Intussusception in children

Seiji Kitagawa, MD; Mohamad Miqdady, MD

Up to date on line 16.1 This topic last updated: Fevereiro 4, 2008
Modificado: Jefferson P Piva

INTRODUCTION Intussusception,

Intussusception

the

slight

invagination

intestine

into

of

itself,

part
is

of

the

the
most

common abdominal emergency in early

childhood,

particularly

in

children

younger than 2 years of age, and the

second

most

intestinal

common

obstruction

cause

after

of

pyloric

stenosis [1]. Intussusception is unusual

in

adults,

and

the

diagnosis

is

commonly overlooked. In the majority

of cases in adults, a pathologic cause is
identified [2]. In contrast, the majority
of cases in children are idiopathic.
EPIDEMIOLOGY Intussusception

is

obstruction in infants between 6 and 36

of

age.

Approximately

60

percent of children are younger than 1

year old, and 80 percent are younger
than 2. Intussusception is rare before 3
months and after 6 years of age. In a
population-wide survey in Switzerland,
the

yearly

mean

incidence

of

intussusception was 38, 31, and 26

cases per 100,000 live births in the
first, second, and third year of life,
respectively, then fell to less than half
that rate in older age groups [3]. Most
episodes occur in otherwise healthy and
well-nourished children.

to

have

predominance,

with

male:female ratio of approximately 3:2.

PATHOGENESIS Intussusception
occurs most often near the ileocecal
junction (ileo-colic), although ileo-ileocolic,

jejuno-jejunal,

colo-colic

jejuno-ileal,

intussusception

also

or

have

been described. The proximal segment

of bowel telescopes into the distal
segment,

dragging

the

associated

mesentery with it. This leads to the

development of venous and lymphatic
congestion

the most common cause of intestinal

months

male

appears

with

resulting

intestinal

edema, which can ultimately lead to

ischemia, perforation and peritonitis.
A lead point can be identified in up to
25%

of

children

with

ileo-colic

intussusception. The remaining 75%

are

considered

although

an

to

be

increasing

idiopathic,
body

of

evidence suggests that viral triggers

may play a role in some cases:
The incidence of intussusception has a
seasonal
coinciding

variation,
with

with
seasonal

peaks
viral

gastroenteritis in some populations

[3,4] .
Intussusception has been associated
with some forms of rotavirus vaccine.
An early form of the vaccine (RRV-TV:
Rotashield) was removed from the

Invaginao intestinal

market because of a 22-fold increase

potentially acts as a lead point for ileo-

in intussusception among vaccinated

colic intussusception [5]. A role for

infants. The vaccine currently used in

corticosteroids

the United States (PRV: Rotateq)

recurrence has been proposed in light

appears

of

to

have

rates

of

intussusception that are similar to

expected background rates. However,
there may be additional cases of
intussusception that have not been
reported. Providers should be alert for
cases of intussusception that may be
associated with rotavirus vaccine, and
report all suspected cases to the
Vaccine

Adverse

event

Reporting

System (VAERS).
Approximately

30%

experience

viral

respiratory

tract

of

patients

illness

(upper

infection,

otitis

media, flu-like symptoms) before the

onset of intussusception.
A strong association with adenovirus

this

in

the

possible

prevention

association

of

with

lymphoid hyperplasia [10,11].

A

lead

point

is

recognized

more

commonly in children older than five

years [1,4,12]. A variety of pathologic
conditions

associated

with

intussusception, including small bowel

lymphoma [13-15], Meckel diverticulum
[16], duplication cysts [17,18] , polyps
[19], vascular malformations [20] ,
inverted appendiceal stumps [21,22] ,
parasites

(eg,

Ascaris

lumbricoides)

[23,24],

Henoch-Schnlein

purpura

[25], and cystic fibrosis [26], have

been described.
The

mechanisms

leading

to

infection has been shown in a variety

intussusception differ depending upon

of populations. In 30 to 40 % of

the specific cause. As examples:

cases, there is evidence of recent

Small

bowel

intussusception

may

infection with enteric and non-enteric

occur after an episode of Henoch-

species of adenovirus [5-9]. In a

Schnlein purpura, with a bowel wall

prospective

study

hematoma acting as the lead point. In

potential

these cases, intussusception typically

examining

case-control
a

variety

of

infectious triggers for intussusception

occurs

after

in Vietnam and Australia, infection

abdominal pain.

resolution

of

the

with adenovirus, as the strongest

In patients with cystic fibrosis, thick

predictor of intussusception in both

inspissated stool may act as the lead

populations [9].

point [26] .

