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Emergency Medicine > PEDIATRIC
Pediatrics, Intussusception
Article Last Updated: Oct 1, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Lonnie King, MD, Consulting Staff, Department of Emergency Medicine, Children's Healthcare of Atlanta at Scottish Rite
Lonnie King is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American College of Emergency Physicians
Editors: Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Author and Editor Disclosure
Synonyms and related keywords:
intussusception, telescoping of the bowel, prolapse of the bowel, intussusceptum, intussuscipiens, red currant jelly stool, upper respiratory illness, diarrheal illness, Henoch-Schönlein purpura, cystic fibrosis, Meckel diverticulum, intestinal polyp, intestinal lymphosarcoma, intestinal hematomas, mesenteric hematomas, hemangioma
Background
Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment. Contrast enema can reduce the intussusception in approximately 75% of cases.
Pathophysiology
Intussusception most commonly occurs at the terminal ileum (ie, ileocolic). The telescoping proximal portion of bowel (ie, intussusceptum) invaginates into the adjacent distal bowel (ie, intussuscipiens).
The mesentery of the intussusceptum is compressed, and the ensuing swelling of the bowel wall quickly leads to obstruction. Venous engorgement and ischemia of the intestinal mucosa cause bleeding and an outpouring of mucous, which results in the classic description of red "currant jelly" stool.
Most cases (90%) are idiopathic, with no identifiable lesion acting as the lead point or pathological apex of the intussusceptum.
Frequency
United States
Intussusception is the predominate cause of intestinal obstruction in persons aged 3 months to 6 years. The estimated incidence is 1-4 per 1000 live births.
Mortality/Morbidity
Most patients recover if treated within 24 hours.
- Mortality with treatment is 1-3%. If left untreated, this condition is uniformly fatal in 2-5 days.
- Recurrence is observed in 3-11% of cases. Most recurrences involve intussusceptions that were reduced with contrast enema.
Sex
- Overall, the male-to-female ratio is approximately 3:1.
- With advancing age, gender difference becomes marked; in patients older than 4 years, the male-to-female ratio is 8:1.
Age
Intussusception is most common in infants aged 3-12 months, with an average age of 7-8 months.
- Two thirds of the cases occur before the patient's first birthday.
- Intussusception occurrence is rare in persons younger than 3 months, and it becomes less common in persons older than 36 months.
History
- The typical presentation is a previously healthy infant boy aged 6-12 months with sudden onset of colicky abdominal pain with vomiting.
- Paroxysms of pain occur 10-20 minutes apart.
- Initially, loose or watery stools are present concurrent with vomiting and, within 12-24 hours, blood or mucous is passed rectally.
- Early in the course, the patient appears completely well between the episodes of abdominal pain.
- Lethargy may dominate the initial presentation. However, lethargy usually occurs later in the process.
- The classic triad of colicky abdominal pain, vomiting, and red currant jelly stools occurs in only 21% of cases.
Physical
- Usually, the abdomen is soft and nontender early, but it eventually becomes distended and tender.
- A vertically oriented mass may be palpable in the right upper quadrant.
- Currant jelly stools are observed in only 50% of cases.
- Most patients (75%) without obviously bloody stools have stools that test positive for occult blood.
- Fever is a late finding and is suggestive of enteric sepsis.
Causes
Most cases are idiopathic. In neonates and in patients older than 3 years, a mechanical lead point usually can be found.
- Predisposing factors
- Recent upper respiratory illness
- Recent diarrheal illness
- Henoch-Schönlein purpura
- Cystic fibrosis
- Chronic indwelling GI tubes
- Processes that result in a mechanical lead point
- Meckel diverticulum
- Intestinal polyp (eg, Peutz-Jeghers syndrome, familial polyposis coli, juvenile polyposis)
- Intestinal lymphosarcoma
- Blunt abdominal trauma with intestinal or mesenteric hematomas
- Hemangioma
- Foreign body
- Henoch-Schönlein purpura (small bowel hematomas cause small bowel intussusception)
Abdominal Trauma, Blunt
Appendicitis, Acute
Hernias
Pediatrics, Gastroenteritis
Testicular Torsion
Other Problems to be Considered
Adhesive band
Volvulus
Meckel diverticulum
Any process causing abdominal pain or GI bleeding
Lab Studies
- Perform lab studies as needed for the febrile, dehydrated, or unstable patient.
Imaging Studies
- If intussusception is strongly suspected, perform a contrast enema without delay. This is contraindicated in patients with an obvious surgical abdomen (eg, signs of peritonitis or perforation) and in unstable patients.
- Plain abdominal radiographic findings may be normal early in the disease or may show perforation, typical obstructive pattern, or soft tissue mass of the intussusception on the right side. A paucity of gas in the right upper quadrant may be present.
- Ultrasonography has been used to diagnose intussusception.
Emergency Department Care
- Provide rehydration and stabilization as needed.
- Contrast enema is diagnostic in approximately 95% of intussusception cases. It is therapeutic and curative in most cases with less than 24-hour duration.
Consultations
Only perform a contrast enema in consultation with the surgeon caring for the child and the radiologist interpreting the study.
Further Inpatient Care
- Admission is indicated for all patients because up to 10% of those with successful radiologic reduction have a recurrence, usually in the first 24 hours.
Transfer
- Radiologic reduction is best performed with the surgeon on standby because complications may develop and require immediate surgery. This may require transfer to a facility with a pediatric surgeon. The benefit of transfer must be weighed against the delay in reduction.
Complications
- Intestinal hemorrhage
- Necrosis and bowel perforation
- Shock and sepsis
- Recurrence
Prognosis
- Prognosis is excellent if diagnosed and treated early; otherwise, severe complications and death may occur.
Medical/Legal Pitfalls
- Failure to consider a mechanical lead point
- Failure to consider the diagnosis in any infant with altered mental status
- Over-reliance on the typical age or typical presentation with currant jelly stool
| Media file 1:
Note intussusception in the left upper quadrant on this plain film of an infant with pain vomiting. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite. |
 |  View Full Size Image | |
Media type: Radiograph
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| Media file 2:
Intussusception evident during air contrast enema prior to reduction. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite. |
 | View Full Size Image | |
Media type: Radiograph
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Pediatrics, Intussusception excerpt Article Last Updated: Oct 1, 2007
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