Intussusception

Summary

Introduction

• Intussusception is invaginating or telescoping of a proximal bowel segment into a distal segment (most commonly occurs at the ileocecal junction).
• This condition is typically seen in infants (rare in adults).
• Etiology is usually idiopathic in children (can be associated with recent viral infections or rotavirus vaccine; peyer’s patches hypertrophy may act as a lead point).
• This condition causes small bowel obstruction, vascular compromise, intermittent abdominal pain, vomiting, and bloody “currant jelly” stools.
• Physical exams may show sausage shaped mass in the right abdomen (patients may draw their legs to chest to ease pain).
• Treatment involves enema and/or surgical removal of lead point.

Epidemiology

• Intussusception is the most common cause of bowel obstruction after the neonatal period in infants younger than 2 years.
• Incidence is 1.5-4 in 1000 live births (peak incidence occurs at 5-9 months of age).
• There is a slight male predominance.

Etiology

• Etiology is generally unknown, but a lead point may act to draw the proximal intestine inward.
• Ileocolic intussusception is the most common site (This condition can occur at multiple sites within the intestine).
• Intussusception causes bowel wall edema, and hemorrhage.
• This may be complicated with bowel ischemia, and infarction.

Clinical Presentation

• Sudden onset of cramps/colicky abdominal pain (pain occurs in intervals followed by periods of calm).
• Vomiting.
• Stools may be normal or have currant jelly appearance, because of intestinal ischemia and mucosal sloughing.
• Sausage-shaped mass may be palpated in the abdominal right upper quadrant.
• May have abdominal distention.

Diagnosis

• Ultrasound may show small bowel obstruction (donut sign).
• Abdominal radiography may show small bowel obstruction (air fluid levels).

Differential Diagnosis

• Intestinal atresia.
• Midgut volvulus.
• Gastroenteritis.
• Appendicitis.
• Meckel’s diverticulum.

Treatment

• Air or contrast enemas (under ultrasound guidance) can successfully reduce the intussusception in 80-90%.
• If the contrast enema fails to reduce the intussusception, or if the child has signs of peritonitis or pneumoperitoneum, operative reduction is indicated.

Complications

• The risk of recurrence is 5% after contrast reduction and 1% after surgical repair.
• Bowel necrosis.
• Bowel perforation.