Viral

infections,

including

enteric

adenovirus, can accentuate lymphatic

tissue in the intestinal tract, resulting in
hypertrophy of Peyer patches in the
lymphoid-rich

terminal

ileum,

which

Patients

with

celiac

disease

may

develop small bowel intussusception

secondary
excessive

to

dysmotility

secretion

weakness [27,28].

or

bowel

and
wall

Invaginao intestinal

Patients

with

Crohn

disease

may

the painful episodes, the child may

develop intussusception because of

behave relatively normally and be free

inflammation and stricture formation

of pain. As a result, initial symptoms

[29] .

can be confused with gastroenteritis

Postoperative: Bowel intussusception

(usually jejuno-jejunal) also has been

[30]. As symptoms progress, increasing

lethargy develops.

described in the postoperative setting

In up to 70 % of cases, the stool

where it is an uncommon but insidious

contains gross or occult blood [31]. The

cause

It

stool may be a mixture of blood and

usually occurs within two weeks of a

mucous, giving it the appearance of

laparotomy and is caused by adhesions.

currant

The patient

abdominal mass may be felt in the right

of

intestinal

typically

obstruction.

does

well

for

jelly.

sausage-shaped

several days and may even resume oral

side

intake before developing symptoms of

classically described triad of pain, a

mechanical obstruction. The diagnosis

palpable

can be difficult to establish because it

mass, and currant-jelly stool is seen in

may be confused with postoperative

less than 15 percent of patients at the

paralytic ileus. The ultrasonography and

time of presentation [30,32] . As many

computed tomography (CT) scanning

as 20% of young infants have no

may be helpful. Diagnostic contrast

obvious pain. Approximately one-third

studies

of patients does not pass blood or

are

not

as

helpful

in

postoperative intussusception because

most cases occur in the small intestine,
CLINICAL

MANIFESTATIONS:

of

abdomen.
sausage

However,

shaped

the

abdominal

mucus or develop an abdominal mass.

Occasionally, the initial presenting sign
may

be

lethargy

altered

Patients with intussusception typically

consciousness

develop

rectal bleeding, or other symptoms that

the

sudden

intermittent,

severe,

progressive

abdominal

onset

of

crampy,

suggest

an

alone,

or
without

intra-abdominal

pain,

process

pain,

[33-35]. In most cases, this clinical

accompanied by inconsolable crying and

presentation occurred in infants, and

drawing up of the legs toward the

was often confused with sepsis. Thus,

abdomen. The episodes usually occur at

intussusception should be considered in

15 to 20 minute intervals. They become

the evaluation of lethargy or altered

more frequent and more severe over

consciousness, especially in infants.

time. Vomiting may follow episodes of

abdominal pain. Initially emesis is nonbilious, but it may become bilious as
the obstruction progresses. Between

DIAGNOSIS

AND

TREATMENT A

NONSURGICAL
high

index

of

suspicion coupled with early diagnosis

Invaginao intestinal

of

intussusception

may

obviate the

need for surgical intervention.

unclear at presentation, initial workup

may include abdominal ultrasound or
abdominal plain films, provided that
these studies do not significantly delay
the definitive diagnosis and treatment
of intussusception.

whom there is a high index of suspicion

intussusception,

may

proceed

directly to an enema contrast study.

studies

can

establish

the

diagnosis of ileocolic intussusception,

and frequently also are therapeutic.
Before obtaining a contrast study, the
patient

should

be

stabilized

and

resuscitated with intravenous fluids; the

stomach should be decompressed with
a nasogastric tube. The patient should
be considered fit for surgery, in case
surgery is necessary, before he or she
undergoes radiographic imaging. The
surgical team should be notified before
attempted reduction because there is a
risk of perforation and because surgical
intervention

may

be

necessary

if

contrast enema fails to reduce the

intussusception.
Abdominal

two

concentric

superimposed

radiolucent

on

the

circles

right

kidney

representing peritoneal fat surrounding

and

within

the

intussusception,

appeared in 26% of 94 patients in one

report

[36].

soft-tissue

density

projecting into the gas of the large

bowel (intussusception image) is called

Patients with a typical presentation, in

These

suggests that bowel perforation has

occurred. A target sign, consisting of

For patients in whom the diagnosis is

for

the "crescent sign".

