Child Intussusception


Article Author:
Shobhit Jain


Article Editor:
Micelle Haydel


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
2/24/2019 2:18:48 PM

Introduction

Intussusception is a condition in which part of the intestine folds into the section next to it. Intussusception usually involves the small bowel and rarely the large bowel. Symptoms include abdominal pain which may wax and wane, vomiting, bloating, and bloody stool. It may result in a small bowel obstruction. Other complications may include peritonitis or bowel perforation.[1][2][3][4]

The cause is typically unknown in children while in adults a lead point due to cancer is often present. Risk factors in children include infections, cystic fibrosis, and intestinal polyps. Risk factors in adults include endometriosis, bowel adhesions, and intestinal tumors. Medical imaging often supports a diagnosis. In children, ultrasound is a preferred the method to diagnose while in adults a CT scan is preferred.

Intussusception requires rapid treatment. Treatment in children is typically by an enema with surgery if not successful. In adults removal of part of the bowel is more often required. Intussusception occurs more commonly in children than adults. In

Intussusception occurs more commonly in children than adults, in children it is more common in males than females. The usual age of occurrence is six to 18 months old.

Etiology

The causes of intussusception are not clearly known. About 90% of cases of intussusception in children arise from an unknown cause. They can include infections, anatomical factors, and altered motility.[5][6][7]

Known causes may include:

  • Infections
  • Anatomical factors
  • Altered motility
  • Meckel's diverticulum
  • Duplication
  • Polyps
  • Appendicitis
  • Hyperplasia of Peyer's patches
  • Idiopathic

An early version of the rotavirus vaccine that is no longer used was thought to cause intussusception, but the current vaccines are not clearly linked.

Epidemiology

Intussusception is usually diagnosed in infancy and early childhood.

  • Intussusception strikes about 2000 children in the United States in the first year of life.
  • Intussusception is usually seen at five months of life, peaks at four to nine months, and then gradually declines at around 18 months.
  • Intussusception occurs more frequently in boys than in girls, with a ratio of approximately 3:1.
  • In adults, intussusception represents 1% of bowel obstructions and is associated with neoplasm.

Pathophysiology

Usually, the ileum enters the cecum. Rarely a part of the ileum or jejunum prolapses into itself. Almost all intussusceptions occur with the intussusceptum having been located proximally to the intussuscipiens. This is because a peristaltic action of the intestine pulls the proximal segment into the distal segment.

  • The part that prolapses into the other is called the intussusceptum.
  • The part that receives it is called the intussuscipiens.
  • An anatomic lead point occurs in approximately 10% of intussusceptions.

The trapped section of bowel may have its blood supply cut off, which causes ischemia. The mucosa is sensitive to ischemia and responds by causing sloughing off into the gut. This creates a "red currant jelly" stool, which is sloughed mucosa, blood, and mucus. "Red currant jelly" occurs in a minority of cases of intussusception and should be considered in the differential diagnosis of children passing any bloody stool.

History and Physical

Early symptoms include periodic abdominal pain, nausea, vomiting (green from bile), pulling legs to the chest, and cramping abdominal pain. Pain is intermittent because the bowel segment transiently stops contracting.

Later signs include rectal bleeding, often with "red currant jelly" stool, and lethargy. Physical examination may reveal a "sausage-shaped" mass. Children may cry, draw their knees up to their chest, or experience dyspnea with paroxysms of pain.

Fever is not a symptom of intussusception but a loop of bowel may become necrotic, secondary to ischemia, this leads to perforation and sepsis, which causes fever.

In rare cases, intussusception may be a complication of Henoch-Schönlein purpura. Such patients often present with severe abdominal pain in addition to the classic signs of Henoch-Schönlein purpura.

Evaluation

Intussusception is often suspected based on examination, including observation of Dance sign (Dance sign consists of evaluating right lower quadrant of the abdomen for retraction, which can be an indication of intussusception).

  • A digital rectal examination is helpful, as a finger may feel the intussusceptum.
  • A definite diagnosis requires confirmation by imaging modalities.
  • Ultrasound is the test of choice for diagnosis of intussusception. The appearance of target sign or doughnut sign usually around 3 cm in diameter, confirms the diagnosis.
  • The image seen on transverse sonography or computed tomography is a doughnut shape, created by the hyperechoic central core of bowel and mesentery surrounded by the hypoechoic outer edematous bowel.
  • In longitudinal imaging, intussusception may resemble a sandwich.

An abdominal x-ray may be indicated to check for intestinal obstruction. An air enema may be used for diagnosis, and the same procedure can be used for treatment.

CT scan is sometimes used to make a diagnosis, especially when the Ultrasound imaging remains doubtful. However, in young children, obtaining a CT scan often requires the use of anesthesia and there is also the risk of intravenous contrast and radiation exposure.

Treatment / Management

Intussusception is not usually immediately life-threatening. It is usually successfully treated with barium, water-soluble, or an air-contrast enema, which both confirms the diagnosis and successfully reduces it. The success rate is more than 80%. However, up to 10% may reoccur within 24 hours.[8][9][10][11]

Cases that cannot be reduced non-surgically require surgical reduction. In surgical reduction, the surgeon manually squeezes the part that has telescoped. If the surgeon cannot successfully reduce it, the affected section is surgically removed. The intussusception may also be reduced by laparoscopy, pulling the segments of intestine apart with forceps.

