INTUSSUSCEPT

ION
IN THE PAEDIATRIC PATIENT
DR BACOMBES UNIT

THE BAISICS
An invagination of a part of the intestine into itself
The intussusceptum, a proximal segment of bowel, telescopes
into the intussuscipiens, a distal segment, dragging the
associated mesentery with it
Occurs most often near the ileocecal junction (ileocolic
intussusception)
Can also be Ileo-ileo-colic, jejuno-jejunal, jejuno-ileal, or colocolic
This leads to the development of venous and lymphatic
congestion with resulting intestinal edema, which lead to
ischemia, perforation, and peritonitis
It is the most common abdominal emergency in early
childhood

EPIDEMIOLOGY
Is the most common cause of intestinal obstruction in
infants between 6 and 36mo of age.
60 % of children are younger than one year old, and 80 %
are younger than two.
Intussusception is less common before 3mo and after 6yr
of age.
Male:female ratio of 3:2.

ETIOLOGY
Approximately 75 % of cases are idiopathic. In these cases
there is no clear disease trigger or pathological lead point.
Most common in children between 3mo and 5yr of age.
25 % of cases involve a pathological lead point, which may
be focal or diffuse. Such triggers are more common in
children younger than 3MO or older than 5Yr.
A lead point is a lesion or variation in the intestine that is
trapped by peristalsis and dragged into a distal segment of
the intestine, causing intussusception
Eg: A Meckel diverticulum (most common), polyp, tumor,
hematoma, or vascular malformation can act as a lead point
for intussusception

ETIOLOGY
There also exists evidence for the influence of viral factors:
Has a seasonal variation, with peaks coinciding with seasonal viral
gastroenteritis
Associated with some forms of rotavirus vaccine
30 % experience viral illness (URTI, otitis media, flu-like symptoms)
before the onset of intussusception
A strong association with adenovirus infection
Viral infections, including enteric adenovirus, can stimulate lymphatic tissue in the
intestinal tract, resulting in hypertrophy of Peyer patches in the lymphoid-rich
terminal ileum, which may act as a lead point for ileocolic intussusception .
treatment with glucocorticoids has been suggested to prevent recurrence.

Bacterial enteritis (Salmonella, E. Coli, Shigella, or

Campylobacter).
Most cases of
intussusception occurred within the first month after bacterial
enteritis.

ETIOLOGY
Postoperative(usually jejuno-jejunal or ileo-ileal) is thought to be
caused by uncoordinated peristaltic activity and/or traction from sutures
or devices.
Affected patients typically do well for several days and may even
resume oral intake before developing symptoms of mechanical
obstruction
The diagnosis can be difficult to establish because intussusception may
be confused with postoperative paralytic ileus.
Evaluation with ultrasonography or (CT) scanning can establish the
diagnosis, monitor for spontaneous reduction, and help to predict which
children are likely to need surgical reduction.
Because most cases of postoperative intussusception occur in the small
intestine, contrast enemas do not usually contribute to the diagnosis.

ASSOCIATED
DISORDERS
Meckel diverticulum (a true congenital diverticulum; a vestigial remnant of
the omphalomesenteric duct)
Polyps
Duplication cysts (congenital malformations of the gastrointestinal tract.
They most frequently occur in the small intestine, particularly the ileum)
Henoch-Schnlein purpura (small-vessel vasculitis in which complexes of
immunoglobulin A (IgA) and complement component 3 (C3) are deposited on
arterioles, capillaries, and venules)
Small bowel lymphoma
Vascular malformations
Inverted appendiceal stumps
Parasites (eg, Ascaris lumbricoides)
Cystic fibrosis
Hemolytic-uremic syndrome

LEAD POINT
FORMATION
Meckel diverticulum, polyps, duplication cysts, lymphomas,
areas of reactive lymphoid hyperplasia, or other focal
abnormalities of the intestinal tract act as lead points,
dragging the intestine into a distal segment of intestine
With Henoch-Schnlein purpura, a small bowel wall
hematoma acts as the lead point. Intussusception typically
occurs after resolution of the abdominal pain
cystic fibrosis; thick inspissated stool may act as the lead
point
celiac disease; dysmotility and excessive secretions or
bowel wall weakness
Crohn disease; inflammation and stricture formation

CLINICAL
MANIFESTATIONS
Sudden onset of intermittent, severe, crampy, progressive abdominal pain,
accompanied by inconsolable crying and drawing up of the legs toward the
abdomen.
The episodes usually occur at 15 to 20 min intervals. They become more frequent
and more severe over time.
Vomiting may follow episodes of abdominal pain. Initially, emesis is non-bilious,
but it may become bilious as the obstruction progresses.
Between the painful episodes, the child may behave relatively normal and be free
of pain. As a result, initial symptoms can be confused with gastroenteritis.
As symptoms progress, increasing lethargy develops, which can be mistaken for
meningoencephalitis.
A sausage-shaped abdominal mass may be felt in the right side of the abdomen. In
up to 70 %of cases, the stool contains gross or occult blood. The stool may be a
mixture of blood and mucous, giving it the appearance of currant jelly.

