Br. J. Surg. Vol.

67 (1980) u)9-212

lntussusception in infancy and childhood

I . F. H U T C H I S O N . B. O L A Y I W O L A A N D D. G . Y O U N G *
SUMMARY Number of Cases
A total of 209 cases of intussusception treated at the 2o01 0
I
Royal Hospital for Sick Children, Glasgow, in the past I
I
decade has been reviewed. The results are compared with 180-
I
I
similar reports for the two preceding decades from the I
same hospital. The mortality rate hasfallen; there were 5 I
I
deaths in this series, 2 of these deaths occurring some 160- 1
months after the presentation with intussusception and I +--*1959-1968
I
death being caused by dissemination of lymphosarcoma. I
I
V 1969-1978
The continuing delay in diagnosis is apparent. 140- I
I
EXPERIENCEwith intussusception in infancy and
childhood a t the Royal Hospital for Sick Children,
Glasgow, has been the subject of two previous reports
(1,2). In these reports the experience over the 10-year
periods 1949-58 and 1959-68 was reviewed. The
current review follows o n from these two reports,
recounting the experience in the decade 1969-78.

Patients and methods

The records of all patients admitted in the period 1969-78 in
whom the diagnosis of intussusception was made have been
reviewed. All patients in whom the clinical diagnosis was
supported by radiological evidence or evidence at laparotomy
are included in this report. These 209 patients include those in
whom spontaneous reduction of intussusception had occurred.
The relevant clinical details have been extracted from the
records.
Age and sex
Of the 209 patients, 128 (61.2 per cent) were under the age of I
year at presentation and of these 106 were aged between 3 and 9 Age in Years
months (Figs. 1 and 2). There were two infants who presented Fig. 1. The age distribution of patients treated during the
in the first month of life and the oldest patient in the series wasa two 10-year periods.
10-year-old boy. There was a male pre onderance, 139 (66.5
per cent) patients being male and 70 Emale (33.5 per cent)
(Table r).
Presentation
The annual incidence of intussusception during the period of
study varied considerably from year to year. In 1974 there were
33 cases while in 1977 there were only 7. Fig. 3 demonstrates
that there is no clear seasonal preponderance although the least
number was seen during the months of February and
November. Table II shows the incidence of symptoms and

j1
//
signs. Abdominal pain (82-3 per cent), which was usually
colicky in nature, and vomiting (79.9 per cent) were by far the
two most common presenting features. Bleeding per rectum
was noted in 36.4 per cent ofcases and in 46 per cent blood was
noted on the examining finger following digital rectal
examination. Constipation was not a feature but diarrhoea was 1 2 5 4 5 6 7 8 S 1 0 l i i2
Ago in Yonlhs
noted in 12.9 per cent. A palpable abdominal mass was present
in 50.2 per cent of patients. In 13 patients (6.2 per cent) a mass Fig. 2. The age distribution of patients below 1 year of age.
was palpable in the rectum but in only 2 patients (0.9 per cent)
did the apex of the intussusception prolapse at the anus. clinical state. Repeat X-ray was not carried out in all of the
Although 44.6 per cent of cases were correctly diagnosed patients. No further problems ensued from their intus-
within 24 h of the onset of symptoms or signs, there were 25.4 susception. At laparotomy in 9 patients the intussusception
per cent of cases in whom the diagnosis of intussusception was was found to have undergone spontaneous reduction, there
missed or was not made until at least 72 h after onset (Fig. 4). being congestion and oedema of the terminal ileum due to
previous invagination of the bowel.
Treatment Hydrostatic barium reduction was attempted in 57 patients
Table III outlines the management of the 209 patients. In 13 (27.3 per cent) and was successful in 33 (15.8 per cent).
patients the intussusception was considered to have undergone
spontaneous reduction. These patients had initially a classic * Royal Hospital for Sick Children, Yorkhill, Glasgow
history and confirmatory radiological evidence of G3 8SJ.
intussusception and subsequently had improvement in their Correspondence to: D. G.Young.
210 I. F. Hutchison et al.

