Intussusception: Difference between revisions
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==Background== | ==Background== | ||
*Most common cause of intestinal obstruction in | *Most common cause of intestinal obstruction in 6mo-6yr | ||
**Usually occurs in | **Usually occurs in 6-36 months | ||
*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=== | ||
* | *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 | ||
** | *Slight male predominance - 3:2 | ||
**Child pulls up knees | ===Adults=== | ||
**May be | *Rare | ||
**Later stages may be associated with lethargy | *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 [[altered mental status (peds)|lethargy]] | |||
*May present as [[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> | |||
===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> | |||
#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== | ==Differential Diagnosis== | ||
{{Pediatric abdominal pain DDX}} | {{Pediatric abdominal pain DDX}} | ||
== | ==Evaluation== | ||
*Classic Triad not always present | |||
**Maintain high index of suspicion | |||
*All labs nonspecific | |||
*Guaiac-positive stool (~50%) | |||
===Imaging=== | |||
'''[[Ultrasound: Abdomen|Ultrasound]]''' | |||
[[File:Intussusception Subramaniam.gif|thumbnail|Intussusception in both short axis and longitudinal view<ref>http://www.thepocusatlas.com/pediatrics/</ref>]] | |||
**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)<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 | |||
==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== | ==Disposition== | ||
* | *Consider discharge if good follow-up, reasonable distance to hospital, parents that can watch | ||
*Recurrence occurs | **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 | ||
*Admission also acceptable in appropriate patient population | |||
==See Also== | ==See Also== | ||
Line 56: | Line 84: | ||
*[[Ultrasound: Abdomen]] | *[[Ultrasound: Abdomen]] | ||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Pediatrics]] | ||
[[Category:GI]] | [[Category:GI]] |
Revision as of 22:47, 5 October 2019
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
- Sensitivity and specificity approach 100%, but operator dependent
- Some emergency departments have successfully implemented bedside point-of-care ultrasound
- Sensitivity and specificity approach 100%, but operator dependent
- 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.