Pediatric Intussusception Surgery Workup

  • Author: Michael S Irish, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP   more...
 
Updated: Apr 14, 2011
 

Laboratory Studies

  • Obtain a CBC count with differential and chemistry profile. Blood chemistry abnormalities are not specific for intussusception. Depending on the duration of illness and associated vomiting and blood loss, laboratory investigations may reflect dehydration, anemia, leukocytosis, or a combination of these.
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Imaging Studies

  • Plain radiography
    • Early in the course of the illness, findings on plain radiographic examination of the abdomen (supine and upright) may be unremarkable. Findings suggestive of intussusception include dilated loops of small bowel with or without air-fluid levels, an airless or opacified right lower quadrant (see the image below), or both. Occasionally, the intussusceptum is apparent on plain abdominal radiography. This is an abdominal plain radiograph of a 14-weekThis is an abdominal plain radiograph of a 14-week-old patient with intussusception. Note the nonspecific appearance of bowel obstruction.
    • In order to increase the diagnostic accuracy, a left-side down decubitus radiographic view of the abdomen can be helpful. Hooker et al found that the diagnostic value of kidney ureter bladder (KUB) radiography increased from 60.3% to 74.1% (P < 0.001) after a decubitus view was added. With the addition of the decubitus view, the exclusion value was also increased, from 25.6% to 58.1% (P < 0.0001).[15]
    • Roskind et al used 3 radiographic views (supine, prone, and left decubitus) and found a sensitivity of 100% when these three showed air in the ascending colon, but a specificity of only 18.4%. The sensitivity went to 96% and specificity to 41% when at least two views revealed air in the ascending colon.[16]
  • Ultrasonography
    • First reported as a useful diagnostic tool in intussusception by Burke in 1977, the utility of ultrasonography in the diagnosis of intussusception has been verified by a number of authors, with a sensitivity and specificity of 100%.[17]
    • Characteristic ultrasonographic findings include a target sign (see the first image below) visible on transverse section and a pseudo-kidney sign (see the second image below) viewed on longitudinal section. Transverse ultrasonographic view (target sign) of Transverse ultrasonographic view (target sign) of intussusception. Longitudinal ultrasonographic view (pseudo-kidney Longitudinal ultrasonographic view (pseudo-kidney sign) of intussusception.
    • Ultrasonography has also been studied as a tool to help differentiate the types of intussusception. Park et al (2007) reported that a transient small bowel intussusception is most likely located in the right lower quadrant or periumbilical region, has a smaller anteroposterior diameter (1.38 cm vs 2.53 cm), has a thinner outer rim (0.26 cm vs 0.53 cm), and is absent of lymph nodes, in contrast to ileocolic intussusception.[18] A study by Munden et al (2007) supported these findings, with a mean anteroposterior diameter of 1.5 cm in ileoileal intussusceptions and 3.7 cm in ileocolic intussusceptions and a mean length of 2.5 cm and 8.2 cm, respectively.[19]
    • With small bowel intussusception, the length may be helpful in determining the necessity of surgery. Munden et al (2007) found that an intussusception length of more than 3.5 cm independently predicted the likelihood of surgery being performed, with a sensitivity of 93% and specificity of 100%.[10]
    • Ultrasonography is best used as a diagnostic tool of exclusion when the index of suspicion for intussusception is lower.
    • The role of ultrasonography in the diagnosis of intussusception is well established; however, experience with ultrasonography-guided hydrostatic reduction of intussusception is limited in the Western hemisphere. In Europe, successful reduction has been reported in 76%-95% of cases and only one case of perforation in 825 cases. In China, a study of hydrostatic reduction in 5218 patients showed a 95.5% rate of success and a colonic perforation rate of only 0.17%.[20] As hydrostatic reduction of intussusception has proven effective in Europe and Asia, it is increasingly being used at some US centers.
  • CT examination: The evaluation of abdominal pain often leads to CT examination. Although not indicated for the diagnosis of intussusception, intussusception can be found incidentally on CT scan (see the image below). Appearance of intussusception on CT scan. Appearance of intussusception on CT scan.
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Diagnostic Procedures

