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. [20]
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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Abdominal radiograph shows small bowel dilatation and paucity of gas in the right lower and upper quadrants.
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Air contrast enema shows intussusception in the cecum.
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Barium enema shows intussusception in the descending colon.
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CT scan reveals the classic ying-yang sign of an intussusceptum inside an intussuscipiens.
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Abdominal ultrasonography reveals the classic target sign of an intussusceptum inside an intussuscipiens.
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Laparoscopic view of a jejuno-jejunal intussusception.
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Note intussusception in the left upper quadrant on this plain film of an infant with pain vomiting. Courtesy of Kelley W Marshall, MD, Children's Healthcare of Atlanta, Emory University School of Medicine.
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Intussusception evident during air contrast enema prior to reduction. Courtesy of Kelley W Marshall, MD, Children's Healthcare of Atlanta, Emory University School of Medicine.
