The Telescoped Intestines

Arnulfo Velasquez
California State University, Stanislaus

The Telescoped Intestines

There are many diseases that affect the pediatric population, some are more common than
others. More specifically when talking about intestinal obstruction there is a clear complication
that is more common than the rest. Intussusception is the most frequent reason for acute
intestinal obstruction in kids that under the age of five (Hockenberry & Wilson, 2009). This was
experienced firsthand at the Children's Hospital in Madera, California during a clinical rotation.
During this experience the care of a child with intussusception was done alongside the
emergency department nurse. During the time there the assessment was done of a patient
suffering from intussusception, and the treatment of this patient was also witnessed. There were
a lot of similarities and a few differences between the patient cared for and what the literature
says.
Intussusception is primarily common in the first two years of life, in fact 80 to 90 percent
of children who suffer from intussusception are under the age of 2 (Kitagawa & Miqdady, 2013).
To be even more specific it occurs 38 times for every 100,000 births during their first year of life
and 31 times for every 100,000 births in the second year of life (Riera, Goodman, Hsiao, Chen,
& Langhan, 2012). There is no evidence that shows any increase incidence rate with being born
prematurely, but there is evidence that says it is more common in males compared to females.
The ratio for this is three males suffer from this to every two females. Most of the time it occurs
in healthy well-nourished children (Kitagawa & Miqdady, 2013). The patient that was cared for
at the Children's Hospital does not fit in the norm because he was over the 2 year mark at 2 years
and 4 months of age. He falls in to a different statistic which is one of cases that happen in the
third year of life. In the third year of life there are 26 cases for every 100,000 births that occur
(Kitagawa & Miqdady, 2013). When the parent of the patient was asked if there was anyone else

in their family who had ever suffered from intussusception and the answer was a clear no. There
is also no scientific evidence that shows any genetic link to increasing chance of intussusception.
This disease seems to just not leave kids alone and the reason for 75 percent kids acquiring this
is idiopathic (Kitagawa & Miqdady, 2013).
Intussusception is when a proximal portion of the of the bowel telescopes into a distal
portion of the bowel, pulling the associated mesentery with it. There could also be a lead point
that causes the telescoping of the intestines. The lead point is some lesion or variation that is
trapped in the intestines by peristalsis. Things that can act as a lead point can consist of a Meckel
diverticulum, polyp, tumor, hematoma, or vascular malformation. When intussusception happens
it leads to the production of venous and lymphatic congestion. This usually results in edema of
the intestines, which could eventually lead to ischemia, perforation, and peritonitis (Kitagawa &
Miqdady, 2013). When there is venous inflammation it also causes blood to leak into the lumen
of the intestines, which results in bloody stools (Hockenberry & Wilson, 2009). This would be
one of the many signs of intussusception that may be presented.
There a various signs and symptoms seem in a child when they are being affected by
intussusception. They typically develop a sudden start of severe, intermittent, progressive pain
and the child is crying without being consoled. One of the actions the child takes is bringing their
legs up to their chest. With more time that passes the pain becomes more severe and frequent. It
is important to know is that the child may behave normal and hove no pain at all between
episodes of pain. The child may also commence to vomit after the episodes of pain. The vomit is
non-bilious, but it could become bilious if the obstruction becomes worse. Another sign seen is a
red currant jelly-like stool that contains blood and mucous. The blood comes from the venous
inflammation that allows blood to leak into the intestinal lumen. Upon physical assessment of a

patient with intussusception it is very common to feel a sausage-like mass on the right side of the
abdomen (Kitagawa & Miqdady, 2013). Some other signs and symptoms are tender and
distended abdominal pain. They also eventually have a fever, prostration, and other signs of
peritonitis (Hockenberry & Wilson, 2009). Although the triad of intussusception is abdominal
pain, blood in stool , and sausage like mass, all three are only seen 15 percent of cases (Kitagawa
& Miqdady, 2013). The patient taken care of at Children's Hospital only had two of these, which
were the bloody stool and the severe abdominal pain. The patient was not wanting to move at all
and was continually crying. The parents said that the child had been vomiting and complaining
that his stomach was hurting while he was at home. When palpating the right side of the
abdomen the sausage-like mass was not found and his temperature was 98.1 degrees Fahrenheit.
This temperature is a normal finding and it indicates that the patient has not developed a fever.
Overall the patient manifested most of the signs and symptoms that are seen in the literature with
the exception of a few.
There are several ways to accurately diagnose if a patient is suffering from
intussusception or if it is just any ordinary stomach ache. A diagnostic test is usually ordered
when there are typical presentations that increase the suspicion of intussusception. There are
many different diagnostic tests. They are ultrasound, fluoroscopy, abdominal plain films,
hydrostatic or pneumatic enemas with sonographic or fluoroscopic guidance, and computed
tomography scan (CT). The diagnostic of choice in most of the institutions in the United States
of America is ultrasonography. An ultrasound is much more reliable to detect the pathological
lead points of the intussusception. The lead point of the intussusception is identified in two thirds
of cases (Kitagawa & Miqdady, 2013). Another benefit of the ultrasound is that it does not
expose the children to radiation. When looking at ultrasound to diagnose the classic image to see