  • Diagnostic and therapeutic enema
    • Once the diagnosis of intussusception is entertained, surgical personnel should be notified and an intravenous line and nasogastric tube placed. The surgeon is preferably present in the radiology suite at the time of contrast enema examination.
    • The diagnostic enema is therapeutic in 80%-90% of patients. Thus, treatment is usually concluded in the radiology suite, and some surgeons elect to observe these patients in the hospital until they can tolerate an oral diet. A successful therapeutic reduction must demonstrate free flow of contrast (air or barium series) proximal to the ileocecal valve. Historically, patients in whom enema reduction was unsuccessful were taken immediately to the operating room for laparotomy and manual reduction. However, in patients who are clinically stable, second and third attempts at pneumatic or hydrostatic reduction have proven effective.
    • Ladd first used barium enema as a diagnostic tool in 1913.[21] Since that time, enemas, with either air or barium, have become a mainstay in both diagnosis and therapy, replacing surgery as the initial management of stable patients. A discussion of the choice between air (see the first image below) or barium (see the second image below) in contrast enemas is beyond the scope of this article, and the reader is referred to a number of reviews discussing the advantages and disadvantages of both techniques. This author prefers to use air initially in the infant or child with suspected intussusception. Perforation is a risk with either barium or air but poses less of a problem with air, as the combination of barium and feces may result in severe peritonitis with wide peritoneal soilage. This ileocolic intussusception is observed using aThis ileocolic intussusception is observed using air-contrast enema. Intussusception has been reduced to the level of the cecum. This ileocolic intussusception is observed using bThis ileocolic intussusception is observed using barium contrast enema. Intussusception has been reduced to the level of the proximal transverse colon.
    • Knowledge of the basic technique and potential complications of contrast enemas in intussusception is important for all clinicians involved in the management of these patients.
    • In preparation for contrast study, patients should have intravenous access, and, although it is not used universally, this author prefers to have a nasogastric tube in place. Furthermore, sedation may be helpful while conducting the examination.
      • A lubricated straight catheter is placed into the rectum and secured by taping the buttocks together tightly. While many radiologists prefer a balloon-tipped catheter, laceration or perforation of the rectum is a risk with balloon inflation.
      • A manometer and blood pressure cuff are connected to the catheter, and air is insufflated slowly to a pressure of 70-80 mm Hg (maximum 120 mm Hg) and followed fluoroscopically as it percolates proximally through the colon. The column of air stops at the intussusception, and a plain radiograph is taken.
      • If no intussusception exists or if the reduction is successful, air is observed to rapidly pass into the small bowel. Another radiograph is taken at this point, and the air is allowed to escape prior to removal of the catheter.
      • At the completion of the procedure, postreduction radiography (in supine and decubitus/upright views) should be used to confirm the absence of free air.
      • Difficult reductions may require several attempts. The use of glucagon (0.5 mg/kg) for facilitating relaxation of the bowel has yielded mixed results and is not routinely used.
      • Success rates of 80%-90% for pneumatic reduction have been reported. In the stable patient, suggestion of a recurrence following enema reduction necessitates a repeat enema examination.
    • Ultrasonography is advocated to aid in diagnosis and to assist with hydrostatic reduction of intussusception. Studies advocating its use for diagnosis report sensitivities of 98.5%-100%, specificities of 88%-100%, and negative predictive values of 100%.
      • In 1997, Chan et al compared the efficacy of ultrasonographically guided versus fluoroscopically guided hydrostatic reduction in 46 patients with intussusception.[22]
      • The ultrasound group had 3 recurrences (11.5%), 1 lead point (4.4%), and 19 successful reductions (73%).
      • Only 1 recurrence (4.2%), 1 lead point (4.4%), and 12 successful reductions (50%) occurred in the same number of patients undergoing hydrostatic reduction with barium.
      • No complications occurred in either group, and the accuracy rate of diagnosing a complete reduction was 100% with both forms of reduction.
      • Hence, the authors concluded that ultrasonographically guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.
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Histologic Findings

Resected specimens show varying degrees of ischemia, necrosis, or both. Benign reactive lymph node hyperplasia and Peyer patch hyperplasia is common. Resected specimens should be carefully examined for potential lead points (eg, Meckel diverticulum, polyps, lymphoma).

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Contributor Information and Disclosures
Author

Michael S Irish, MD  Adjunct Clinical Assistant Professor, Department of Surgery, University of Iowa, Roy J and Lucille A Carver College of Medicine; Consulting Pediatric Surgeon, Department of Pediatric Surgery, Blank Children's Hospital and Children's Hospital Physicians Group

Michael S Irish, MD is a member of the following medical societies: International Pediatric Endosurgery Group and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Jason K Shellnut, MD  Staff Physician, Department of Surgery, Iowa Methodist Hospital

Disclosure: Nothing to disclose.

Philip M Bovet, DO, MPH  Resident Physician in Family Medicine, University of Wisconsin Health Clinic

Philip M Bovet, DO, MPH is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Osteopathic Association, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Rebeccah Brown, MD  Associate Director of Trauma Services, Associate Professor, Department of Clinical Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital

Rebeccah Brown, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and American Medical Women's Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Deborah F Billmire, MD  Associate Professor, Department of Surgery, Indiana University Medical Center

Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

H Biemann Othersen Jr, MD  Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina

H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP  Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University School of Medicine

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress

Disclosure: Nothing to disclose.

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Diagram illustrating the anatomy of intussusception.
Intraoperative appearance of ileoileal intussusception.
Intraoperative appearance of ileocolic intussusception.
Intraoperative appearance of ileocolic intussusception due to Meckel diverticulum.
This is an abdominal plain radiograph of a 14-week-old patient with intussusception. Note the nonspecific appearance of bowel obstruction.
Transverse ultrasonographic view (target sign) of intussusception.
Longitudinal ultrasonographic view (pseudo-kidney sign) of intussusception.
Appearance of intussusception on CT scan.
This ileocolic intussusception is observed using air-contrast enema. Intussusception has been reduced to the level of the cecum.
This ileocolic intussusception is observed using barium contrast enema. Intussusception has been reduced to the level of the proximal transverse colon.
 
 
 
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