Intussusception in Children Michael J. Campbell, MD Virginia Mason Medical Center Seattle, Washington

Case Presentation HPI: ISH is a 9 month old healthy boy with 12 hours of worsening, intermittent abdominal pain. Colicky episodes lasting 5 minutes with 30 minute periods of sleep intervening. Increasing frequent. Mom noted him assuming the fetal position during the attacks. One episode of non-bilious vomiting. One episode of non-bloody diarrhea. No preceding viral illnesses PE: AF, low grade tachycardia to 160s, but otherwise stable. Gen: Comfortable, and sleeping Abd: soft, mod distended. Mildly tender with a questionable soft mass in the RLQ. LABS: WCT of 17.1 with 17% bands

Case Presentation

Case Presentation

Case Presentation Taken to the Fluoroscopy suite where pneumatic decompression was attempted. Resolution of the evident intussusception, but not able to pass air or contrast into the small bowel Subsequently, watched on the floor and returned for a plain film and US 4 hrs later which showed no evidence of intussusception Started on a diet and d/c’d the next day.

Case Presentation

Case Presentation

Background Intussusception refers to the invagination of a part of the intestine into itself. It is the most common abdominal emergency in early childhood

Epidemiology Intussusception is the most common cause of intestinal obstruction in infants between 6 and 36 months of age. Approximately 60 percent of children are younger than one year old, and 80 percent are younger than two. Male predominance, with a male:female ratio of approximately 3:2. Swiss study looking at cases of intusscusception over a 3 year period. Intussusception is unusual in adults, Pediatrics. 2007 Sep;120(3):473-80.

Pathophysiology Intussusception occurs most often near the ileocecal junction Approximately 75 percent of cases of intussusception in children are considered to be idiopathic The intussusceptum, a proximal segment of bowel, telescopes into the intussuscipiens, a distal segment, dragging the associated mesentery with it. This leads to the development of venous and lymphatic congestion with resulting intestinal edema, which can ultimately lead to ischemia, perforation, and peritonitis. In the majority of cases in adults, a pathologic cause is identified Study of 13 adults with intuss out of turkey over 7 years. Ten had intuss of the small intestine. A pathologic cause was found in 12 (92%). With 42% representing malignant processes.

Pathophysiology In the majority of cases in adults, a pathologic cause is identified In children, pathologic lead points include: Meckel’s Diverticulum Polyps Lymphoma HSP It is estimated that 75% of childhood cases of intusscusception are idiopathic in nature, with 25% having a pathological lead point. Meckels, polyps, small bowel lymphoma, Henoch-Schönlein purpura, a small bowel wall hematoma Account for a greater proportion of cases of intussusception in children younger than three months or older than five years

Pathophysiology Tiawanese study looked a throat cultures in kids with intussception and found an association with adenovirus vs control The incidence of intussusception has a seasonal variation, with peaks coinciding with seasonal viral gastroenteritis Intussusception has been associated with some forms of Rota Vaccine Approx 30% of patients experience viral illness prior to intussception Viral infections, can stimulate lymphatic tissue in the intestinal tract, resulting in hypertrophy of Peyer patches of terminal ileum acting as a lead point for ileocolic intussusception

Pathophysiology Small bowel intussusception (usually jejuno-jejunal or ileo-ileal) has been described in the postoperative period The intussusception is thought to be caused by uncoordinated peristaltic activity and/or traction from sutures or devices

Clinical Manifestations Classic Triad Colicky abdominal pain Palpable sausage-shaped abdominal mass Currant jelly stool Patients with intussusception typically develop the sudden onset of intermittent, severe, crampy, progressive abdominal pain, accompanied by inconsolable crying and drawing up of the legs toward the abdomen. The episodes usually occur at 15 to 20 minute intervals. Vomiting may follow episodes of abdominal pain. Between the painful episodes, the child may behave relatively normal and be free of pain. A sausage-shaped abdominal mass may be felt in the right side of the abdomen. up to 70 percent of cases, the stool contains gross or occult blood the classically described triad of pain, a palpable sausage-shaped abdominal mass, and currant-jelly stool is seen in less than 15 percent of patients at the time of presentation

Diagnosis Abdominal plain film features consistent with intussusception include signs of intestinal obstruction, which may include massively distended loops of bowel with absence of colonic gas The presence of air in the cecum or terminal ileum can help to exclude intussusception in patients with a low clinical suspicion of the disease. Retrospective series out of Columbia Presyterian 129 pts, 27 of which had intuss If all three views had air in ascending colon then 100% sens, NPV of 100% for r/o intuss If two views had air in the ascending colon then 96% sensitiv and 98% NPV The presence of air in the cecum on at least two views had high sensitivity for excluding intussusception in this patient population with a low clinical suspicion of disease (sensitivity 96 percent).

Diagnosis Target Sign Crescent Sign A “target sign”, consisting of two concentric radiolucent circles superimposed on the right kidney, represents peritoneal fat surrounding and within the intussusception. A soft tissue density projecting into the gas of the large bowel (representing the intussusception) is called the "crescent sign."

Diagnosis The classic ultrasound image of intussusception is a "bull's eye" or "coiled spring" lesion representing layers of the intestine within the intestine The sensitivity and specificity of this technique approach 100 percent in the hands of an experienced ultrasonographer. An advantage of ultrasonography is that it can diagnose the rare ileoileal intussusception and identify the lead point of intussusception in approximately two-thirds of cases in which underlying pathology exists

Diagnosis Contrast or Air Enema is both diagnostic and therapeutic

Treatment Prior to reduction the patient should be resuscitated and given antibiotic coverage

Nonoperative Reduction Treatment Nonoperative Reduction Surgery Indications for surgery include flee air or peritonitis.

Treatment Reduction of intussusception is typically performed under fluoroscopic guidance, using either hydrostatic (contrast) or pneumatic (air) enema Successful reduction is indicated by the free flow of contrast or air into the small bowel. Success rates of 85% - 95% are reported.

Pneumatic technique Air enemas reduce the intussusception more easily, and may be advantageous if perforation occurs The technique begins with insertion of a Foley catheter into the rectum. Reflux of air into the terminal ileum and the disappearance of the mass at the ileocecal valve usually indicates reduction A sphygmomanometer can be used to monitor colonic intraluminal pressure (typically not to exceed 120 mm Hg) to aid in reduction If fluoroscopy is used, water-soluble contrast material can be instilled to confirm the reduction, or the air reduction can be repeated if the completeness of reduction is questioned

Risks and Complications Perforation of the bowel, occurs in 1 percent or fewer patients Risk factors for perforation include age younger than six months, long duration of symptoms (eg, three days or longer), evidence of small bowel obstruction The pneumatic reduction technique provides an advantage if perforation occurs, because air is generally less harmful than other contrast materials in the peritoneal cavity

Success Rates Nonoperative reduction using hydrostatic or pneumatic techniques is successful in approximately in 80 to 95 percent of patients with ileocolic intussusception In some institutions, repeated, delayed attempts at nonoperative reduction are made for patients in whom the initial attempt was unsuccessful. The intussusception recurs in approximately 10 percent of children after successful nonoperative reduction The delay between attempts varies from 30 minutes to a few hours. A few series suggest that this approach is successful and avoids surgery for some patients Patients with intussusception limited to the small bowel are managed somewhat differently compared to ileocolic intussusception, small bowel intussusceptions are less likely to respond to nonoperative reduction