is a target sign consisting of two concentric radiolucent rings superimposed on the right kidney.
This is seen in 26 percent of patients (Kitagawa & Miqdady, 2013). The abdominal plain film are
plain radiographs of the abdomen and are far less specific to the diagnoses of intussusception.
They are usually done as an opening evaluation with patients that have the symptoms. A study
showed that 20 percent of patients that had intussusception has negative plain films (Kitagawa &
Miqdady, 2013). This give a clear understanding of how unreliable this form of diagnosis is. The
hydrostatic enema is when they give an enema using either a contrast solution or just saline. The
pneumatic enema is when they give an enema using air. When these are performed they have
sonographic and fluoroscopic guidance to be able to see if the diagnosis is confirmed. These
enemas can be treatments as well as being a diagnostic tool. The last choice of the diagnostic
tests is the CT scan. This is chosen last due to it being more time consuming, and the children
usually have to be sedated to perform the CT scan. The CT scan is generally used only on the
patients that tried the other imaging sources and could not get a confirmed diagnosis. They are
also reserved to be used in characterizing the pathological lead points (Kitagawa & Miqdady,
2013). One thing to keep in mind is that the most excellent tactic for diagnosing depends on the
clinical suspicion, due to the presentation, for intussusception. The patient that was admitted in to
Children's Hospital got to experience some these techniques. After the doctor and nurse
discussed all of the clinical manifestations the doctor decided to order an ultrasound. The
ultrasound then confirmed the diagnosis of intussusception, so the ultrasound was deemed
positive for intussusception. There were no labs drawn or ordered while the patient was in the
emergency department. The next step was for the doctor decide on the treatment of this child.
The literature states that if a patient is stable and there is no evidence of perforation in the
bowel they should be treated with a nonoperative technique. The nonoperative techniques consist

of the hydrostatic and pneumatic enemas and these have very sigh success rates in children with
intussusception. This by far the treatment of choice (Kitagawa & Miqdady, 2013). The one big
risk of this treatment is the chance of perforating the bowel if there is too much pressure applied,
but the risk of this actually happening is only 1 percent (Kitagawa & Miqdady, 2013). These
enemas are performed with a fluoroscopic guidance and have a success rate of 80 to 95 percent
(Kitagawa & Miqdady, 2013). In the pneumatic enema the patient has a Foley catheter inserted
in the rectum. Air is then instilled without applying too much pressure because perforation is still
a risk. They can also use carbon dioxide instead of air, and it has an advantage due to it being
related to less dicomfort in the gut and is less dangerous than air (Kitagawa & Miqdady, 2013).
The benefit of a pneumatic over a hydrostatic is that there is less complication with air during
perforation than a contrast liquid or saline. If the patient at hand is acutely ill or is known to have
perforation it is highly recommended that surgery is used as the treatment. Another reason
surgery could be used is that the facility of the patient does not have radiographic expertise is not
available easily. Lastly surgery is also used for treatment when the patient has tried the
nonoperative techniques and have failed to have a reduction done (Kitagawa & Miqdady, 2013).
The patient that was being helped at Children's Hospital was not acutely ill and did not have
perforation of the bowel, so the doctor chose to go with the nonoperative route. The doctor
decided to go with the hydrostatic enema, using 5 bottles that were 300 ml each of 8.5 percent
organically bound iodine. It was called Cystografin dilute (Diatrizoate Melgumine), and it was a
water soluble liquid. This was a different solution being used than what is taught in courses at
certain universities. Traditionally the contrast used in a hydrostatic enema was barium. Now the
water soluble contrasts are favored due to risk of perforation of the bowel during the procedure.
The water soluble solution reduces the risk of electrolyte imbalance and peritonitis in patient's

that suffer of a perforation during the procedure (Kitagawa & Miqdady, 2013). The sonographer
that performed the procedure just looked at a screen while the contrast was being instilled and in
less than a minute the reduction had occurred. The patient was free of pain instantly. The same
kid that was complaining of pain and not moving due to the pain was now smiling and jumping
around like a normal kid. The treatment of this child went right along with the literature that is
out on treatments for intussusception.
The patient was admitted to the medical surgical floor soon after the hydrostatic enema
due to the chance of reoccurrence of intussusception. There is a 10 percent chance the
intussusception recurs in a successful nonoperative reduction and therefore the child should be
monitored closely for the next day or two (Kitagawa & Miqdady, 2013). There is no long term
management. Once it is cured that is it no follow up in necessary. There is no medication the
child needs to take either and can begin having his normal diet.
Intussusception happens so often in kids and is one of the biggest reason kids are seen in
the emergency department with acute abdominal pain. It was very astonishing to see a real life
case of intussusception and that it was so similar to the literature of how to manage this
complication.

References
Hockenberry, M. J. & Wilson, D. (2009).Wongs Essentials of Pediatric Nursing (8th ed.). St.
Louis, Mo: Mosby Elsevier.
Riera, A., Goodman, R., Hsiao, A.L., Chen, L., Langhan, M. (2012). Diagnosis of
intussusception by physician novice sonographers in the emergency department. Annals
of Emergency Medicine, 60, pg 264-268.
Kitagawa, S., Miqdady, M. (2013). Intussusception in children. Retrieved from
http://www.uptodate.com.