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Intussusception
Pediatric Medicine Rotation (PEDO 8950)
University of Nevada, Las Vegas
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Aetiology
In most cases of intussusception, there is no clear cause. It can be associated with a preceding viral infection and may occur due to an enlarged Peyer9s patch acting as a 8lead point9, facilitating the telescoping of the ileum through the ileocaecal valve.
Around 10% of cases occur due to the presence of a pathological lead point. This is an abnormal area in the bowel which is caught and pulled by peristalsis , thus leading the intussusception.
Intussusception due to a pathological lead point is more likely in patients presenting outside the typical age range or where intussusception occurs away from the ileocaecal valve.
Examples of pathological lead points and other secondary causes of intussusception include:
● Meckel9s diverticula (and other congenital bowel defects) ● Intestinal polys ● Lymphomas and leukaemias ● Henoch-Schonlein purpura (HSP) ●
Risk factors
Intussusception most frequently occurs in children aged four to eighteen months and is slightly more common in boys.
Clinical features
History The typical triad of symptoms of intussusception include:
● Intermittent, severe abdominal pain : may present as screaming episodes during which the child is inconsolable and draws their knees up to their chest. The child may appear well between episodes but will become more lethargic over time as dehydration worsens. ● Vomiting : becomes bilious in later stages when bowel obstruction occurs ● Redcurrant jelly stool : a late feature that occurs when ischaemic mucosal tissue is sloughed off and is excreted in the stool, mixed with blood and mucus (it is a rare presenting feature).
In clinical practice, only one-third of patients present with all three of these symptoms. Other symptoms may include lethargy or episodes of pain with odd posturing which may be mistaken for seizure activity.
Other important areas to cover in the history include:
● Birth and developmental history: including antenatal scans and neonatal problems ● Systemic enquiry: to identify cases where there is an underlying secondary cause, such as HSP
Clinical examination
An ABCDE approach should be adopted in order to quickly identify the unwell, dehydrated child who requires early resuscitation. This type of systematic examination is also important to identify signs of an underlying cause of intussusception.
Observation is an important part of the initial clinical assessment. Typical findings on observing the child may include:
● Signs of dehydration, such as sunken eyes and dry lips ● Episodes of screaming +/- drawing knees up to their chest ● Lethargy or excessive sleepiness ● Rashes or other features of secondary causes
The hallmark sign of intussusception is a sausage-shaped mass palpable in the right upper quadrant of the abdomen.
Other signs on abdominal examination may include tenderness, reduced/absent bowel sounds, distension (secondary to bowel obstruction) and, in the late stages, peritonitis (secondary to perforation).
● Full blood count: neutrophilia may be present in later stages ● Urea & electrolytes: dehydration and vomiting may cause electrolyte disturbances ● Liver function tests: to exclude a hepatobiliary cause ● CRP: may be elevated in later stages
Imaging investigations
The gold-standard investigation for suspected intussusception is an abdominal ultrasound.
This classically shows a 8target sign 9 and has a sensitivity and specificity of close to 100% (Figure 2). Ultrasound may also give important information about the likely success of subsequent reduction.
An abdominal X-ray can also be performed. However, this is less sensitive and specific than ultrasound and is not commonly requested. Abdominal X-ray may show a typical picture of bowel obstruction, with distended proximal loops of bowel and paucity of distal bowel gas.
Management
Initial management
Prompt and adequate fluid resuscitation is vital for the management of intussusception and failure to instigate this early is one of the main causes of mortality in intussusception.
Additional initial management should include:
● Analgesia: this might be in the form of intravenous paracetamol or opioids ● Inserting a nasogastric tube to decompress the stomach ● Making the child nil-by-mouth
Definitive management
Non-surgical
For most cases, the first-line method to reduce intussusception is an air enema or water enema.
Enemas are successful in over 80% of cases and have around a 10% recurrence rate. The procedure is carried out under fluoroscopic guidance. Air is introduced to the gut via a foley catheter in the rectum under pressure to reduce the intussusception.
This approach is less likely to be successful in children who have a pathological lead-point and is contraindicated if there is evidence of shock, perforation or peritonitis.
Surgical
Where non-surgical reduction is unsuccessful, or there is evidence of perforation or peritonitis , surgery is required to manually reduce the intussusception. This can be performed laparoscopically but is often converted to an open procedure. If this is unsuccessful, bowel resection may be required.
Complications
The main causes of mortality are late presentation , sepsis and a failure to instigate appropriate fluid resuscitation early.
Serious complications are uncommon when intussusception is identified and treated promptly. Where there is a delay to definitive management, bowel necrosis, perforation, peritonitis and sepsis may occur.
Intussusception
Course: Pediatric Medicine Rotation (PEDO 8950)
University: University of Nevada, Las Vegas