Table 1: NUMBERS O F CASES, SEX AND Table III: OUTLINE O F TREATMENT IN u)9
MORTALITY PATIENTS WITH INTUSSUSCEPTION
1959-68 1969-78 Spontaneous reduction 10.1Yo
Hydrostatic reduction successful 15.8%
Total number 288 209 Failed hydrostatic reduction 11.5%
Total males I95 139 Operative reduction 56.9%
Total females 93 70 Resection of bowel 16.8%
Total deaths 10 5
Total 0-1 year old 198 I28
Operative treatment was the main procedure in this series and
simple operative reduction wascarried out in 1 19 patients (56.9
per cent). Resection and anastomosis was carried out in 35
patients (16.8per cent).
In this series of the 163 patients undergoing laparotomy 9
had a definite predisposing patholo y precipitating the
intussusception. Of these 7 had a Meckefs diverticulum and 2
patients had Henoch-Schonlein purpura. In the majority of
cases there was evidence of enlarged mesenteric lymph glands,
which may be of significance.
Results
Five of the 209 patients died during the 10-year period
(Tables Zand IV). Three (1.4 per cent) of the deaths were
directly attributable to intussusception and all 3 patients
had undergone laparotomy. Two of these patients had
had symptoms for 2 !4 days before admission and one
was in a very collapsed condition on admission to
hospital. In these 3 cases death was attributed to
"1 anastornotic breakdown and hyperpyrexia, to pseudo-
membranous enterocolitis complicating the post-
operative course and to faecal peritonitis secondary
0 to perforation of the transverse colon after reduction of
Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep.0ct. Nov. Dec. the intussusception, respectively. The other 2 patients
Fig. 3. The monthly incidence of intussusception during the who died had lymphosarcoma and died several months
10-year period of study. after laparotomy despite postoperative radiotherapy
and administration of cytotoxic drugs.
Table II: SYMPTOMS AND SIGNS IN ORDER O F
FREQUENCY
Discussion
Incidence Although the incidence of intussusception varies from
Symptoms and signs (%) year to year, it is evident when comparing our figures
Abdominal pain 82.3 with those of Strang (1) and Dennison and Shaker (2)
Vomiting 79.9 (Table I) from the same hospital that there has been a
Palpable abdominal mass 50.2 fall in the incidence of intussusception during the past 10
Blood on rectal exam. 46 years. This fall is more apparent than real, as during the
Bleeding per rectum 36.4 past decade there has been a fall in the birth rate from
Diarrhoea 12.9 approximately 100 000 births per year during the period
Abdominal distension 9.1 of Dennison and Shaker's series to approximately
Palpable rectal mass 6.2 75 OOO births per year in Scotland during the time of the
Rectal prolapse 0.9
Miscellaneous 35.4 reported series. There is still a preponderance of males
(66.5 per cent) and the commonest affected age remains
3-9 months (Fig.2). This is similar to the findings of the
previous studies.
OIo Of caws
In the present series only 2 patients (1 per cent) were
301 under the age of 1 month and similar figures (0.3 per
cent) have been recorded in other centres (3,4). As in the
previous series from Glasgow, we have found
intussusception uncommon in the older child and only
10 of our patients were 6 years of age or more. Wayne
and colleagues (5) have stated that in a child of 6 or over
lymphosarcoma should be suspected until it is proved
otherwise. In the present series the oldest child in the
group had lymphosarcoma.
The classic triad of colicky abdominal pain, a
palpable abdominal mass and rectal bleeding makes the
diagnosis easy, but all three are not usually present. In a
0-12 12-24 24-48 48-72 w72 review of 52 patients (6) only 12 per cent of the cases had
Hous these classic symptoms and signs. In our series 82.3 per
Fig. 4. The interval between onset of symptoms of cent had abdominal pain, 50.2 per cent had a palpable
intussusception and presentation to hospital. abdominal mass and 36.4 per cent had bleeding per
 Childhood intussusception 211

Table I V ANALYSIS OF DEATHS IN THE SERIES

Duration Condition
Case of on Time of
no. Year Age and sex symptoms admission Procedure death Remarks
1 1971 6 mth 12-24 h Poor Resection 4th day Hyperpyrexia:
Male End-to-end postop. breakdown of
anastomosis anastomosis
Apex: Gangrenous,
Meckel’s
diverticulum
2 1978 4 mth 5d Very poor Operative reduction 5th day Initial recovery
Female postop. for 4 days postop.
then sudden deterioration:
pseudomembranous
enterocolitis
at post-mortem
3 1978 2 mth 2d Moderate Operative reduction 3rd day Transverse colon
Female postop. perforation:
faecal peritonitis:
died hours following
second laparotomy
4* 1975 1 yr2mth 5d Poor Resection, 7 mth Postop. radiotherapy
Female I ymphosarcoma postop. and cytotoxic drugs:
widespread metastases
including CNS
at post-mortem
5* 1975 10yr6mth 4d Poor Resection, 9 mth Postop. radiotherapy and
Male lymphosarcoma postop. cytotoxic drugs:
tumour recurrence:
no post-mortem
* Death unrelated to intussusception.

