Intussusception

Background

• Most common cause of intestinal obstruction in 3mo-6yr
  • Usually occurs in 3-36 months
• Due to telescoping of one part of intestine into another
  • Mesentery involvement > ischemia, bloody/mucous stool
• Peds - typically no pathological lesions
  • Slight male predominance - 3:2
• Adults
  • Rare
  • 80% involve small bowel
  • 70% risk of malignancy

Clinical Features

• Classic Triad:
  • Sudden colicky pain
  • Palpable sausage shaped mass on right
  • Currant jelly stool (only 50% of cases; late manifestation of the disease)
• Intermittent episodes of pain
  • Child pulls up knees
  • May be asymptomatic between episodes
  • Later stages may be associated with lethargy

Adults

• Typically have partial/SBO symptoms
• Vomiting, rectal bleeding, constipation
• Distended
• Late Stage: sepsis

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

• Emergent
  • Necrotizing Enterocolitis
  • Volvulus
  • Testicular torsion
  • Inguinal hernia
    • Incarcerated hernia
  • Trauma
  • Pyloric stenosis
  • Toxic megacolon
  • Hirschsprung's Disease
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Colic

3 mo–3 y old

• Emergent
  • Intussusception
  • Testicular Torsion
  • Trauma
  • Volvulus
  • Appendicitis
  • Toxic megacolon
  • Vaso-occlusive crisis
• Nonemergent
  • Acute Gastroenteritis
  • Constipation
  • Urinary tract infection
  • Henoch-Schonlein purpura

3 y old–adolescence

• Emergent
  • Appendicitis
  • DKA
  • Vaso-occlusive crisis
  • Toxic ingestion
  • Testicular Torsion
  • Ovarian Torsion
  • Ectopic Pregnancy
  • Trauma
  • Toxic megacolon
  • Inflammatory bowel disease
  • Gastric ulcer disease
  • Ovarian cyst
  • Pregnancy
  • Pancreatitis
  • Cholecystitis
  • Intussusception (to age 6)
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Nonspecific viral syndrome
  • Streptococcus pharyngitis
  • Urinary tract infection
  • Pneumonia
  • Renal Stone
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease
  • Vulvovaginitis

Evaluation

• Classic Triad
• All labs nonspecific
• Guaiac-positive stool (~50%)

Imaging

• Ultrasound
  • Sensitivity and specificity approach 100%, but operator dependent
  • Classically see bulls eye lesion
• Air contrast enema
  • Diagnostic and frequently curative
  • Prior to procedure, IV hydration, NG tube decompression, surgery consult
• CT for adults (air contrast or barium enemas not sufficient)
  • 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/NG tube
  • Air-contrast enema (reduces 80%)
• Surgery consult
  • Surgery is indicated when nonoperative reduction is incomplete.
  • In stable, asymptomatic patient with ileo-ileo 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

• Admit
• Recurrence occurs in ~10% of cases reduced by enema
  • initial management same

See Also

• Abdominal Pain (Peds)
• Ultrasound: Abdomen