Essay 44

Intussusception
Intussusception is an acquired disorder that is most common between the ages of 6 weeks and 2 years.
There appears to be a seasonal increase in incidence in the spring and autumn, probably because higher
levels of microorganisms are present in the environment in these seasons leading to lymphatic swelling.
The condition arises when a segment of bowel becomes telescoped into the bowel immediately distal to
it (Fig. 50.14). The lead point (intussusceptum) that gives rise to the intussusception is commonly a
thickening of the bowel wall caused by non-specific or viral hypertrophy of Peyer's lymphatic patches.
The invaginated segment progressively elongates as it is propelled distally by peristalsis. Ileocolic
intussusception is the most common variety and the intussusception commonly extends well into the
transverse colon and may even present at the anus.

Intussusception presents with abdominal pain. If left untreated, the affected segment may undergo
venous infarction over a period of hours or days. Intussusception sometimes occurs in older children and
adults, when the initiating factor is a bowel wall tumour or polyp.

Pathology other than hypertrophy of Peyer's patches may initiate intussusception, and other causes
should be suspected in a child presenting outside the usual age range or if intussusception recurs after
radiological reduction. Meckel's diverticulum or even a lymphoma may present in this manner. Children
with Henoch-Schönlein purpura (characterised by a purpuric rash on the extensor surface of the legs
and buttocks) may sometimes develop ileo-ileal intussusception, i.e. the pathology is proximal to the
colon.

Clinical Features
Intussusception classically presents with bouts of severe colicky abdominal pain lasting for some
minutes during which the child is doubled up and screaming. These episodes are separated by periods
when the child appears entirely well. Within the first few hours, the child often passes a small amount of
jelly-like blood per rectum. This is described as redcurrant jelly stool, which is almost pathognomonic of
intussusception when the other clinical features are present. Vomiting begins later, consistent with
distal bowel obstruction, but even without complete intestinal obstruction there may be profound fluid
depletion. Some children with intussusception may be very drowsy, and this can only partly be explained
by fluid depletion.

Diagnosis should be made on clinical grounds. On examination, a sausage-shaped mass is usually

palpable, lying across the upper abdomen. The rectum is empty but may contain a little blood.
Ultrasound may detect an intussusception but a normal result does not exclude it; however, a diagnostic
air enema is quick to carry out and reliably demonstrates the condition. Intussusception is potentially
life threatening so a definite diagnosis must be made urgently with a view to treatment, even in children
 Essay 44

who appear well at presentation. In Henoch-Schönlein purpura, an air enema does not give the
diagnosis because the colon is unaffected; ultrasound can be helpful in these cases.

MANAGEMENT
Intussusception is potentially dangerous and treatment needs to be prompt and active, even if the child
seems well. Intravenous access should be secured as rapid deterioration may be imminent. The
intussusception can usually be reduced radiologically using an air or fluid contrast enema with carefully
controlled pressure, performed under X-ray screening (Fig. 50.14c). Radiological reduction is
inappropriate if the child is unwell; in these cases, rapid resuscitation with intravenous fluids should be
followed by laparotomy. At operation, the intussusception is reduced by gentle manipulation and the
appendix can be removed. Resection becomes necessary if the intussuscepted intestine is ischaemic or if
it proves impossible to completely reduce the lesion without causing major trauma to the bowel.