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Intussusceptu
m
=proximal
portion
Intussuscipen
=distal portion
Epidemiology
Second most common cause of acute abdominal pain in
children following appendicitis
2. Intramural
=Bowel wall abnormality prevents normal
contraction, a.k.a. lead point
3. Extraluminal
=Extraluminal abnormality prevents
normal contraction, a.k.a. lead point
Why does IS happen?
Idiopathic 60%
Most are ileocolic
Hypotheses of etiologies:
-Lymphoid tissue swelling
-Dietary factors
-Rotavirus and polio vaccine
-Mesenteric LN swelling
Just as a refresher
The Rotavirus Connection
Rhesus rotavirus tetravalent (RRV-TV) was introduced in 1998 as
a 3 part vaccination (2, 4, 6 months)
Possible causes
-bolus of virus causing high viral titer
-replication of wild-type rotaviruses
Infarction,
perforation
Multiple studies have shown that classic triad is only present in 20-50%
70% found to have 2 sx
9% found to have 1 sx
Other common signs of
presentation
Colicky pain found to be best indicator
85% incidence
4-5 min of pain + pulling up knees to abdomen 10-20
min of rest
Lethargy
Irritability
Vomiting
Diarrhea/Constipation
Uses:
-Diagnosis of IS
-Evaluating for risk of perforation before enema
treatment
-Diagnosis of other diseases (SBO, LBO, volvulus)
Findings:
1) Intracolonic mass
2) Target sign
3) Crescent sign
4) SBO
5) Presence/absence of gas in RLQ
Where is
the
target
sign?
Created by
gas trapped
between two
layers of
intestinal
wall
Where
is the
crescen
t sign?
Created by
gas
surrounding
invagination
Gas in RLQ?
There is dilation of
LUQ, but no
presence of gas
anywhere else in
the bowel.
Literature review
(Ratcliffe, et al) Four observers evaluated 1120 plain films for 4
IS signs (mass, target, crescent, SBO)
Crescent sign most accurate, but least common (30%)
Abdominal mass most unreliable, but most common (78%)
Target sign in middle
SBO not specific for IS
(Sargent, MA) Three observers evaluated 182 AXR (60 with IS,
122 without IS) to determine interobserver variability and validity
of IS signs
Agreement among all observers in only 7pts with IS
Equivocal reading in >50% overall
PPV of 32-42%, depending on position of AXR
Abdominal mass and absence of RLQ gas has best PPV
Findings:
-target sign (transverse)
-pseudokidney or sandwich sign
(longitudinal)
Target Sign
Cylindrical
hyperechoic center
(C) that continues
from intestinal
lumen and is
surrounded on both
sides by
hypoechoic
mesentary (M)
Literature
(Pracros, et al) Found 100% accuracy in diagnosing
145 cases of IS out of 426 pts with clinical suspicion
-IS diagnosis must have 3 findings: target sign,
sandwich sign (found longitudinally) and
continuity between intestinal lumen and
intussusceptum
-Needs to be scanned in transverse and saggital
section
Hydrostatic
Pros - No staining of peritoneum
Cons Could cause rapid fluid shifts if not using
isoosmolar concentrations
Barium
Pros Familiar technique
Cons Perforation, higher chance of peritoneal
contamination
Pt is 8 yo girl in
ED with low-
grade fever and
colicky R
abdominal pain.
ED physician
wants a barium
enema.
You think
WWADFBVD
??
(What would a doctor from Burlington, Vermont do???)
Answer:
Look
closer!
Appendicolit
h!!
The next night
ED calls for a 5 month old male with colicky abdominal
pain and a RUQ longitudinal mass
See
anything
?
Crescent
sign!
THE
END!!!
References
Agostino JD. Common abdominal emergencies in children Emer Med Clinics of N Amer (2002)
20(1): 139-151.
Bruce J, Soo YH, Cooney DR, et al. Intussusception: evolution of current management Journ
Pediatr Gastroen and Nutr (1987) 6:663-674.
Byrne AT, Goeghegan T, Govender P, Lyburn ID, Colhoun E, Torreggiani WC. The imaging of
intussusception Clin Rad (2005) 60: 39-46.
Daneman A, Alton DJ. Intussusception: issues and controversies related to diagnosis and
reduction Pediatr Gastrointes Radiol (1996) 34(4): 743-756.
Fischer TK, Bihrmann K, et al. Intussusception in early childhood: a cohort study of 1.7 million
children Pediatr (2004) 114(3): 782-785.
Hernandez JA, Swischuk LE, Angel CA. Validity of plain films in intussusception Emer Rad (2004)
10: 323-326.
Huppertz HI, Soriano-Gabarro M, et al. Intussusception among young children in Europe Pediatr Inf
Dis Journal (2006) 25(1): S22-S29.
References cont.
Pracros JP, Tran-Minh VA, Morin De Finfe CH, Deffrenne-Pracros P, Louis D, Basset T. Acute
intestinal intussusception in children: contribution of ultrasonography (145 cases) Ann Radiol
(1987) 30(7): 525-530.
Ratcliffe JF, Fong S, Cheong L, Connell PO. The plain abdominal film in intussusception: the
accuracy and incidence of radiographic signs Pediatr Radiol (1992) 22: 110-111.
Sargent MA, Babyn P, Alton DJ. Plain abdominal radiography in suspected intussusception: a
reassesment Pediatr Radiol (1994) 24:17-20.