Intussusception: Difference between revisions
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==Background== | ==Background== | ||
[[File:Intussusception EN.png|thumb|Schematic of intussusception.]] | [[File:Intussusception EN.png|thumb|Schematic of intussusception.]] | ||
*Most common cause of intestinal obstruction in 6mo-6yr | *Most common cause of intestinal obstruction in 6mo-6yr | ||
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*Due to telescoping of one part of intestine into another | *Due to telescoping of one part of intestine into another | ||
**Mesentery involvement > ischemia, bloody/mucous stool | **Mesentery involvement > ischemia, bloody/mucous stool | ||
===Pediatrics=== | ===Pediatrics=== | ||
*Typically no pathological lesions | *Typically no pathological lesions | ||
**If > 6 years old, more likely to have a lead point | **If > 6 years old, more likely to have a lead point | ||
***Lead points: Peyer patches, Meckel diverticulum, duplication cyst, polyp, tumor, hematoma, vascular malformation, parasite (eg Ascaris), Henoch-Schonlein purpura | ***Lead points: Peyer patches, Meckel diverticulum, duplication cyst, polyp, tumor, hematoma, vascular malformation, parasite (eg Ascaris), Henoch-Schonlein purpura | ||
*Slight male predominance - 3:2 | *Slight male predominance - 3:2 | ||
===Adults=== | ===Adults=== | ||
*Rare | *Rare | ||
*80% involve small bowel | *80% involve small bowel | ||
*70% risk of malignancy | *70% risk of malignancy | ||
==Clinical Features== | ==Clinical Features== | ||
Intermittent episodes of pain are often present and may be associated with other symptoms such as: | Intermittent episodes of pain are often present and may be associated with other symptoms such as: | ||
*[[Vomiting]] (non-bilious, late stages bilious) | *[[Special:MyLanguage/Vomiting|Vomiting]] (non-bilious, late stages bilious) | ||
*Child pulls up knees to chest | *Child pulls up knees to chest | ||
*Asymptomatic periods between episodes where patient has no pain | *Asymptomatic periods between episodes where patient has no pain | ||
**May be completely benign, smiling, playful | **May be completely benign, smiling, playful | ||
**Suspect intussusception if there are recurrent brief pain episodes, especially if wake child from sleep | **Suspect intussusception if there are recurrent brief pain episodes, especially if wake child from sleep | ||
**Later stages may be associated with [[altered mental status (peds)|lethargy]] | **Later stages may be associated with [[Special:MyLanguage/altered mental status (peds)|lethargy]] | ||
*May present as [[altered mental status (peds)|lethargy]] alone ('''Neurologic intussusception'''), without any of the classic triad | *May present as [[Special:MyLanguage/altered mental status (peds)|lethargy]] alone ('''Neurologic intussusception'''), without any of the classic triad | ||
*Neurologic intussusception has also been described as presenting with an isolated [[seizure (peds)|seizure]] and [[abdominal pain|abdominal pain]]<ref>Kleizen KJ et al. Acta Paediatr. 2009 Nov;98(11):1822-4</ref> | *Neurologic intussusception has also been described as presenting with an isolated [[Special:MyLanguage/seizure (peds)|seizure]] and [[Special:MyLanguage/abdominal pain|abdominal pain]]<ref>Kleizen KJ et al. Acta Paediatr. 2009 Nov;98(11):1822-4</ref> | ||
===Classic Triad=== | ===Classic Triad=== | ||
The classic triad may only be present in up to 21% of cases<ref>Bruce J, Huh YS, Cooney DR, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr 1987;6:663-674. </ref> | The classic triad may only be present in up to 21% of cases<ref>Bruce J, Huh YS, Cooney DR, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr 1987;6:663-674. </ref> | ||
#Sudden colicky [[abdominal pain]] | #Sudden colicky [[Special:MyLanguage/abdominal pain|abdominal pain]] | ||
#Palpable sausage shaped mass on right | #Palpable sausage shaped mass on right | ||
#Currant jelly stool (only 50% of cases; late manifestation of the disease) | #Currant jelly stool (only 50% of cases; late manifestation of the disease) | ||
===Adults=== | ===Adults=== | ||
*Typically have partial/[[SBO]] symptoms | |||
