Intussusception: Difference between revisions

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==Background==
==Background==
*Most common cause of intestinal obstruction in 3mo-6yr
*Most common cause of intestinal obstruction in 6mo-6yr
**Usually occurs in 3-36 months
**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
*Peds - typically no pathological lesions
*Adults
**Rare
**80% involve small bowel


==Diagnosis==
===Pediatrics===
*Classic Triad:
*Typically no pathological lesions
**Sudden colicky pain
**If > 6 years old, more likely to have a lead point
**Palpable sausage shaped mass on right
***Lead points: Peyer patches, Meckel diverticulum, duplication cyst, polyp, tumor, hematoma, vascular malformation, parasite (eg Ascaris), Henoch-Schonlein purpura
**Currant jelly stool (only 50% of cases)
*Slight male predominance - 3:2
*Intermittent episodes of pain
 
**Child pulls up knees
===Adults===
**May be asymptomatic between episodes
*Rare
**Later stages may be associated with lethargy
*80% involve small bowel
*Guaiac-positive stool (~50%)
*70% risk of malignancy
*Adults
 
**Typically have partial/SBO symptoms
==Clinical Features==
**Vomiting, rectal bleeding, constipation
Intermittent episodes of pain are often present and may be associated with other symptoms such as:
**Distended
*[[Vomiting]] (non-bilious, late stages bilious)
**Late Stage: sepsis
*Child pulls up knees to chest
**Large bowel obstruction associated with malignancy
*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)


*Imaging
===Adults===
**[[Ultrasound: Abdomen|Ultrasound]]
*Typically have partial/[[SBO]] symptoms
***Sensitivity and specificity approach 100%, but operator dependent
*[[Vomiting]], [[rectal bleeding]], [[constipation]]
***Classically see bulls eye lesion
*Abdominal distension
**Air contrast enema
*Late Stage: [[sepsis]]
***Diagnostic and frequently curative
***Prior to procedure, IV hydration, NG tube decompression, surgery consult
*All labs nonspecific


==Differential Diagnosis==
==Differential Diagnosis==
{{Pediatric abdominal pain DDX}}
{{Pediatric abdominal pain DDX}}


==Treatment==
==Evaluation==
#Stable patients with a high clinical suspicion and/or radiographic evidence of intussusception and no evidence of bowel perforation should be treated with nonoperative reduction.
*Classic Triad not always present
##NPO/NG tube
**Maintain high index of suspicion
##Air-contrast enema (reduces 80%)
*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


#Surgery consult
==Management==
##Surgery is indicated when nonoperative reduction is incomplete.
*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
##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
**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==
*Admit
*Consider discharge if good follow-up, reasonable distance to hospital, parents that can watch
*Recurrence occurs in ~10% of cases reduced by enema
**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>
**initial management same
**Majority of recurrence does not occur within 24-48 hours
*Admission also acceptable in appropriate patient population


==See Also==
==See Also==
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*[[Ultrasound: Abdomen]]
*[[Ultrasound: Abdomen]]


== Source ==
==References==
Uptodate
<references/>


[[Category:Peds]]
[[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
  • 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]

  1. Sudden colicky abdominal pain
  2. Palpable sausage shaped mass on right
  3. Currant jelly stool (only 50% of cases; late manifestation of the disease)

Adults

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Evaluation

  • Classic Triad not always present
    • Maintain high index of suspicion
  • All labs nonspecific
  • Guaiac-positive stool (~50%)

Imaging

Ultrasound

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
    • Recurrence occurs 5-12% of cases[5][6]
    • Majority of recurrence does not occur within 24-48 hours
  • Admission also acceptable in appropriate patient population

See Also

References

  1. ↑ Kleizen KJ et al. Acta Paediatr. 2009 Nov;98(11):1822-4
  2. ↑ Bruce J, Huh YS, Cooney DR, et al. Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr 1987;6:663-674.
  3. ↑ http://www.thepocusatlas.com/pediatrics/
  4. ↑ Marinis A et al. Intussusception of the bowel in adults: A review. World J Gastroenterol. 2009 Jan 28; 15(4): 407–411.
  5. ↑ Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.
  6. ↑ 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.
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