The presence of air in the ascending
colon

can

to

exclude

intussusception in cases with a low

clinical suspicion of the disease. In a
retrospective

study

from

single

center, plain radiographs with three

views (supine, lateral, and prone) were
used to screen patients with suspected
intussusception [37]. The presence of
air in the ascending colon on at least
two of these views had high sensitivity
for excluding intussusception in this
patient population with a low clinical
suspicion of disease (sensitivity 96.3
percent, 95% CI 89.2-100). However,
the sensitivity of plain radiographs may
be

considerably

lower

in

different

clinical settings or when fewer views

are analyzed. Therefore, we do not
recommend

relying

on

plain

films Plain

radiography to exclude intussusception

radiographs of the abdomen may be

if there is a significant clinical suspicion

helpful because they may show frank

of the disease.

intestinal

plain

help

obstruction

or

massively

distended loops of bowel with absence

of colonic gas. Although rarely seen,
the

presence

of

pneumoperitoneum

Ultrasonography Ultrasonography
also can be useful; its sensitivity and
specificity approach 100 percent in the

Invaginao intestinal

hands

of

an

experienced

water

ultrasonographer [38-40] . The classic

ileum.

ultrasound image of intussusception 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 the development of ischemia.
An advantage of ultrasonography is
that it can diagnose the rare ileoileal
intussusception and identify the lead
point

of

intussusception

in

and bubbles

Contrast

in the terminal

studies The

standard

procedure for diagnosis and treatment

of

ileocolonic

intussusception

is

contrast (air or radiopaque) enema

[46]. Broad-spectrum antibiotics may
be

administered

before

attempting

nonoperative reduction since there is a

risk

of

perforation

with

these

procedures.
As

compared

with

ileocolonic

approximately two-thirds of cases in

intussusception, small bowel (ileoileal,

which underlying pathology exists [41].

jejunoileal,

Ultrasonography may also be useful in

predicting

which

children

are

most

likely to need surgical intervention for

small bowel intussusception. In a small
retrospective study, cases in which the
intussusceptum was less than 3.5 cm
were

more

likely

to

resolve

or

jejunojejunal)

intussusception is less likely to be

reducible by contrast enema [47,48].
Intussusceptum length as measured by
ultrasonography

may

be

helpful

in

determining which patients may be

managed expectantly, and which are
likely to require surgical intervention.

spontaneously during or shortly after

Barium

the ultrasonographic examination as

contrast Traditionally,

compared

been the preferred contrast agent in

to

cases

with

longer

under

water-soluble
barium

has

most North American and European

intussusceptum [42] .
Reduction

and

ultrasonographic

control without fluoroscopy has been

described [43,44] . Signs of successful
reduction include the disappearance of
the intussusception and the retrograde
flow of the water-soluble contrast into
the small intestine. Ultrasound guided
water enema also has been used [45].

centers

[49-51].

Before

instilling

barium, a water-soluble contrast enema

should be considered, particularly if
there is a high risk of perforation.
Water-soluble agents reduce the risk of
electrolyte disturbances and peritonitis
in patients in whom perforation has
occurred.

Signs of successful reduction with water

Barium

include

the

intussusception can be performed if

intussusception and the appearance of

there is no evidence of perforation. The

the

disappearance

of

enema

reduction

of

Invaginao intestinal

standard method of reduction is to

valve. However, benign and malignant

place a reservoir of barium 1 meter

lesions

above the patient so that constant

radiologic

hydrostatic pressure is generated. With

result,

experience (and depending upon the

laparotomy may indicate if any concern

clinical

of a benign or malignant lead point

status

physician

of

may

the

patient),

undertake

more

aggressive reduction.

cannot
a

repeat

study

As

or

even

After the successful reduction of an

the

temperature

intraluminal-filling

alone.

by

exists [53].

ileo-colic

column

distinguished

examination

In a typical ileo-colic intussusception,

barium

be

appears

as

defect.

an
The

intussusception,
higher

than

38C

(100.4F) often is noted because of the

intussusception can be found in any

release

part of the large bowel, even the

bacterial

rectum. Occasionally, some barium may

should be admitted to the hospital for

coat

12

the

outer

surface

of

the

of

to

endotoxin,

cytokines,

translocation.
24

hours

The

for

or

patient

observation.

intussuscipiens, resulting in a coiled

Nasogastric

spring pattern.