*[[Vomiting]], [[rectal bleeding]], [[constipation]] | *Typically have partial/[[Special:MyLanguage/SBO|SBO]] symptoms | ||
*[[Special:MyLanguage/Vomiting|Vomiting]], [[Special:MyLanguage/rectal bleeding|rectal bleeding]], [[Special:MyLanguage/constipation|constipation]] | |||
*Abdominal distension | *Abdominal distension | ||
*Late Stage: [[sepsis]] | *Late Stage: [[Special:MyLanguage/sepsis|sepsis]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Pediatric abdominal pain DDX}} | {{Pediatric abdominal pain DDX}} | ||
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==Evaluation== | ==Evaluation== | ||
*Classic Triad not always present | *Classic Triad not always present | ||
**Maintain high index of suspicion | **Maintain high index of suspicion | ||
*All labs nonspecific | *All labs nonspecific | ||
*Guaiac-positive stool (~50%) | *Guaiac-positive stool (~50%) | ||
===Imaging=== | ===Imaging=== | ||
'''[[Ultrasound: Abdomen|Ultrasound]]''' | '''[[Ultrasound: Abdomen|Ultrasound]]''' | ||
[[File:Invagination Sonografie.jpg|thumb|Ultrasound showing characteristic target sign for intussusception.]] | [[File:Invagination Sonografie.jpg|thumb|Ultrasound showing characteristic target sign for intussusception.]] | ||
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*For adults (air contrast or barium enemas not sufficient)<ref>Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009 Jan 28; 15(4): 407–411.</ref> | *For adults (air contrast or barium enemas not sufficient)<ref>Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009 Jan 28; 15(4): 407–411.</ref> | ||
**Up to 20% of cases do not have lead point | **Up to 20% of cases do not have lead point | ||
==Management== | ==Management== | ||
*Stable children with a high clinical suspicion and/or radiographic evidence of intussusception and no evidence of bowel perforation should be treated with nonoperative reduction | *Stable children with a high clinical suspicion and/or radiographic evidence of intussusception and no evidence of bowel perforation should be treated with nonoperative reduction | ||
**NPO | **NPO | ||
**Consider [[NG tube]] as indicated | **Consider [[Special:MyLanguage/NG tube|NG tube]] as indicated | ||
**Air-contrast enema (reduces 80%) | **Air-contrast enema (reduces 80%) | ||
**Hydrostatic (saline or water-soluble contrast) may also be used | **Hydrostatic (saline or water-soluble contrast) may also be used | ||
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**In stable, asymptomatic patient with ileo-ileal intussusception, short length of intussusception <2.3 cm, expectant management is reasonable as many of these cases will resolve spontaneously | **In stable, asymptomatic patient with ileo-ileal intussusception, short length of intussusception <2.3 cm, expectant management is reasonable as many of these cases will resolve spontaneously | ||
**In all adults with intussusception due to high incidence of malignancy | **In all adults with intussusception due to high incidence of malignancy | ||
==Disposition== | ==Disposition== | ||
*Consider discharge if good follow-up, reasonable distance to hospital, parents that can watch | *Consider discharge if good follow-up, reasonable distance to hospital, parents that can watch | ||
**Recurrence occurs 5-12% of cases<ref>Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.</ref><ref>Beres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg. 2014 May;49(5):750-2.</ref> | **Recurrence occurs 5-12% of cases<ref>Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.</ref><ref>Beres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg. 2014 May;49(5):750-2.</ref> | ||
**Majority of recurrence does not occur within 24-48 hours | **Majority of recurrence does not occur within 24-48 hours | ||
*Admission also acceptable in appropriate patient population | *Admission also acceptable in appropriate patient population | ||
==See Also== | ==See Also== | ||
*[[Abdominal Pain (Peds)]] | |||
*[[Ultrasound: Abdomen]] | *[[Special:MyLanguage/Abdominal Pain (Peds)|Abdominal Pain (Peds)]] | ||
*[[Ultrasound: Abdomen|Ultrasound: Abdomen]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:GI]] | [[Category:GI]] | ||
