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Intussusception
Alexandra C. Maki • Mary E. Fallat
Intussusception is the most frequent cause of bowel most common lead point is a Meckel diverticulum fol-
obstruction in infants and toddlers. It is an acquired lowed by polyps and duplications. Other benign lead
invagination of the proximal bowel (intussusceptum) into points include the appendix, hemangiomas, carcinoid
the distal bowel (intussuscipiens). It was first described in tumors, foreign bodies, ectopic pancreas or gastric
1674 by Paul Barbette of Amsterdam, defined by Treves mucosa, hamartomas from Peutz–Jeghers syndrome (Fig.
in 1899, and operated on successfully in 1873 by John 38-1), and lipomas. Malignant causes, although rare,
Hutchinson.1,2 increase in incidence with age and include lymphomas
and small bowel tumors.13 Systemic diseases, including
Henoch–Schönlein purpura and cystic fibrosis, have been
PATHOPHYSIOLOGY associated with intussusception. Other rare diseases
related to intussusception are celiac disease and Clostrid-
The intussusceptum telescopes into the distal bowel by ium difficile colitis.14
peristaltic activity. There may or may not be a lead point.
As the mesentery of the proximal bowel is drawn into
the distal bowel, it is compressed, resulting in venous INCIDENCE
obstruction and bowel wall edema. If reduction of the
intussusception does not occur, arterial insufficiency Idiopathic intussusception can occur at any age. Most
will ultimately lead to ischemia and bowel wall necrosis. patients are well-nourished, healthy infants, and approxi-
Although spontaneous reduction can occur, the natural mately two-thirds are boys. The highest incidence occurs
history of an intussusception is to progress to bowel in infants between ages 4 and 9 months,15 and it is also
ischemia and necrosis unless the condition is recognized the most common cause of small bowel obstruction in
and treated appropriately. this age group.16 Intussusception is uncommon below 3
months and after 3 years of age. The condition has been
described in premature infants where it has been postu-
Primary Intussusception lated as the cause of small bowel atresia in some cases.17
The vast majority of cases do not have a lead point and are
classified as primary or idiopathic intussusceptions. The
cause is generally attributed to hypertrophied Peyer CLINICAL PRESENTATION
patches within the bowel wall.3 Intussusception occurs
frequently in the wake of an upper respiratory tract infec- The classic presentation is an infant or a young child with
tion or an episode of gastroenteritis, providing an etiology intermittent, crampy abdominal pain associated with
for the hypertrophied lymphoid tissue. Adenoviruses in ‘currant jelly’ stools and a palpable mass on physical
children older than age two, and to a lesser extent rotavi- examination, although this triad is seen in less than a
ruses, have been implicated in up to 50% of cases.4,5 Other fourth of children.18 The abdominal pain is sudden and
contributing evidence that viruses may play a role in the child may stiffen and pull the legs up to the abdomen.
intussusception includes the rise in cases during seasonal The pain can also be associated with hyperextension,
respiratory viral illnesses and the increased risk associated writhing, breath holding and vomiting. The attack often
with previous rotavirus immunization.6 The newest ceases as suddenly as it started. Between attacks, the child
immunization formulas available in the USA, RotaTeq® may appear comfortable but eventually will become
and Rotarix®, have not been associated with intussuscep- lethargic. Small or normal bowel movements will stop as
tion in both pre- and post-marketing studies.6–10 the obstruction progresses and becomes associated with
bilious emesis and increasing abdominal distention.
Stools may be blood tinged as impending ischemia causes
Secondary Intussusception mucosal sloughing and compression of mucous glands
An intussusception may have an identifiable lesion that leading to evacuation of dark, red mucoid clots or ‘currant
serves as a lead point, drawing the proximal bowel into jelly’ stools. This is often a late sign as are laboratory
the distal bowel by peristaltic activity. The incidence of derangements. A pitfall is to wait for the currant jelly
a lead point varies from 1.5% to 12% and the presence stool, leukocytosis, and electrolyte abnormalities that are
of a lead point increases in proportion with age.11,12 The often hallmarks of ischemic bowel.
