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Intussusception is much more common in children than in adults. See separate Intussusception in Adults article.
Intussusception is a term derived from the Latin intus (within) and suscipere (to receive). One segment of the bowel (intussusceptum) invaginates into another (intussuscipiens) just distal to it, leading to obstruction. The bowel may simply 'telescope' on itself (non-pathological lead point - up to 75%), or some pathology may be the focus of the invagination (pathological lead point). The mesentery of the intussuscepted bowel becomes compressed. The bowel wall distends and obstructs the lumen. Peristalsis is disrupted leading to colicky abdominal pain and vomiting. Lymphatic and venous obstruction occurs, causing ischaemia. In most children the intussusception is ileocaecal, although ileo-ileocolic and ileo-ileal or colocolic cases can occur.
- The male-to-female ratio is approximately 3:2.
- Two thirds of patients are under 1 year old, the peak age being between 5-10 months.
- Intussusception is the most common cause of intestinal obstruction in patients aged 5 months to 3 years and accounts for up to 25% of abdominal emergencies in children up to age 5.
- It is rare preterm.
- One large Swiss study found an overall incidence of 38, 31 and 26 cases per 100,000 live births in the first, second and third year of life respectively.
- It has been associated with the rotavirus vaccine but the incidence is small and it is outweighed by the benefits of the vaccine[3, 4].
- It is usually of sudden onset and may be more insidious in the older child.
- There are paroxysms (about every 10-20 minutes) of colicky abdominal pain (>80%) ± crying.
- The child may appear well between paroxysms initially.
- There is early vomiting - rapidly becoming bile-stained.
- Neurological symptoms such as lethargy, hypotonia or sudden alterations of consciousness can occur.
- There may be a palpable 'sausage-shaped' mass (often in the right upper quadrant).
- There may be absence of bowel in the right lower quadrant (Dance's sign).
- Dehydration, pallor, shock.
- Irritability, sweating.
- Later, mucoid and bloody 'redcurrant' stools.
- Late pyrexia.
Causes and associated conditions
Non-pathological lead point (>90%)
- Viral 50% - rotavirus, adenovirus and human herpesvirus 6 (HHV6).
- Amoebomata, shigella, yersinia.
- Peyer's patch hypertrophy.
Pathological lead point (<10%)
NB: older patients (may have longer history):
- Meckel's diverticulum (75%).
- Polyps and Peutz-Jeghers syndrome (16%).
- Henoch-Schönlein purpura (3%).
- Lymphoma and other tumours (3%).
- Reduplication - a process by which the bowel wall is duplicated (2%).
- Cystic fibrosis.
- An inflamed appendix.
- Nephrotic syndrome.
- Foreign body.
- Postoperative - rarely, postoperative intussusception following operative treatment of an intussusception has been reported.
- Exclusive breast-feeding.
- Weight above average.
- Rotavirus vaccine.
- Abdominal tuberculosis.
- FBC - may show neutrophilia.
- U&Es - may reflect dehydration.
- Abdominal X-ray - may show dilated gas-filled proximal bowel, paucity of gas distally, multiple fluid levels (but may be normal in the early stages).
- Ultrasound - may show doughnut or target sign, pseudokidney/sandwich appearance. It is a very effective modality and many consider it the investigation of choice.
- Bowel enema - barium has been gold standard (crescent sign, filling defect) but air and water-soluble double-contrast now available; each has pros and cons - the choice is left to the individual radiologist.
- CT/MRI scanning - more often used in adults than in children.
- Any child with possible intussusception or other serious cause of abdominal pain should be referred urgently to hospital for further assessment.
- Early diagnosis reduces the need for open surgery.
- Resuscitation - 'drip and suck' - nasogastric tube and IV fluids.
- Laparotomy (reduction/resection) - indications:
- Prolonged history (>24 hours).
- High likelihood of pathological lead point.
- Failed enema.
- Hospital admission is usually required but outpatient management may on occasions be an acceptable alternative.
- Missed diagnosis.
- Ischaemia of the intussusceptum/intussuscipiens.
- Sepsis and septicaemia.
- Failure of enema reduction.
- Chronic intussusception - rare cause of failure to thrive.
With treatment, prognosis is excellent. Spontaneous resolution may also occur and depends on multiple factors - eg, location and length. For example, small bowel intussusception without a lead point can be asymptomatic and an incidental finding.
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Further reading & references
- Young L; Intussusception, Case Based Pediatrics For Medical Students and Residents, Department of Pediatrics, University of Hawaii, John A. Burns School of Medicine, Chapter X.4. 2002
- Buettcher M, Baer G, Bonhoeffer J, et al; Three-year surveillance of intussusception in children in Switzerland. Pediatrics. 2007 Sep 120(3):473-80.
- Tate JE, Yen C, Steiner CA, et al; Intussusception Rates Before and After the Introduction of Rotavirus Vaccine. Pediatrics. 2016 Sep 138(3). pii: e20161082. doi: 10.1542/peds.2016-1082. Epub 2016 Aug 24.
- Jiang J, Jiang B, Parashar U, et al; Childhood intussusception: a literature review. PLoS One. 2013 Jul 22 8(7):e68482. doi: 10.1371/journal.pone.0068482. Print 2013.
- Kleizen KJ, Hunck A, Wijnen MH, et al; Neurological symptoms in children with intussusception. Acta Paediatr. 2009 Nov 98(11):1822-4. Epub 2009 Aug 10.
- Kim J; US Features of Transient Small Bowel Intussusception in Pediatric Patients. Korean Journal of Radiology 2004 September
- Lehnert T, Sorge I, Till H, et al; Intussusception in children--clinical presentation, diagnosis and management. Int J Colorectal Dis. 2009 Oct 24(10):1187-92. Epub 2009 May 6.
- Byrne AT, Geoghegan T, Govender P, et al; The imaging of intussusception. Clin Radiol. 2005 Jan 60(1):39-46.
- Justice FA, Auldist AW, Bines JE; Intussusception: Trends in clinical presentation and management. J Gastroenterol Hepatol. 2006 May 21(5):842-6.
- Herwig K, Brenkert T, Losek JD; Enema-reduced intussusception management: is hospitalization necessary? Pediatr Emerg Care. 2009 Feb 25(2):74-7.
- Park SB, Ha HK, Kim AY, et al; The diagnostic role of abdominal CT imaging findings in adults intussusception: focused on the vascular compromise. Eur J Radiol. 2007 Jun 62(3):406-15. Epub 2007 Apr 6.
- Malakounides G, Thomas L, Lakhoo K; Just another case of diarrhea and vomiting? Pediatr Emerg Care. 2009 Jun 25(6):407-10.
- Gray MP, Li SH, Hoffmann RG, et al; Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul 134(1):110-9. doi: 10.1542/peds.2013-3102. Epub 2014 Jun 16.
- Sadigh G, Zou KH, Razavi SA, et al; Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children. AJR Am J Roentgenol. 2015 Nov 205(5):W542-9. doi: 10.2214/AJR.14.14060.
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