CLINICAL
MANIFESTATIONS
Classic clinical manifestations (pain, a palpable sausage-shaped mass, and currant-jelly
stool) is seen in less than 15 % of patients at the time of presentation.
20 % of young infants have no obvious pain. 1/3 of patients do not pass blood or mucus,
nor do they develop an abdominal mass.
Many older children have pain alone without other signs or symptoms.
Occasionally, the initial presenting sign is lethargy or altered consciousness alone,
without pain, rectal bleeding, or other symptoms that suggest an intraabdominal
process. This clinical presentation primarily occurs in infants and is often confused with
sepsis. Thus, intussusception should be considered in the evaluation of
otherwise unexplained lethargy or altered consciousness, especially in infants.
An intussusception is sometimes discovered incidentally during an imaging study
performed for other reasons or for nonspecific symptoms. If these intussusceptions are
short and if the patient has few symptoms, they may not require intervention

DIAGNOSIS
Depends on the clinical suspicion for intussusception (typical or
atypical presentation) and experienced radiologists.
Patients with a typical presentation (sudden onset of
intermittent severe abdominal pain with or without rectal
bleeding) or characteristic findings on radiography, may
proceed directly to nonoperative reduction using hydrostatic
(contrast or saline) or pneumatic (air) enema, performed under
either sonographic or fluoroscopic guidance. In these cases, the
procedure is both diagnostic and therapeutic.
If diagnosis is unclear at presentation, initial workup may
include abdominal ultrasound or abdominal plain films. If the
study supports the diagnosis of intussusception, nonoperative
reduction is then performed.

ULTRASONOGRAPHY
The method of choice to detect intussusception. The sensitivity
and specificity approach 100 % in the hands of an experienced.
Advantages over fluoroscopy
More accurate at detecting pathological lead points
Monitoring the success of a reduction
Does not expose patient to radiation

The classic ultrasound image is a "bull's eye" or "coiled spring"

lesion representing layers of the intestine within the intestine.
In addition, a lack of perfusion in the intussusceptum detected
with color duplex imaging may indicate ischemia. USS can
diagnose the rare ileo-ileal intussusception and identify the lead
point of intussusception in 2/3 of cases .

ULTRASONOGRAPHY
Ultrasound features for small bowel intussusception
include location of the intussusception in the
paraumbilical or left abdominal region and/or lesion size
3 cm;
I n such cases, evaluation with a CT scan may help to
confirm the location of the intussusception and whether
there is a lead point.
In small bowel intussusceptions, the length of the
intussusceptum, as measured by ultrasound or CT, helps
determine prognosis and management.

PLAIN ABDOMINAL
RADIOGRAPH
Plain radiographs of the abdomen are less sensitive and
less specific than ultrasonography for the diagnosis of
intussusception, but are often performed as part of the
evaluation of patients with abdominal symptoms.
Radiographic features include signs of intestinal
obstruction, massively distended loops of bowel with
absence of colonic gas

PLAIN ABDOMINAL
RADIOGRAPH
Other findings may be seen:
A target sign, consisting of two concentric radiolucent circles
superimposed on the right kidney, represents peritoneal fat
surrounding and within the intussusception. This finding appeared in
26 % of patients.
A soft tissue density projecting into the gas of the large bowel
(representing the intussusception) is called the "crescent sign.
An obscured liver margin
Lack of air in the cecum, which prevents its visualization
pneumoperitoneum suggests that bowel perforation has occurred.
The presence of air in the cecum on at least two views had high
sensitivity for excluding intussusception with a low clinical suspicion .
more than 20 % of patients with intussusception had negative plain
films.

TREATMENT
Stable patients with a high clinical suspicion and/or
radiographic evidence of intussusception and no evidence
of bowel perforation should be treated with
nonoperative reduction.
Surgical treatment is indicated in acutely ill or
perforation. radiographic facilities and expertise to
perform nonoperative reduction are not available.
nonoperative reduction is unsuccessful, or for evaluation
or resection of a pathological lead point.
intussusception limited to the small bowel (ileo-ileal,
jejuno-ileal, or jejuno-jejunal).