531
532 SECTION IV Abdomen
A B C
FIGURE 38-1 ■ (A) Operative view of the outside of the jejunum shows a palpable mass as the lead point of a reduced intussuscep-
tion. (B) A hamartomatous polyp is characteristic of Peutz–Jeghers syndrome. (C) Mucocutaneous macular lesions are seen in this
patient with Peutz–Jeghers syndrome. Note extension of the pigmentation beyond the vermilion border.
FIGURE 38-2 ■ This 10-year-old boy has a palpable sausage- FIGURE 38-3 ■ This abdominal radiograph in a patient with intus-
shaped mass (arrows) due to an intussusception. susception shows dilated loops of small bowel in the right lower
quadrant and a right upper quadrant soft tissue mass density
in the vicinity of the transverse colon near the hepatic flexure
PHYSICAL EXAMINATION (arrow).
utilized as a screening tool when one of the abnormal intussusception.21 Equivocal findings using this modality
findings listed above is found.19 should mandate a conventional contrast or air enema.23
A B C
FIGURE 38-6 ■ Concurrent contrast enema and pelvic CT images of an intussusception. (A) Contrast study showing the intussusception
low in pelvis. (B) CT image of the intussusception. (C) CT image of the ‘layered’ intussuscepted mass. This is the ‘target sign’ on CT.
534 SECTION IV Abdomen
should be based on clinical findings in symptomatic for younger infants and 110–120 mmHg for older infants.
patients.25 Laparoscopy is an excellent means to evaluate Potential drawbacks of pneumatic reduction include the
these patients if surgical intervention is needed. possibility of developing tension pneumoperitoneum,
and poor visualization of lead points and/or the intus-
susception reduction process, resulting in false-positive
NONOPERATIVE MANAGEMENT reductions.32–34 Rates of perforation range from 0.4–2.5%
with the most recent publications citing an average rate
If the diagnosis of intussusception is suspected, a nasogas- of 0.8%.16,35
tric tube may be helpful to decompress the stomach. Tension pneumoperitoneum is best treated with
Bowel rest and intravenous fluid resuscitation should be immediate cessation of the procedure and immediate
initiated. A complete blood cell count and serum electro- release of the pneumoperitoneum using a 14, 16, or
lytes are obtained. An air or contrast enema is first-line 18-gauge needle or angiocatheter above or below the
treatment as long as there are no contraindications to umbilicus. This should be followed by immediate opera-
nonoperative reduction. Contraindications include intes- tive exploration.36
tinal perforation (free intra-abdominal air), peritonitis, or For unsuccessful reduction, several studies have shown
persistent hypotension. The advantages of nonoperative improved reduction rates using a second attempt after
reduction are decreased morbidity, cost, and length of waiting between 30 minutes to 24 hours after the initial
hospitalization. attempt.28 In some instances, this is done in the operating
room prior to laparoscopy or in conjunction with laparo-
scopic reduction.37
Hydrostatic and Pneumatic Reduction If nonoperative reduction is successful either by
The methodology for hydrostatic reduction has not hydrostatic or pneumatic technique, the patient should
changed significantly since its first description in 1876.26 be admitted for observation, receive a short period of
Hydrostatic reduction with barium under fluoroscopic bowel rest, and given intravenous fluids. Any clinical
guidance has historically been used.27 More recently, chil- signs of abdominal pain after reduction could be a sign
dren’s hospitals have transitioned to air or water-soluble of ischemic bowel or recurrent intussusception and repeat
isotonic contrast because of the potential hazard of ultrasound is necessary.
