eMedicine Specialties > Pediatrics: Surgery > General Surgery

Intussusception: Surgical Perspective

Author: Michael S Irish, MD, Assistant Professor, Department of Surgery, The University of Iowa; Consulting Pediatric Surgeon, Department of Pediatric Surgery, Blank Children's Hospital and Children's Hospital Physicians Group
Coauthor(s): Jason Shellnut, MD, Surgical Resident, Department of Surgery, Iowa Methodist Hospital
Contributor Information and Disclosures

Updated: Jul 6, 2006

Introduction

Intussusception, the telescoping or invagination of a proximal portion of intestine (intussusceptum) into a more distal portion (intussuscipiens), is one of the most common causes of bowel obstruction in infants and toddlers.

History of the Procedure

Intussusception was first described by Barbette in 1674, and Wilson was the first to successfully treat it surgically in 1831. In 1876, Hirschsprung first reported the technique of hydrostatic reduction, and after monitoring a series of 107 cases, reported a 35% mortality rate in 1905.

Problem

Intussusception is the telescoping or invagination of a proximal portion of intestine into a more distal portion (see Images 1-2). Vascular compromise and subsequent bowel necrosis are the primary concerns with intussusception. Although uncommon, in patients who undergo operative reduction of intussusception, as many as 10% may require bowel resection.

Frequency

The incidence of intussusception is 1.5-4 cases per 1000 live births, with a male-to-female ratio of 3:2. The greatest incidence of idiopathic intussusception is in infants aged 9-24 months. A seasonal incidence has been described, with peaks in the spring, summer, and the middle of winter. These periods correspond to peaks in the occurrence of seasonal gastroenteritis and upper respiratory tract infections.

Etiology

Intussusception is most often (80%) ileocolic (see Image 1), but it may be ileoileal (see Image 3), colocolic, or ileoileocolic. Most infants and toddlers (95%) do not have an identifiable specific lead point. In these idiopathic cases, careful examination may reveal hypertrophied mural lymphoid tissues (Peyer patches), which are due to adenovirus or rotavirus. A specific lead point that draws the proximal intestine and its mesentery inward and propagates it distally through peristalsis is identified in only 5% of cases and is most commonly found in cases of ileoileal intussusception.

Specific lead points are more commonly found in children older than 3 years and almost always in adults with intussusception. Meckel diverticulum (see Image 4) is the most common lead point, followed by polyps and duplications. Other lead points described include lymphomas, submucosal hemorrhage with Henoch-Schönlein purpura, hemangiomas, and lymphosarcomas. Children with cystic fibrosis (CF) may present with intussusception due to inspissated meconium in the terminal ileum. While generally observed as a complication in older children with CF, neonatal intussusception with meconium plug syndrome associated with CF has been reported.

Postoperative jejunoileal or ileoileal intussusception, which usually does not have a specific lead point, accounts for approximately 1% of intussusceptions in children of all ages.

Pathophysiology

Intussusception results in bowel obstruction, followed by congestion and edema with venous and lymphatic obstruction. This progresses to arterial obstruction and subsequent necrosis of the bowel. Ischemia and then necrosis results in fluid sequestration and bleeding from the GI tract. If untreated, the bowel may perforate and the patient becomes septic.

Presentation

The infant with intussusception has a history of severe cramping or colicky abdominal pain occurring intermittently every 5-30 minutes. During these attacks, the infant screams and flexes at the waist, draws the legs up to the abdomen, and may appear pale. These episodes may last for only a few seconds and are separated by periods of calm normal appearance and activity. However, some infants become quite lethargic and somnolent between attacks. Early on, vomiting of undigested food may occur. As attacks continue, emesis may turn bilious. Stools that appear normal in character early in the course of the illness eventually become dark red and mucoid (resembling currant jelly), a sign of intestinal ischemia and mucosal sloughing.

In 1941, Ladd and Gross described the deceivingly healthy appearance of infants with intussusception. One rarely finds intussusception in a child who is thin, undernourished, and poorly developed. On the contrary, babies with intussusception are usually well nourished and are generally above average in physical development. This fat and healthy appearance is apt to mislead the physician if he or she sees the baby in the early hours of illness. Thus, the first visit may result only in the impression that the parent is overanxious, whereas a return visit the next day shows that the child is desperately ill.

Disorders characterized by bowel obstruction, colicky abdominal pain, blood in the stool, an intra-abdominal mass, or a combination of these should be considered in the differential diagnosis of intussusception. These include gastroenteritis, appendicitis, Meckel diverticulum, malrotation with midgut volvulus, or incarcerated hernia.

Ideally, the dramatic paroxysms described above alert the parents sufficiently to seek medical attention early in the course of the illness. If this is the case, initial inspection may reveal a robust infant who appears healthy. Between attacks, the infant may appear somnolent or quite normal, and findings on examination of the abdomen may be quite unremarkable. During an attack or spasm, the infant suddenly appears startled or anxious and begins to scream. Upon initial inspection, the abdomen may appear scaphoid; during paroxysms, it may be rigid; and later in the course of the illness, it may become distended with signs of peritonitis. Careful palpation after an attack has subsided may reveal an ill-defined or sausage-shaped mass.

With early ileocolic intussusception, the mass is typically found in the right upper quadrant or abdomen. The right lower quadrant may seem empty upon examination, a finding known as the Dance sign. This mass may be difficult to locate in inconsolable infants because of abdominal rigidity from muscle straining. If episodes of cramping are witnessed, the careful examiner may auscultate peristaltic rushes in the area of the intussusception.

The rectal examination should commence with inspection of fecal material in the diaper. Normal-appearing stool should be tested for occult blood. The presence of mucoid or frankly bloody stool supports the diagnosis. Rarely, inspection of the anus may reveal the prolapsed tip of the intussusception. A digital rectal examination should be performed routinely, looking for blood or a mass higher in the anal canal.

Indications

Stable patients with a high index of suspicion for intussusception without evidence of ischemic bowel, perforation, or sepsis may undergo immediate contrast enema for diagnosis and treatment of suspected intussusception.

Immediate surgery is indicated in unstable patients, in patients who have peritonitis, or in patients with bowel perforation during attempted enema reduction. Elevated temperature and WBC counts have also served as relative indicators for surgery. Patients requiring surgery must be aggressively resuscitated with fluids, and care must be taken to preserve body temperature preoperatively, intraoperatively, and postoperatively.

Relevant Anatomy

Intussusception is the telescoping or invagination of a proximal portion of intestine into a more distal portion. Intussusception may be ileoileal, colocolic, ileoileocolic, or ileocolic, which is most common (see Image 1). The primary concern with intussusception is vascular compromise and subsequent bowel necrosis. In addition to bowel obstruction, edema with venous obstruction and eventual obstruction of arterial flow leads to ischemia and eventual full-thickness necrosis of the intussuscepted bowel and mesentery.

Contraindications

Contraindications to enema reduction include evidence of bowel perforation and peritonitis.

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