NONOPERATIVE
REDUCTION
Reduction is typically performed under sonographic (ultrasound) or
fluoroscopic guidance, using either hydrostatic (contrast) or pneumatic
(air) enema. Has high success rates (80 to 95 %) and is an appropriate
choice if the treating physicians have more experience with this
technique than with ultrasound-guided reduction.
Contridications: long duration of symptoms and/or suspected bowel
perforation.
Patient should be stabilized and resuscitated with IVF, and the stomach
decompressed with a nasogastric tube. Because there is a risk of
perforation during nonoperative reduction, the surgical team should be
notified and steps should be taken to ensure that the patient is fit for
surgery.
Antibiotics are administered before attempting nonoperative reduction
because of the risk of perforation.

NONOPERATIVE
REDUCTION
After successful reduction, the patient should be observed
in the hospital for 12 to 24 hours because:
A high grade pyrexia may develop because of bacterial
translocation or the release of endotoxin or cytokines.
There is risk of developing recurrent intussusception in the
near term, possibly because of residual bowel inflammation,
which may itself act as a lead point.
Nasogastric suction usually is maintained until bowel function
has returned and the patient has had a bowel movement.
Feedings then are advanced as tolerated.

SUCCESSFUL
REDUCTION
Barium contrast enema and repeat clinical assessment can confirm
whether or not the bowel has returned to normal anatomical functionality:
Free flow of contrast or air into the small bowel. Reduction is complete only
when a good portion of the distal ileum is filled with contrast.
Relief of symptoms and disappearance of the abdominal mass. A characteristic
sound also may be appreciated with auscultation.
In some patients, the contrast material does not reflux freely into the small
bowel even with a complete reduction, however a successful reduction is
suggested by lack of a filling defect in the caecum (apart from the ileocecal
valve), and clinical resolution of symptoms and signs.
A post-reduction filling defect in the cecum commonly is seen, probably the
result of residual edema in the ileocecal valve. However, this finding cannot be
distinguished from a focal lead point by radiologic examination alone. As a
result, a repeat study or even laparotomy may be indicated if there is any
concern of a focal lead point.

BARIUM CONTRAST
ENEMA
Barium,a water-soluble contrast enema is preferred
because of the risk of perforation before or during the
procedure.
It also reduces the risk of electrolyte disturbances and
peritonitis in patients in whom perforation has occurred.

NON OPERATIVE
TECHNIQUES
Hydrostatic techniqueThe standard method of reduction is to
place a reservoir of contrast 1 meter above the patient so that
constant hydrostatic pressure is generated. With experience (and
depending upon the clinical status of the patient), a physician
may undertake a more aggressive reduction.
When hydrostatic reduction is performed under ultrasonographic
guidance, normal saline is used for the enema.
Pneumatic techniqueAir reduction techniques have gained
popularity as an alternative to the hydrostatic methods, and can
be used under either ultrasonographic or fluoroscopic guidance.
Air enemas reduce the intussusception more easily, and may be
advantageous if perforation occurs.

NON OPERATIVE
TECHNIQUES
The technique begins with insertion of a Foley catheter into the rectum.
Fluoroscopy or ultrasound is used to monitor the procedure. Air is then
instilled until the intussusceptum is pushed back gently, taking care to
avoid excessive pressure.
A sphygmomanometer can be used to monitor colonic intraluminal
pressure (typically not to exceed 120 mm Hg) to aid in reduction. Carbon
dioxide can also be used instead of air. It has the advantage of being
absorbed rapidly from the gut, is associated with less discomfort, and is
less dangerous than air, which potentially could cause an air embolism
(although air embolisms have not been reported).
Reflux of air into the terminal ileum and the disappearance of the mass
at the ileocecal valve usually indicates reduction. If fluoroscopy is used,
water-soluble contrast material can be instilled to confirm the reduction,
or the air reduction can be repeated if the completeness of reduction is
questioned.

COMPLICATIONS
Perforation of the bowel (1 % risk) on distal side of the intussusception,
often in the transverse colon, and commonly where the intussusception
was first demonstrated by radiographic studies.
Risk factors:

age younger than 6mo

long duration of symptoms (eg, 3 days or longer)
evidence of small bowel obstruction
Use of higher pressures during the reduction should not be attempted in
prolonged symptoms or any signs of peritoneal irritation or free peritoneal air.

Pneumatic reduction provides an advantage if perforation occurs. When

perforation is noted with air reduction, the colonic wall tears are smaller
than those observed with the hydrostatic contrast techniques, and
peritoneal pathology tends to be minimal.
Needle decompression of the abdomen may be necessary if the excess air
in the peritoneal cavity compromises the patient's respiratory status.

THANK YOU