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Latest revision as of 23:13, 4 January 2026
Background
- Most common cause of intestinal obstruction in 6mo-6yr
- Usually occurs in 6-36 months
- Due to telescoping of one part of intestine into another
- Mesentery involvement > ischemia, bloody/mucous stool
Pediatrics
- Typically no pathological lesions
- If > 6 years old, more likely to have a lead point
- Lead points: Peyer patches, Meckel diverticulum, duplication cyst, polyp, tumor, hematoma, vascular malformation, parasite (eg Ascaris), Henoch-Schonlein purpura
- If > 6 years old, more likely to have a lead point
- Slight male predominance - 3:2
Adults
- Rare
- 80% involve small bowel
- 70% risk of malignancy
Clinical Features
Intermittent episodes of pain are often present and may be associated with other symptoms such as:
- Vomiting (non-bilious, late stages bilious)
- Child pulls up knees to chest
- Asymptomatic periods between episodes where patient has no pain
- May be completely benign, smiling, playful
- Suspect intussusception if there are recurrent brief pain episodes, especially if wake child from sleep
- Later stages may be associated with lethargy
- May present as lethargy alone (Neurologic intussusception), without any of the classic triad
- Neurologic intussusception has also been described as presenting with an isolated seizure and abdominal pain[1]
Classic Triad
The classic triad may only be present in up to 21% of cases[2]
- Sudden colicky abdominal pain
- Palpable sausage shaped mass on right
- Currant jelly stool (only 50% of cases; late manifestation of the disease)
Adults
- Typically have partial/SBO symptoms
- Vomiting, rectal bleeding, constipation
- Abdominal distension
- Late Stage: sepsis
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
- Classic Triad not always present
- Maintain high index of suspicion
- All labs nonspecific
- Guaiac-positive stool (~50%)
Imaging
Intussusception in both short axis and longitudinal view[3]
- Sensitivity and specificity approach 100%, but operator dependent
- Some emergency departments have successfully implemented bedside point-of-care ultrasound
- Scanning technique involves using a linear probe and applying graded compression serially over all 4 quadrants of the abdomen, looking for a "bullseye lesion" in the short axis view and a "pseudokidney sign" in the longitudinal view
- Ultrasound can diagnose ileo-ileal intussusception, whereas contrast enema cannot
- Negative ultrasound = may still be intermittent intussusception
Air contrast enema
- Diagnostic and frequently curative
- Prior to procedure, IV hydration, NG tube decompression, surgery consult
- Hydrostatic (saline or water-soluble contrast) enema also may be used
CT Abdomen
- For adults (air contrast or barium enemas not sufficient)[4]
- Up to 20% of cases do not have lead point
Management
- Stable children with a high clinical suspicion and/or radiographic evidence of intussusception and no evidence of bowel perforation should be treated with nonoperative reduction
- NPO
- Consider NG tube as indicated
- Air-contrast enema (reduces 80%)
- Hydrostatic (saline or water-soluble contrast) may also be used
- Surgery consult
- Surgery is indicated when nonoperative reduction is incomplete, or patient is toxic, or has perforation or peritonitis.
- In stable, asymptomatic patient with ileo-ileal intussusception, short length of intussusception <2.3 cm, expectant management is reasonable as many of these cases will resolve spontaneously
- In all adults with intussusception due to high incidence of malignancy
Disposition
- Consider discharge if good follow-up, reasonable distance to hospital, parents that can watch
- Admission also acceptable in appropriate patient population
See Also
References
- ↑ Kleizen KJ et al. Acta Paediatr. 2009 Nov;98(11):1822-4
- ↑ Bruce J, Huh YS, Cooney DR, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr 1987;6:663-674.
- ↑ http://www.thepocusatlas.com/pediatrics/
- ↑ Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009 Jan 28; 15(4): 407–411.
- ↑ Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.
- ↑ Beres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg. 2014 May;49(5):750-2.