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Intussusceptum
=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)
Resulted in 15 cases of intussusception which occurred 3-14 days after the first
injection
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
crescent
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
There are not yet any large, prospective studies comparing the success
of pneumatic vs hydrostaticstay tuned
Pneumatic Enema: Before and After
Barium Enema:
From dusk till
dawn
Treatment
17% of IS spontaneously reduce
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!
Appendicolith!!
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.
Daneman A, Navarro O. Intussusception, Part 1: A review of diagnostic approaches Pediatr Radiol (2003) 33: 79-85.
Daneman A, Navarro O. Intussusception, Part 2: An update on the evolution of management Pediatr Radiol (2004) 34: 97-
108.
Daneman A, Navarro O. Intussusception, Part 3: Diagnosis and management of those with an identifiable or predisposing
cause and those that reduce spontaneously Pediatr Radiol (2004) 34: 305-312.
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.
Meyer JS. The current radiologic management of intussusception: a survey and review Pediatr Radiol (1992) 22:323-325.
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.
Verschelden P, Filiatrault D, et al. Intussusception in children: reliability of US in diagnosis prospective study Radiol
(1992) 184: 741-744.