Pearls and Other Issues

Intussusception is a medical emergency if not treated early and may result in death if not reduced. In developing countries, death is almost inevitable.

The prognosis for intussusception is excellent if treated quickly, but if untreated it can lead to death within two to five days. The longer the intestine segment is prolapsed and the longer it goes without a blood supply, the less effective a non-surgical reduction. Prolonged intussusception increases bowel ischemia and necrosis, requiring surgical resection.

The differential diagnosis of intussusception includes acute gastroenteritis and rectal prolapse.

  • Abdominal pain, vomiting, and stool with blood and mucus occur in acute gastroenteritis, but diarrhea is the leading symptom.
  • In rectal prolapse expect projecting mucosa that can be felt in continuity with the perianal skin, whereas in intussusception, the finger may pass indefinitely into the depth of the sulcus.

It is important to note that air contrast enema is not used to treat adults with intussusception; adults tend to have a lead point or an organic lesion that is often the cause of the problem.

Enhancing Healthcare Team Outcomes

Intussusception is a surgical emergency. The disorder is managed by an interprofessional team that consists of a radiologist, pediatrician, emergency department physician, and a pediadritic surgeon. The majority of cases are reduced non-surgically and have a good outcome. Cases not reduced by air or barium need surgery. Usuallly no bowel resection is required. Complications are rare after surgery and recurrences are very rare.[12] (Level V) 


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Child Intussusception - Questions

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A 2-year-old boy is seen in the emergency department with sudden onset of abdominal pain. The child has an otherwise negative past medical history. On examination of the right lower quadrant, there appears to be a retraction of the right iliac fossa. The intern says this is indicative of Dance sign. What is the possible diagnosis?



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What is the most common cause of intestinal obstruction in an infant 6 months to a child 4 years of age?



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A 3-year-old boy is brought to the office after a bout of crying, curling into a ball, and clutching his abdomen. This was followed by marked lethargy. This sequence has occurred several times over the past 5 hours. There has been no vomiting, diarrhea, or fever, but he did pass a single bloody stool. The patient has no past medical history and no recent sick contacts. The exam is normal except for the fact that the child is sleepy but arousable. Which of the following is the most likely diagnosis?



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What is the treatment of choice for intussusception?



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A 3-year-old boy who is diagnosed with intussusception is treated with an air enema. What is the next step in the patient's management?



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Approximately 10 days after a viral respiratory illness, a 16-month-old child is seen because of abdominal pain and bloody mucous rectal discharge. A sausage-shaped mass is palpable in the right upper quadrant. Which is true about intussusception?



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An 11-month-old boy is seen for bloody diarrhea and abdominal pain. There is a sausage-shaped mass in the right upper quadrant. What is the most likely diagnosis?



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A child presents with vomiting. On examination, the child has episodic abdominal cramping with no palpable masses. Digital rectal examination reveals blood-streaked stool. What is the most likely diagnosis?



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Which of the following findings may be observed in a child with intussusception?



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A child with intussusception may present with what color stools?



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What is usually the most appropriate initial treatment for intussusception in a 3-year-old child?



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In a child with intussusception, reduction with air enema should be attempted how many times?



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A 1-year-old boy was brought in for evaluation of bloody diarrhea. His mother claims that he has intermittent abdominal pain. There is a sausage-shaped mass felt at the right upper quadrant. What is the most likely diagnosis?



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Which of the following is the most common cause of intestinal obstruction in children?



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Which of the following is not true about intussusception?



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In a child with "currant jelly" stools, what is the most likely diagnosis?



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What is true of contrast enema in suspected intussusception in infants and young children?



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A 2-year-old girl presents with episodic abdominal pain and bloody stool. She recently had an upper respiratory infection. Abdominal ultrasound shows a target sign. What would be the best management of this patient?



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A 1-year-old female presents with episodic abdominal pain for 1 day, anorexia, and loose stools. She has no fever or upper respiratory symptoms. On physical exam, her abdomen is soft and non-tender but her stools are bloody and the hemoccult test is positive. Of the following, which radiologic study would be best used to confirm the suspected diagnosis?



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A 1-year-old girl presents to your office with episodic abdominal pain for 1 day, anorexia, and loose stools. She has no fever or upper respiratory symptoms. On physical exam, her abdominal exam is soft and non-tender, but her stools are Hemoccult positive. An air enema is both diagnostic and therapeutic. Which of the following is false regarding this patient's condition?



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What is the most common cause of intestinal obstruction in an infant?



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A 1-year-old girl presents with episodic abdominal pain, drawing the legs up to the abdomen and kicking the legs in the air for 1 day, anorexia, and loose stools. She has no fever or upper respiratory symptoms. On physical exam, her abdominal exam is soft and non-tender, but her stools are stool guaiac test positive. Of the following, which radiologic study would be recommended for screening?



