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

2. 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

3. Case Presentation

4. Case Presentation

5. 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.

6. Case Presentation

7. Case Presentation

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

9. 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 Sep;120(3):

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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).

16. 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."

17. 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

18. Diagnosis
Contrast or Air Enema is both diagnostic and therapeutic

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

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

21. 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.

22. 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

23. 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

24. 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