
    • A left lateral decubitus view is also helpful.7 If the view exhibits air in the cecum, the presence of ileocecal intussusception is highly unlikely.
    • Morrison et al evaluated the ability of pediatric emergency physicians to recognize intussusception on abdominal radiographs.8 In a prospective experimental study, 14 pediatric emergency physicians interpreted radiographs of 50 cases of intussusception and 50 matched controls; these interpretations showed a sensitivity of 48% and a specificity of 21%. In 11% of cases, the abdominal radiographs were incorrectly interpreted as reassuring. Morrison et al concluded that, when interpreted by pediatric emergency physicians, abdominal radiographs have a low sensitivity and specificity for diagnosing intussusception.
  • Ultrasonography is a noninvasive modality that can aid in making the diagnosis of intussusception. Its accuracy reaches 100%.
    • Hallmarks of ultrasonography include depiction of the intussusceptum and its mesentery within the intussuscipiens (target and pseudokidney signs).
    • Ultrasonography is highly operator dependent; therefore, interpret results with caution.
    • It eliminates the risk of exposure to ionizing radiation and can help depict lead points and residual intussusceptions.
    • It helps to rule out other possible causes of abdominal pain.
    • The presence of ascites and long segments of intussusception can be used as sonographic predictors of failure for nonoperative management.
    • Sonographic detection of ascites, air, and absence of blood flow in the intestinal wall strongly suggest bowel gangrene.
  • CT scanning has also been proposed as a useful tool to diagnose intussusception; however, CT findings are unreliable, and CT carries risks associated with intravenous contrast administration, radiation exposure, and sedation.
  • The traditional and most reliable way to make the diagnosis of intussusception in children is to obtain a contrast enema (either barium or air).
    • Contrast enema is quick and reliable and has the potential to be therapeutic.9
    • Exercise caution when performing contrast enema in children older than 3 years because most of these patients have a surgical lead point, usually in the small bowel. The diagnostic and therapeutic yield of the enema is lower in these patients.
    • Enema is contraindicated in patients in whom bowel gangrene or perforation is suspected.

Histologic Findings

  • If a segment of intestine is resected at the time of operative reduction, intestinal obstruction with edema, congestion, lymphocytic infiltration, and transmural infarction are typical findings.

More on Intussusception

Overview: Intussusception
Differential Diagnoses & Workup: Intussusception
Treatment & Medication: Intussusception
Follow-up: Intussusception
Multimedia: Intussusception
References
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References

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Further Reading

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Keywords

intussusception, bowel obstruction, bowel torsion, abdominal pain, Henoch-Schönlein purpura, HSP, cystic fibrosis, hematologic dyscrasias, idiopathic intussusception, enteroenteral intussusception, jejunojejunal intussusception, jejunoileal intussusception, ileoileal intussusception, peristalsis

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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, The George Washington University School of Medicine; 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.

Medical Editor

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
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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

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.

 
 
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