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A 9-month-old male from Central America is brought to the emergency department with a 6-hour history of intermittent, inconsolable crying and hugging his knees to his abdomen. He has had two bloody stools and vomiting. The infant is irritable with a temperature of 38.5 C. The abdomen seems tender, and the child continues crying. What is the best initial diagnostic test?



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What is the best initially treatment option of intussusception?



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What stool characteristic is associated with intussusception?



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A 6-month old child suddenly cries out in pain while eating dinner and becomes very lethargic. In the emergency room, the diaper reveals the presence of jelly-like stools. On physical exam of this infant which of the following would be unusual?



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A 16-month-old child is eating his lunch and suddenly complains of abdominal pain and vomits. He quickly becomes lethargic, and when you open his diaper, you see the following (see image). Which type of gastrointestinal pathology is most commonly associated with such a presentation?

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  • Image 5995 Not availableImage 5995 Not available
    image courtesy s bhimji MD
Attributed To: image courtesy s bhimji MD



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A child presents with abdominal pain, emesis, and lethargy. Examination reveals an overweight child, but otherwise in good health. The child appears to be having alternating episodes of crying spells and is diaphoretic. Upon opening the diaper, you note the following (see image). What height should the column of barium be held at to reduce this patient's pathology?

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  • Image 5995 Not availableImage 5995 Not available
    image courtesy s bhimji MD
Attributed To: image courtesy s bhimji MD



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A 4-month-old infant is being evaluated in the pediatric emergency department. The mother barely speaks any English, but she is distressed and feels that there is something not right with her child. While waiting for a translator, the provider notices that the baby is lethargic with intermittent crying spells. The chest and abdominal exam are unremarkable. An image of the infants open diaper is shown below. Which one of the following should be the next best step in the management of this patient?

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    image courtesy s bhimji MD
Attributed To: image courtesy s bhimji MD



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Which of the following signs and symptoms are consistent with intussusception in an infant? Select all that apply.



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A healthcare provider is educating a group of students on intussusception. Which of the following statements made by the provider are correct concerning this abdominal emergency? Select all that apply.



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A nurse is rounding on an infant recently admitted to the pediatric unit with a diagnosis of intussusception. As the primary nurse in charge of the infant, it is imperative to know the signs and symptoms that would alert the nurse to a potential complication or deterioration in the infant's condition. What signs might the infant exhibit if deteriorating to a state of shock? Select all that apply.



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Child Intussusception - References

References

McRae JE,Quinn HE,Saravanos GL,McMinn A,Britton PN,Wood N,Marshall H,Macartney K, Paediatric Active Enhanced Disease Surveillance (PAEDS) annual report 2016: Prospective hospital-based surveillance for serious paediatric conditions Communicable diseases intelligence (2018). 2019 Feb 1;     [PubMed]
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Isaacs D, Intussusception after rotavirus vaccine in Africa. Journal of paediatrics and child health. 2018 Dec;     [PubMed]
Restivo V,Costantino C,Giorgianni G,Cuccia M,Tramuto F,Corsello G,Casuccio A,Vitale F, Case-control study on intestinal intussusception: implications for anti-rotavirus vaccination. Expert review of vaccines. 2018 Dec;     [PubMed]
Bogdanović M,Blagojević M,Kuzmanović J,Ječmenica D,Alempijević Đ, Fatal intussusception in infancy: forensic implications. Forensic science, medicine, and pathology. 2018 Nov 5;     [PubMed]
Cha PI,Gurland B,Forrester JD, First Reported Case of Intussusception Caused by Escherichia coli O157:H7 in an Adult: Literature Review and Case Report. Surgical infections. 2019 Jan;     [PubMed]
Wu PW,Wang CC, Concurrent Campylobacter jejuni bacteremia and intussusception in an immunocompetent five-year-old child. Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi. 2018 Sep 24;     [PubMed]
Zhang Y,Zou W,Zhang Y,Ye W,Chen X,Liu Q,Liu H,Si C,Jia H, Reducing Antibiotic Use for Young Children with Intussusception following Successful Air Enema Reduction. PloS one. 2015;     [PubMed]
Sáez-Llorens X,Velázquez FR,Lopez P,Espinoza F,Linhares AC,Abate H,Nuñez E,Venegas G,Vergara R,Jimenez AL,Rivera M,Aranza C,Richardson V,Macias-Parra M,Palacios GR,Rivera L,Ortega-Barria E,Cervantes Y,Rüttimann R,Rubio P,Acosta CJ,Newbern C,Verstraeten T,Breuer T, A multi-country study of intussusception in children under 2 years of age in Latin America: analysis of prospective surveillance data. BMC gastroenterology. 2013 May 27;     [PubMed]
Davidson A, Anesthetic management of common pediatric emergencies. Current opinion in anaesthesiology. 2013 Jun;     [PubMed]
Rice-Townsend S,Chen C,Barnes JN,Rangel SJ, Variation in practice patterns and resource utilization surrounding management of intussusception at freestanding Children's Hospitals. Journal of pediatric surgery. 2013 Jan;     [PubMed]
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