Pediatric Intussusception Surgery Clinical Presentation

Updated: Jun 30, 2017
  • Author: Michael S Irish, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Presentation

History

In 1941, Ladd and Gross described the deceptively healthy appearance of infants with intussusception. [13]  One rarely finds intussusception in a child who is thin, undernourished, and poorly developed. This is evident in that babies with intussusception are usually well nourished and generally above average in physical development.

This fat and healthy appearance is apt to mislead the physician in the early hours of the patient’s illness. Thus, the first visit may leave the physician with 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 diagnoses of intussusception. These include gastroenteritisappendicitisMeckel diverticulum, malrotation with midgut volvulus, or incarcerated hernia.

Most infants with intussusception have a history of intermittent severe cramping or colicky abdominal pain, occurring 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, the infant may vomit undigested food. As attacks continue, emesis may turn bilious. Stool 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.

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Physical Examination

Ideally, the dramatic paroxysms that are common in this condition would sufficiently alert the parents 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 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 (RUQ) or abdomen. The right lower quadrant (RLQ) 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 reveals the prolapsed tip of the intussusception. A digital rectal examination (DRE) should be performed routinely, looking for blood or a mass higher in the anal canal.

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Clinical Diagnostic Criteria

In view of concerns about rotavirus vaccine–associated intussusception, the Brighton Collaboration Intussusception Working Group established a clinical diagnosis using a mix of major and minor criteria. This stratification helps to devise a working model based on three levels of evidence to suggest definite, probable, and possible cases of intussusception. [14]

Major and minor criteria

Major criteria for the clinical diagnosis of intussusception are as follows:

  • Evidence of intestinal obstruction - This criterion consists of a history of bile-stained emesis, along with abdominal distention or abnormal or absent bowel sounds
  • Features of intestinal invagination - This criterion includes at least one of three key findings—abdominal mass, rectal mass, or rectal prolapse—as well as an abdominal radiograph, sonogram, or computed tomography (CT) scan showing visible intussusceptum or a soft-tissue mass
  • Evidence of intestinal vascular compromise or venous congestion - This criterion manifests as rectal bleeding or “red currant jelly” stool or blood on rectal examination

Minor criteria include the following:

  • Male infants younger than 1 year
  • Abdominal pain
  • Vomiting
  • Lethargy
  • Pallor
  • Hypovolemic shock
  • Abdominal radiograph showing nonspecific abnormality

Evidence levels

The likelihood of the diagnosis is stratified on the basis of evidence levels.

Level 1 (definite) includes any one of the following:

  • Surgical criteria - Invagination of intestine found during surgery
  • Radiologic criteria - Gas or liquid contrast enema showing invagination or abdominal sonogram with specific features proven to be reduced by enema on postreduction sonogram
  • Autopsy criteria - Invagination of the intestine

Level 2 (probable) includes either of the following:

  • Two major criteria (see above)
  • One major criterion and three minor criteria (see above)

Level 3 (possible) includes the following:

  • Four or more minor criteria (see above)

The relevance of this definition has been clinically tested in Switzerland, where it correctly identified 86 of 96 confirmed episodes, 82 of which met level 1 evidence. Regarding sensitivity in comparison to this level 1 evidence, level 2 (probable) had a sensitivity of 65%, whereas level 3 (possible) had a sensitivity of only 30%. [15]

A 2011 prospective study by Weihmiller et al focused on establishing predictive clinical criteria to risk stratify patients while performing a workup for intussusception. [16]  The three strongest clinical predictors for high risk were as follows:

  • Male sex ( P=.007)
  • Age >5 months ( P=.04)
  • Report of lethargy ( P=.001)

If a patient is older than 5 months, then he or she may be considered low-risk if the abdominal radiograph is negative and there is diarrhea with no bilious emesis.

This study also recommended plain abdominal radiographs for all patients suspected of having intussusception. [16]  An abnormal abdominal plain film had a P value of .0001. Their definitions for an abdominal radiographs were classified as either (a) negative, with no intussusception suspected, or (b) positive or possibly positive for intussusception, which led to more testing using either ultrasonography or air enema.

Of note, this study identified 38 intussusceptions out of 310 pediatric patients and did not find abdominal pain, abdominal mass, or guaiac-positive stools to be significant. [16]  However, these clinical findings are classic for intussusception on the basis of prior research; therefore, the presence of these symptoms and signs should still raise clinical suspicion for intussusception.

In a study of 379 patients, Fallon et al concluded that significant predictors for operative treatment included abdominal symptoms for more than 2 days, age younger than 1 year, multiple ultrasonographic findings, and failure of initial enema reduction. [17]

In a 7-year multicenter retrospective study of intussusception in 153 pediatric patients aged 12 years or younger, Banapour et al found that children older than 5 years were significantly more likely to have a pathologic lead point, which suggested that early surgical intervention should be considered. [18]  In this age group, enema reduction, though safe, yielded only minimal benefit.

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