Abdominal Pain Intussusception Author: Philip Wolfson, M.D. Jefferson Medical College Revision Editor: Linda Barney, M.D. Joseph Iocono, M.D.

Emme Hall Your patient in the ER is a 14-month-old female with a 12 hour history of irritability and abdominal discomfort.

What other points of the history do you want to know?

History, Emme Hall Characterization of symptoms Temporal sequence Consider the Following Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms

History, Emme Hall Characterization of pain: Unable to verbalize but discomfort seems intermittent, in spasms Temporal sequence: Has become more pronounced in past 4 hrs Activity level: Much less active than usual, irritability with the pain alternating with periods of lethargy Associated Signs & Symptoms Vomited 3 X, initially clear but now yellowish; had a watery bowel movement with a mixture of blood and mucus PMH Born at 37 weeks’ gestation. Otitis media at age 8 months. Upper respiratory infection 2 weeks ago

What would you look for on physical examination?

Physical Examination, Emme Hall Vital Signs: T= 101.2 P= 144 R= 22 BP= 80/55 General: Well nourished, pale, irritable Abdomen Inspection – mild distention, symmetric, shallow breathing Auscultation – bowel sounds present but diminished Percussion – tympanitic; elicits tenderness in RLQ and RUQ Palpation - generally soft, but + RUQ and RLQ tenderness Rectal: Normal patency, no mass palpable, gross blood on glove Remainder of examination is within normal limits

What is your Differential Diagnosis?

What studies would you obtain? Diagnostic Studies What studies would you obtain?

Studies ordered, Emme Hall CBC Hgb Hematocrit WBC Electrolytes Abdominal x-rays

Laboratory Studies, Emme Hall CBC Hb 14.2 Hematocrit 41 WBC 15.6 Electrolytes 137/103/3.9/22

X-ray results, Emme Hall Obstructive Series – chest x-ray normal; abdominal films show mildly dilated loops of small intestine. There is a paucity of gas in the right colon.

Clinical Studies, Emme Hall The hemoglobin is normal. The white cell count is moderately elevated, suggesting an infection or inflammation. The serum electrolytes are normal. The abdominal x-rays suggest the possibility of an intestinal abnormality, but the findings are nonspecific.

What is your revised Differential Diagnosis?

Differential Diagnosis Viral gastroenteritis Intussusception Appendicitis

Management What would you do now?

Further management, Emme Hall An attempt should be made to reduce this intussusception radiographically, using pressure from barium or air and visualized fluoroscopically. Some physicians prefer to have intravenous fluids running and administer broad spectrum antibiotics before this procedure.

Air enema Sequential images with arrows demonstrating reducing lead point of intussusception

Air enema The air passes up through the large intestine until it reaches the right side of the transverse colon where it encounters a filling defect. The radiologist is able to reduce the “mass” up to the proximal right colon but no further.

Further Management What does this mean? What should be done next?

Management, Emme Hall The intussusception can only be partially reduced, and there remains a filling defect in the cecum.

Management, Emme Hall Since the intussusception cannot be reduced, surgery is necessary and should be performed immediately. Broad spectrum antibiotics effective for lower intestinal organisms should be administered preoperatively.

Management, Emme Hall A right lower quadrant incision is made, and the ascending colon is delivered. There is an intussusception of the ileum half-way up the right colon.

Management, Emme Hall Using manual pressure on the colon above the intussusception, the ileum is reduced. The bowel is pink and viable; no pathological “lead point” is seen. An appendectomy is also performed.

Hospital Course Emme Hall recovers uneventfully and is discharged the following day, tolerating a regular diet

Discussion Intussusception is a telescoping of one portion of the intestine into another, and typically affects children between the ages of 6 to 18 months. The ileum usually invaginates and advances a variable distance into the colon. It often follows a nonspecific viral illness and may be due to hypertrophy of Peyer’s patches; rarely is there a pathological lead point in the intestinal wall. The patient presents with intermittent bouts of pain where they may draw their knees up to the chest; in between episodes they may be irritable or lethargic. Vomiting is common and as the condition progresses there may be blood and mucus (classically the “current jelly”) in the stools as the mucosa becomes ischemic. Physical examination may be fairly normal initially but there may be irritability, somnolence, fever, and right sided abdominal tenderness; occasionally a right upper abdominal mass can be palpated. Abdominal x-rays may appear normal or show a paucity of air in the right lower quadrant and some dilatation of the small intestine.

Discussion Intussusception is considered to be an emergency, as the intestine can become necrotic. If the diagnosis is suspected, a contrast enema will be diagnostic and often therapeutic. Radiologists are increasingly utilizing air rather than barium because of the greater success with contrast reduction and lower morbidity if there should be a perforation. Some advocate administration of intravenous fluids and broad spectrum antibiotics at the time of the x-ray studies, especially if the child is ill. Successful radiographic reduction is confirmed if there is reflux of contrast into the ileum, in which case the child is admitted to the hospital for 24 hours of observation. If contrast reduction is unsuccessful, surgery is mandatory to reduce the intussusception manually. The appendix is usually removed. If the intestine is necrotic, a resection is necessary. Recurrence of intussusception occurs in approximately 5% of children. The diagnosis of intussusception must be considered in any patient between 6 months and 2 years with unexplained abdominal pain, and a contrast x-ray usually is obtained. There may also be a role for ultrasound as a screening test.

Adult Intussusception Older children and adults with Intussusception usually have a pathological lead point, which is a malignant tumor in approximately half of all instances. Patients present with small intestinal obstruction and have a "target" sign on CT scan.  Surgical intervention is usually required

CT Scan Ileo-colonic Intussusception

CT Scan Ileo-colonic Intussusception

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Summary

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