barium peritonitis in patients with intestinal perfora-
tion16,28. Successful reduction (Fig. 38-7) in uncompli-
cated patients is seen in about 85% of cases and ranges
from 42% to 95%.29
OPERATIVE MANAGEMENT
Pneumatic reduction was first described in 1897.30 It Open Approach
gained popularity in the late 1980s. Since then, many
institutions have adopted pneumatic decompression An operation is needed when nonoperative reduction is
because it is quicker, safer, less messy, and decreases the unsuccessful or incomplete, for signs of peritonitis, the
exposure time to radiation.31 The procedure is fluoro- presence of a lead point, or radiographic evidence of
scopically monitored as air is insufflated into the rectum pneumoperitoneum. Preoperative preparation includes
(Fig. 38-8). The maximum safe air pressure is 80 mmHg administration of broad-spectrum antibiotics, intravenous
A B C
FIGURE 38-7 ■ Fluoroscopic examination using isotonic contrast for hydrostatic reduction of intussusception. (A) Intussusception
(arrow) seen in midtransverse colon. (B) Reduction has occurred to the hepatic flexure. (C) Complete reduction with reflux of contrast
medium into the terminal ileum. Note the edematous ileocecal valve (arrow).
38 Intussusception 535
AA B C
FIGURE 38-8 ■ Plain radiography and fluoroscopic examination using air for pneumatic reduction of an intussusception. (A) Plain
radiograph showing a mass effect in the right upper quadrant. (B) Pneumatic reduction to the vicinity of the cecum with the intus-
susception still present (arrow). (C) Complete reduction with reflux of air into multiple loops of small intestine. (Courtesy of Charles
Maxfield, MD.)
Laparoscopic Approach
Initially, the use of laparoscopy in the operative manage-
ment of intussusception was strictly diagnostic, or was
FIGURE 38-9 ■ A right lower quadrant muscle-splitting incision
allows delivery of the intussusception through the incision. used in cases with equivocal radiographic studies or in
Gentle and continuous massage from distal to proximal usually patients with suspected lead points, and was associated
results in reduction of the intussusception. with conversion rates in up to 70% of cases.40 More
recently, there has been increased success with laparo-
scopic reduction with some studies showing conversion
fluid resuscitation, insertion of a urinary catheter, and rates as low as 5.4%41 but more in the range of
placement of a nasogastric tube for gastric decompression. 12–40%.37,42–44
Most commonly, the cecum and terminal ileum are Where laparoscopy fits into a surgeon’s therapeutic
involved, and can be delivered through the traditional algorithm is a topic frequently discussed. It would be
right lower abdominal incision (Fig. 38-9). It is important beneficial to identify any preoperative risk factors. No
to evaluate the extent of the intussusceptum before deliv- study to date has specifically addressed this topic although
ering it as it can extend into the rectosigmoid region in some have noted an increased conversion rate associated
severe cases which usually requires extension of the with lead points. Recently, a retrospective analysis of
incision. 65 cases found that in patients unable to be reduced
Once the leading edge of the intussusceptum is identi- laparoscopically, 33% had a lead point that necessitated
fied, it is gently manipulated back toward its normal posi- conversion to open (Fig. 38-10).45 Contraindications to
tion in the terminal ileum. Excessive force or pulling is laparoscopy include peritonitis, hemodynamic instability,
avoided to prevent injury or perforation of the bowel. and severe bowel distension that precludes adequate
Inability to manually reduce the intussusception, the visualization.41
536 SECTION IV Abdomen
A B
FIGURE 38-10 ■ (A) This laparoscopic photograph shows an incompletely reduced intussusception with the intussusceptum (white
arrow) telescoping into the intussuscipiens (black arrow). (B) A pathologic lead point due to a Burkitt lymphoma was found requiring
conversion to open.
A B
C D
FIGURE 38-11 ■ Laparoscopic reduction of intussusception with hypertrophied lymph nodes is depicted in these four operative pho-
tographs. (A) Intussusceptum (white arrow) is seen telescoping into the intussuscipiens (black arrow). (B) The intussusception has
almost been completely reduced. (C) This intussusception has been completely reduced and the bowel appears viable. (D) Hyper-
trophied mesenteric lymphadenopathy (arrows) is seen. This lymphadenopathy may reflect a recent viral illness.
38 Intussusception 537
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