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Intussusception Workup

  • Author: Felix C Blanco, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Mar 03, 2016
 

Approach Considerations

Laboratory investigation is usually not helpful in the evaluation of patients with intussusception, although leukocytosis can be an indication of gangrene if the process is advanced. With persistent vomiting and sequestration of fluid in the obstructed bowel, dehydration and electrolyte imbalance occur.

Ultrasonographic imaging has been found to have a high sensitivity and specificity in the detection of ileocolic intussusception. Abdominal radiographs can also reveal diagnostic characteristics of intussusception, but their sensitivity and specificity has been called into question.

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.

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Radiographs

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 cases. (See the images below.) Plain radiograph findings may be normal early in the course of intussusception.[18] As the disease progresses, the 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.

Abdominal radiograph shows small bowel dilatation Abdominal radiograph shows small bowel dilatation and paucity of gas in the right lower and upper quadrants.
Note intussusception in the left upper quadrant on 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.

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.[19] If the view exhibits air in the cecum, the presence of ileocecal intussusception is highly unlikely.

Limitations of radiography

Morrison et al concluded that, when interpreted by pediatric emergency physicians, abdominal radiographs have a low sensitivity and specificity for diagnosing intussusception.[18] 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.

A study by Tareen et al concluded that abdominal radiography is not recommended for the diagnosis of intussusception in children, for the prediction of the outcome of pneumatic reduction of intussusception or for the detection of occult pneumoperitoneum. The study further noted that abdominal radiography should always be performed when clinical peritonism is present but is not otherwise necessary.[20]

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Ultrasonography and CT Scanning

Hallmarks of ultrasonography include the target and pseudokidney signs. (See the image below.)

Abdominal ultrasonography reveals the classic targ Abdominal ultrasonography reveals the classic target sign of an intussusceptum inside an intussuscipiens.

One study reported that the overall sensitivity and specificity of ultrasonography for detecting ileocolic intussusception was 97.9% and 97.8%, respectively. The authors concluded that ultrasonography should be used as a first-line examination for the assessment of possible pediatric intussusception.[21]

Ultrasonography eliminates the risk of exposure to ionizing radiation and can help to depict lead points and residual intussusceptions. It also helps to rule out other possible causes of abdominal pain. Even so, ultrasonography is highly operator dependent; therefore, interpret results with caution.

The presence of ascites and long segments of intussusception can be used as sonographic predictors of failure for nonoperative management.[22] Sonographic detection of ascites, air, and absence of blood flow in the intestinal wall strongly suggest bowel gangrene.

Computed tomography (CT) scanning has also been proposed as a useful tool to diagnose intussusception (see the image below); however, CT scan findings are unreliable, and CT scanning carries risks associated with intravenous contrast administration, radiation exposure, and sedation.

CT scan reveals the classic ying-yang sign of an i CT scan reveals the classic ying-yang sign of an intussusceptum inside an intussuscipiens.
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Contrast Enema

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.[23] (See the images below.)

Barium enema shows intussusception in the descendi Barium enema shows intussusception in the descending colon.
Intussusception evident during air contrast enema Intussusception evident during air contrast enema prior to reduction. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite.

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.

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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)

Garry Wilkes, MBBS, FACEM Director of Clinical Training (Simulation), Fiona Stanley Hospital; Clinical Associate Professor, University of Western Australia; Adjunct Associate Professor, Edith Cowan University, Western Australia

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, American College of Emergency Physicians

Disclosure: Nothing to disclose.

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, International Pediatric Endosurgery Group, American Medical Association, American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

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

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, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

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

Hisham Nazer, MB, BCh, FRCP, , DTM&H is a member of the following medical societies: American Association for Physician Leadership, Royal College of Paediatrics and Child Health, Royal College of Surgeons in Ireland, Royal Society of Tropical Medicine and Hygiene, Royal College of Physicians and Surgeons of the United Kingdom

Disclosure: Nothing to disclose.

References
  1. 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. 2008 Jul. 43(7):1249-53. [Medline].

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

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

  4. 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. 2009 Jan. 44(1):e17-20. [Medline].

  5. 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. 2009 Jul-Dec. 6(2):131. [Medline].

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

  7. 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. 2009 Apr. 44(4):755-8. [Medline].

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

  9. Lappalainen S, Ylitalo S, Arola A, Halkosalo A, Räsänen S, Vesikari T. Simultaneous presence of human herpesvirus 6 and adenovirus infections in intestinal intussusception of young children. Acta Paediatr. 2012 Jun. 101(6):663-70. [Medline].

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

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

  12. 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. 2006 Jan 5. 354(1):11-22. [Medline].

  13. Contopoulos-Ioannidis DG, Halpern MS, Maldonado Y. Trends in Hospitalizations for Intussusception in California in Relationship to the Introduction of New Rotavirus Vaccines, 1985-2010. Pediatr Infect Dis J. 2015 Jul. 34 (7):712-7. [Medline].

  14. Douglas D. More Intussusception Hospitalizations in California After Rotavirus Vaccine Intro. Reuters Health Information. Available at http://www.medscape.com/viewarticle/843091. April 14, 2015; Accessed: June 17, 2015.

  15. 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. 2012 Jan 2. [Medline].

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

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

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

  20. Tareen F, Mc Laughlin D, Cianci F, Hoare SM, Sweeney B, Mortell A, et al. Abdominal radiography is not necessary in children with intussusception. Pediatr Surg Int. 2016 Jan. 32 (1):89-92. [Medline].

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

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  23. 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. 2009 Jan. 44(1):247-9; discussion 249-50. [Medline].

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

  25. Flaum V, Schneider A, Gomes Ferreira C, Philippe P, Sebastia Sancho C, Lacreuse I, et al. Twenty years' experience for reduction of ileocolic intussusceptions by saline enema under sonography control. J Pediatr Surg. 2016 Jan. 51 (1):179-82. [Medline].

  26. 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].

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

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  29. Hill SJ, Koontz CS, Langness SM, Wulkan ML. Laparoscopic Versus Open Reduction of Intussusception in Children: Experience over a Decade. J Laparoendosc Adv Surg Tech A. 2013 Feb. 23(2):166-9. [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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