maintained until bowel function has

Successful reduction is indicated by the

free flow of contrast into the small
bowel. Reduction is complete only when
a good portion of the distal ileum is

suction

returned

and

the

passage

of

Feedings

then

usually

patient
bowel

are

has

is
had

movement.

advanced

as

tolerated.

filled with barium, thus excluding ileo-

Air

ileal intussusception. Other indications

techniques have gained popularity as

of successful reduction include relief of

an

symptoms and disappearance of the

hydrostatic

abdominal mass. A characteristic sound

technique begins with insertion of a

also

Foley

may

be

appreciated

with

contrast Air
alternative

to

methods

catheter

contrast

[54-57].
the

rectum.

contrast material does not reflux freely

presence of bowel gas in the abdomen.

into the small

Air is then instilled, initially by hand

complete reduction, but no filling defect

pump, until the diagnosis is established

in the cecum is present apart from the

and the intussusceptum is pushed back

ileocecal valve and symptoms and signs

gently [49,50] .

with

of these patients resolve.

to

The

Fluoroscopy

even

used

the

auscultation. In occasional patients, the

bowel

is

into

reduction

assess

the

An electric pump is connected if the

A post-reduction filling defect in the

intussusceptum stops moving despite

cecum commonly is seen, probably the

the use of the hand pump. Both of

result of residual edema in the ileocecal

these pumps must have a pressure

Invaginao intestinal

release system so that the pressure

symptoms or any signs of peritoneal

remains between 80 and 120 mmHg.

irritation or free peritoneal air.

Carbon dioxide can 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
indicate reduction.

Success

rate Nonoperative

reduction using barium or air contrast

techniques

is

successful

in

approximately in 60 to 90% of patients

with ileo-colic intussusception [3,6466]. Success is more likely to be
achieved in patients with idiopathic
intussusception (ie, no identifiable lead
point),

although

accomplished

in

it

also

patients

can
with

be
a

recognized lead point [53]. Successful

An advantage of this method is the

radiographic reduction is more likely if,

ease with which the intussusception can

during reduction, the small bowel is

be reduced with less radiation exposure

visualized before the appendix [67].

and cost, and the relatively harmless

nature of air in the peritoneal cavity,
compared with that of other contrast
materials.

of

hydrostatic

or

pneumatic

reduction is perforation of the bowel,

which occurs in 1% or fewer patients
[58-60]. The perforation usually occurs
on

the

distal

side

of

the

intussusception, often in the transverse

colon,

and

commonly

where

the

intussusception was first demonstrated

by radiographic studies [61,62] . The
risk of perforation is greatest in infants
younger than 6 months of age who
have had symptoms for three days or
longer and in patients with evidence of
small

more difficult to reduce because the

barium often percolates along the loops
of small bowel in the colon, reducing

Risk and complications The main

risk

lleo-ileo-colic intussusception may be

bowel

obstruction

[63].

Nonoperative reduction should not be

attempted in patients with prolonged

the effective pressure of the enema.

In addition, success is less likely to be
achieved in infants younger than 1 year
of age (particularly younger than 3
months), in children older than 5 years
of age, and when plain films show signs
of intestinal obstruction [30,58,64] .
Although some authors have noted a
reduced likelihood of reduction when
symptoms have been present for longer
than 48 hours [30,58,66,68] , others
have found no such correlation [65] . In
these high-risk cases, the barium study
should still be performed to confirm the
diagnosis and attempt therapy, but a
pediatric surgeon

should be readily

available in the imaging department.

Invaginao intestinal

Recurrence

after

successful

ileocecal valve. Thus, when a filling

nonoperative reduction is close to 10%

defect appears to be associated with

[30,69,70].

not

edema in the area, an ultrasonographic

necessarily an indication for surgery.

or repeat contrast study should be

Each recurrence should be handled as if

performed

it were the first episode, provided that

have resolved.

Recurrence

is

each is successfully reduced [71].

provided

that

symptoms

Broad-spectrum intravenous antibiotics

SURGERY Surgery is indicated when

should be given before surgery. Manual

nonoperative reduction is incomplete or

reduction at operation is attempted in

when

defect,

most cases, but resection with primary

indicating a mass lesion, is noted [71] .

anastomosis needs to be performed if

As noted above, a residual filling defect

manual reduction is not possible or if a

may be seen because of edema of the

lead point is seen.

persistent

filling

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