rectum. Symptoms vary considerably. Ein and
colleagues (7) reported that 13per cent of their cases had
no abdominal pain, while in this present series painless
intussusception occurred in 17.7 per cent.
Unfortunately, there is still delay in diagnosis, 36 per
cent in the present series being undiagnosed at 48 h after
the onset. This delay may be due in part to the
variability of the signs and symptoms but in some
instances it is due to the lack of awareness of the
attending physician. In some patients delay in seeking
medical advice was the prime cause of delay in
diagnosis.
Once the diagnosis has been made there is a choice of
treatment between operation and hydrostatic reduction
using barium enema. With radiographic control
hydrostatic reduction is now an established line of
treatment. The choice between the two methods
depends on the general condition of the patient, the
duration of the disease and the availability of a skilled
radiological service. There are reports of perforation of
the colon following barium enema reduction (8,9)
although this is rare in the hands of experienced
radiologists. Table IZI outlines the treatment in our 209
patients: in 27.3 per cent hydrostatic reduction was
attempted and this was successful in 15.8 per cent; 73.7
per cent of patients underwent laparotomy and 56.9 per
cent had operative reduction of the intussusception
while 16.8 per cent required resection of bowel. The
number of cases whose intussusception is irreducible
either with hydrostatic reduction or at laparotomy
increases with the duration of symptoms (10). Our series
confirms this view, as of the 35 patients (16.8 per cent)
(Table ZZZ) requiring bowel resection 22 had had
symptoms for longer than 48 h.
Resection and primary anastomosis is the best
method of treatment of irreducible intussusception
provided that the surgeon has extensive experience in
bowel surgery in children and the patient can be
adequately resuscitated and supported by blood
transfusion during the operation. In the present series
resections and primary anastomoses were all performed
by experienced paediatric surgeons. The side-to-side
anastomosis or a Mikulicz-type resection advocated
previously (10, 1 1) have not been used in this series and
with adequate supportive therapy they have little place
now.
The 3 deaths directly related to the intussusception
give a mortality rate of 1.4 per cent. This compares
favourably with the previous studies from this hospital;
3.4 per cent in Dennison and Shaker’s series (2) and 5.7
per cent in Strang’s series (1). Each of the deaths (Cases
1,2, and 3 in Table IV) had undergone laparotomy and
the duration of symptoms in two of them was 48 h or
longer; these two intussusceptions were reduced at
operation and the third patient had a relatively short
history of 12-14 h but required bowel resection. In
Dennison and Shaker’s series (2) 8 of the 10 patients
who died had had symptoms for 48 h or over. Our
figures confirm that the mortality rate increased with
delay in diagnosis.
As well as the decrease in mortality in the present
series, there has been a decrease in the period of
hospitalization. This is mainly due to the increase in
successful hydrostatic reduction which has occurred in
the current series. Where experienced radiologists are
available, it is preferable that hydrostatic reduction be
attempted and only where this fails should operation be
undertaken. One exception to this is the infant whose
plain abdominal X-ray shows gross evidence of
intestinal obstruction. Successful hydrostatic reduction
benefits the patient by avoiding the risks of operation
and decreasing the period of hospitalization. These
212 I. F. Hutchison et PI.
benefits outweigh the slightly increased risk of
recurrence of intussusception.
Aclrwwledgemeats
We would like to acknowledgethe help of the Department of
Medical Illustration and to thank our surgical colleagues for
permission to review their patients.
References
1. STRANG R. P.: Intussusception in infancy and childhood.
Br. J . Surg. 1959;46: 484-95.
2. DENN~SONw. M. and SHAKBR M.: Intussusception in infancy
and childhood. Br. J. Surg. 1970;57: 679-84.
3. mB0l-r c.c.,CABELL 6.6. and ORLECH 0.:The significance
of intussusception. Arch. Surg. 1962; 84: 365-70.
4. SWENSON 0. . and oec0~0~opou~ous c.: The omrative
~~~~
5. WAYNE 8. R., CAMPBELL 1. B., KOSLOSKE A. M. et d.:
Intussu tion in the older child-susgect lympho-
sarcoma? Paediatr. Surg. 1976; 11:789- 4
6. FR~ZTNDH., HURW H. and SCHILLER M.: Aetiology and
therapeuticas t5 of intussusceptionin childhood.Am. J.
Surg. 1977;1r272-4.
7. EIN s. H., ~ P H E N Sc. A. and MINOR A.: The painless
intussusception. J. Paediatr. Surg. 1876; 11: 563-4.
8. PIERCER. I. and B,+HOUR s. 6.: Perforation of "0-1 colon
by barium enema u1 an infant wth gangrenous ~leocollc
intussusception. Am. J. Surg. 1966,112:787-90.
9. GERUP J., IORULF H. and L I V A D ~ SA.: Management of
intussusceptionin infants and children-a survey based on
288 consecutive cases. Paediarrics 1972; 50: 535-46.
10. D E N N m N w.M.: Sur ery in Infancy and Childhood, 3rd ed.
Edinburgh: Churchii Livingstone, 1973: 236.
I I . GROSS R. E.: The Surgery of Infancy and Childhood.

Philadelphia: Saunders, 1953: 292.

treatment of acute intussusception in infants and young
children. Am. J. surg. 1962;103: 599-605. Paper accepted 31 August 1979.

Grape pour I'Avancemeot de la Microcblnvgie

ixth International Microsurgical Meeting of the Groupe pour I'Avancement de la
The S
Microchirurgie will take place on 14-18 May 1980 aboard the Kureliya. cruising from
MarscillesMahokPalma-Iviza-Marseilles.
The @en& programme w.ill comprise threehalfday sessions.The first two will be devoted
to reammation u1 vascular mmosurgery and free bone transfers as cornparad to traditional
methods. The third halfday session will cover.other themes: at this hme then will be a
neurosurgery symposium on the theme of faclal nerve preservation in the treatment of
acoustic neurinoma.
For details contact: Dr G. Magalon, Service du Pr. H.Bureau, Bd Jean Moulin. 13005
Marseille, France. (Tel.: (91)49.39.1 1.)