INTUSSUSCEPTION

DEFINITION
• Intussusception (IS) is one of the most common paediatric intestinal emergencies
in infants and toddlers (1).
• Intussusception is the invagination of one segment of the intestine within a more
distal segment [1], [2]
• It is defined as a process in which a segment of intestine telescopes into the
adjoining intestinal lumen eventually leading to perforation of the intestine if
left untreated.
• In most infants, the intussusception involves the ileum invaginating through the
ileocecal valve into the cecum.
• As the bowel intussuscepts, it pulls along its blood supply.
• If the intussusception is not relieved, the vascular supply of the bowel may be
compromised, resulting in intestinal ischemia and possibly perforation.
• Untreated intussusception may be fatal.

1. Blanch AJ, Perel SB, Acworth JP. Paediatric intussusception: epidemiology and outcome. Emerg Med Australas 2007; 19:45–50.
1. Bines JE, Kohl KS, Forster J, Zanardi LR, Davis RL, et al. (2004) Acute intussusception in infants and children as an adverse event
following immunization: case definition and guidelines of data collection, analysis, and presentation. Vaccine 22: 569–574. [PubMed]
2. Bines JE, Patel M, Parashar U (2009) Assessment of postlicensure safety of rotavirus vaccines, with emphasis on intussusception. J
Infect Dis 200 Suppl 1S282–290. [PubMed]
2. Intussusception: Incidence and Treatment—Insights From the Nationwide German Surveillance
Jenke et al, April 2011
 EPIDEMIOLOGY

It is the most common cause of bowel obstruction

in infants, occurring usually between 4 and 10
months of age [3].

3. WHO (2002) Acute intussusception in infants and children. Incidence, clinical presentation and management: a global
perspective. Geneva: World Health Organization. Document WHO/V & B/02 (19)1–98.
 PATHOGENESIS
• The pathogenesis of intussussception is thought to be
secondary to an imbalance of longitudinal forces along the
intestinal wall with a mass, for example, lymph nodes, acting
as lead in combination with a disorganised pattern of
peristalsis.
• An important aetiologic factor in the development of
intussusceptions seems to be viral as well as bacterial
gastroenteritis even though only retrospective analyses
currently support the present view (2).
•As the intussussception develops, the mesentery is dragged
into the bowel. This leads to the development of venous and
lymphatic congestion with resulting intestinal edema. If
untreated, the process can ultimately lead to ischemia,
perforation, and peritonitis.
2. Nylund CM, Denson LA, Noel JM. Bacterial enteritis as a risk factor for childhood intussusception: a retrospective cohort study. J Pediatr
2010; 156:761–765.
 Idiopathic — Approximately 75 percent of cases of childhood intussusception
are considered to be idiopathic because there is no clear disease trigger or
pathologic lead point. Idiopathic intussusception is most common in children
between three months and five years of age [2].
Influence of viral factors — An increasing body of evidence suggests that viral
triggers may play a role in some cases, as illustrated by the following
observations:
●The incidence of intussusception has a seasonal variation, with peaks coinciding
with seasonal viral gastroenteritis in some populations [6,8].
●Intussusception has been associated with some forms of rotavirus vaccine.
●Approximately 30 percent of patients experience viral illness (upper
respiratory tract infection, otitis media, flu-like symptoms) before the onset of
intussusception.
Viral infections, including enteric adenovirus, can stimulate lymphatic tissue in the
intestinal tract, resulting in hypertrophy of Peyer patches in the lymphoid-rich
terminal ileum, which may act as a lead point for ileocolic intussusception (picture
1) [9,14].
6,8 Three-year surveillance of intussusception in children in Switzerland.
Buettcher M, Baer G, Bonhoeffer J, Schaad UB, Heininger U
Pediatrics. 2007;120(3):473
9, 14 Adenovirus infection and childhood intussusception.
Bhisitkul DM, Todd KM, Listernick R
Am J Dis Child. 1992;146(11):1331
 Lead point — A lead point is a lesion
or variation in the intestine that is
trapped by peristalsis and dragged
into a distal segment of the intestine,
causing intussusception (figure 1). A
Meckel diverticulum, polyp,
duplication cyst, tumor, hematoma, or
vascular malformation can act as a
lead point for intussusception [16].

Illustration of intussusception in a child. In ileocolic intussusception, the ileum invaginates

(telescopes) through the ileocecal junction into the colon. This is the most common form,
accounting for about 90 percent of all cases. Other types of intussusception are ileo-ileal,
ileo-ileo-colic, jejuno-jejunal, jejuno-ileal, or colo-colic. A pathological lead point is
identified in a minority of cases (as shown in the illustration of ileo-ileal intussusception
above).
Modified from: Trelease RB. Netter's Surgical Anatomy Review P.R.N., Elsevier, Philadelphia
2011.
Clinical characteristics of intussusception secondary to pathologic lead points in children: a single-center experience with 65 cases.
Lin XK, Xia QZ, Huang XZ, Han YJ, He GR, Zheng N
Pediatr Surg Int. 2017;33(7):793. Epub 2017 Jun 5
Surgical view of an ileocolonic intussusception, the most common
form of intussusception in infants and young children. The terminal
ileum (intussusceptum) is seen extending in to the cecum
(intussuscipiens).

Courtesy of David Wesson, MD.

 CLINICAL CHARACTERISTIC
Primary Intussussception is idiopathic
 often seen following upper respiratory illness
Thought to be due to hyperthrophic lymphatic
nodule in the bowel wall
Adenovirus and rotavirus are identified in up to
50 percents of cases.
More common than secondary intussussception

Intussusception
Brennan bowker, MSH, PA-C, CPAAPA; Sheeree Rascati, MHS, PA-C
 Secondary Intussussception
Occur as a result of an identifiable lead point
Lead points ( found in 2-8% of children with IS),
typically are benign and can include meckel’s
diverticulum (most common), hemangioma, carcinoid
tumors, foreign bodies, lipoma
Malignant lead points such as lyphoma and small
bowel tumor in children but it increase with age
Systemic disease including crohn’s dzs, celiac dzs and
cytic fibrosis are also a/w IS
Most cases of IS are ileocolic, although ileoileocolic and
ileoilealcolic also are seen.

Intussusception
Brennan bowker, MSH, PA-C, CPAAPA; Sheeree Rascati, MHS, PA-C
HISTORY
• Sudden onset of intermittent, crampy, abdominal
pain, often lasting 15-20minutes.
• Cannot be console and may draw their knees to the
chest
• Pain may be associated with vomiting which is often
initially non bilious but may progress to bilious
• Children may act normally between episode, may
develop lethargy
 Bowel function may or may not be present
Stool often appear normal early in the process
As the IS evolves, bowel fx may cease ( little to no
flatus, no bowel movement)
The classic “currant jelly” stool is often a late sign
and it indicates bowel ischemia; fewer than half of
pt have this findings.
 Classic triad of pain, bloody “currant jelly” stools,
and vomiting is present in < 20% of cases.
 PHYSICAL EXAMINATION
Vital signs
Maybe normal early on
Later, patient may show symptoms of shock including
fever, hypotension, tachycardia
Abdominal examination
Between episodes, the abdominal examination may
be benign and minimally helpful for determining of
diagnosis.

Intussusception
Bowker, Brennan, MHS, PA-C, CPAAPA; Rascati, Sheree, MHS, PA-C
Journal of the American Academy of PAs: January 2018 - Volume 31 - Issue 1 - p 48–49
doi: 10.1097/01.JAA.0000527710.61686.02
 INVESTIGATIONS
Plain abdominal Xray
Performed to exclude perforation or bowel obstruction
A normal AXR does not exclude intussusception
Signs of intussusception on a plain Xray include:
Target sign - 2 concentric circular radiolucent lines
usually in the right upper quadrant
Crescent sign - a crescent shaped lucency usually in the
left upper quadrant with a soft tissue mass
Ultrasound scan
 Ultrasonography has a false-negative rate
approaching zero and is a reliable screening tool for
children at low risk for intussusception 5-9.
 Children with classic findings of intussusception,
however, need to be investigated with contrast enema,
which is both diagnostic (the gold standard in the
diagnosis of intussusception) and therapeutic.
 Ultrasound signs include:
target sign (also known as the doughnut sign)
pseudokidney sign
Air/ contrast enema
 Diagnostic and
therapeutic
 Shows a filling defect
in the head of contrast
where its advance is
obstructed by the IS
 “ contrast material
between the
intussusceptum and
intussuscipiens is
responsible for the coil
spring apperance.
 MANAGEMENT
The approach to treatment of intussusception depends upon patient
characteristics:
•Most patients – Patients with a high clinical suspicion and/or imaging
evidence of ileocolic intussusception, normal vital signs, and no evidence of
bowel perforation should be treated with nonoperative reduction
•Acutely ill or with perforation – Surgical treatment is indicated as a primary
intervention for patients with suspected intussusception who are acutely ill or
have evidence of perforation.
1) Nonoperative reduction
• using hydrostatic or pneumatic pressure by enema is the treatment of
choice for an infant or child with ileocolic intussusception who is clinically
stable and has no evidence of bowel perforation or shock, when
appropriate radiologic facilities are available.
• Enema reduction has high success rates in children with ileocolic
intussusception.
• In settings in which nonoperative reduction is not available (eg, in resource-
limited countries), patients with intussusception usually should be managed
with surgical reduction.
• Before attempting reduction by enema, the patient should be stabilized
and given intravenous fluids if there is evidence of volume depletion.
• The surgical team should be notified before attempting nonoperative
reduction and remain immediately available because there is a risk of
perforation during the procedure.
• Surgical intervention also may be necessary if nonoperative reduction fails
to reduce the intussusception.
• Fluoroscopic or sonographic guidance — Reduction of intussusception is
most commonly performed under fluoroscopic guidance, using either
hydrostatic (saline or contrast) or pneumatic (air) enema.
• The techniques are performed as follows:
• Sonographic guidance – Sonographic guidance requires a hydrostatic technique
(saline enema) to provide retrograde pressure, because use of air would interfere
with ultrasound visualization. Sonographic signs of successful reduction include the
disappearance of the intussusception and the appearance of water and bubbles in
the terminal ileum.
• Fluoroscopic guidance – Under fluoroscopy for a typical ileocolic intussusception, the
intussusceptum appears as a filling defect within the bowel lumen. This is seen as
either a low density filling defect when contrast is used for hydrostatic reduction, or a
higher density filling defect when air is used as a negative contrast with pneumatic
reduction techniques. The intussusception can be found in any part of the large bowel,
even the rectum. Occasionally, contrast may coat the outer surface of the
intussuscipiens, resulting in a coiled spring pattern.
• Hydrostatic or pneumatic reduction — Either pneumatic (air) or hydrostatic (saline or
contrast) technique is acceptable for reduction of intussusception in stable children.
 2) Surgery
Indications for urgent surgical intervention include:
• Unstable patient – In this case, initiate resuscitation, consult surgeon, and
stabilize the patient before proceeding to the operating room.
• Peritonitis or intestinal perforation.
• Nonoperative reduction is completely unsuccessful. If the reduction attempt
was partially successful, it may be repeated.
• Surgery is also indicated when imaging reveals a persistent focal filling
defect, indicating a mass lesion.
• However, not all filling defects are indications for surgery:
• If the patient has undergone successful nonoperative reduction (as
indicated by relief of symptoms) and there is a residual filling defect that
is consistent with an edematous ileocecal valve, the patient can be safely
observed.
• However, repeat evaluation with ultrasound or contrast study within 12 to
24 hours is appropriate to confirm successful reduction.

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MANAGEMENT
 Stabilized the patient
 Insert NG tube
 Insert IVL – for hydration
 Antibiotic may be needed to treat any infection
 Radiologically
 Reduction if there is no sign of peritonitis, perforation, shock.
Laparotomy (reduction or resection) – indication:
Peritonitis
Perforation
Prolonged history more than 24 hours
High likelihood of pathological lead point
Failed enema
TREATMENT
Non operative reduction
In stable patient with high clinical suspicions and /
or radiographic evidence of IS and no evidence of
bowel perforation.
Surgical treatment
Acutely or perforation
If radiography facilities not available and expertise
not available
Non operative reduction is unsuccessful.