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Intussusception

para>5% of all intussusceptions occur in adults

<5% of intestinal obstruction cases in adults are due to intussusception (1)[B].

90% of adult cases have pathologic lead point (1)[B].

Pediatric Considerations

  • Annual incidence 5.4 cases per 10,000 infants in United States.
  • Most are idiopathic ileocolic intussusceptions; pathologic lead point identified only in 2-12%
  • Most common abdominal emergency in infancy (2)[C]
  • Postoperative intussusception (1 to 24 days postoperatively) typically involves the small bowel and is difficult to reduce hydrostatically.

EPIDEMIOLOGY

  • Predominant age5 to 10 months (~65% are <1 year of age)Only ~10-25% of cases occur after 1 year of age.
  • Predominant sex: male > female (3:2). Male preponderance is more obvious in older infants.

ETIOLOGY AND PATHOPHYSIOLOGY

  • ChildrenMarked hypertrophy of Peyer patches: 92-98%Lead point in 2-12%Meckel diverticulum, duplication cyst, aberrant tissue, intestinal polyp, ectopic pancreas, lymphoma, Henoch-Sch śnlein purpura as causes of pathologic lead point (if identified)Allergic reactions, diet changes, and changes in intestinal activity may be contributory.Idiopathic intussusceptions commonly associated with preceding adenovirus infection (24-40%)1/10,000 to 1/32,000 vaccinated children developed intussusception with previous versions of rotavirus vaccine which has been withdrawn (3)[C].Safety and efficacy trials of newer rotavirus vaccines (RV1 [Rotarix] and RV5 [RotaTeq]) show minimal intussusception risk (5.3 per 100,000 infants with RV1 and 1.5 excess cases of intussusception per 100,000 with RV5) (4,5,6,7,8)[A].
  • Adults: Pathologic lead point is typical.Neoplasm in 70% of adult intussusceptionsIntussusception of small bowel is usually caused by benign neoplasms; large bowel is usually caused by malignant neoplasms.

RISK FACTORS

  • Age (<1 year of age)
  • Recent upper respiratory tract infection (24-40%)
  • Recent operation (1 to 24 days previously)
  • Recent viral GI illness
  • Meckel diverticulum
  • Recent operative procedure

COMMONLY ASSOCIATED CONDITIONS

  • Henoch-Sch śnlein purpuraIntussusception is a rare but well-recognized complication.
  • Cystic fibrosisIntussusceptions occur in ~1% of cystic fibrosis patients.
  • Lymphoma (rare)
  • Polyps (rare)
  • Small bowel carcinoma

DIAGNOSIS

HISTORY

  • History of intermittent colicky abdominal painEpisodes lasting 5 to 10 minutesOften completely asymptomatic between episodes
  • Most have vomiting.
  • History of bloody stool ("currant jelly" stools): 65-95%, highest in infants
  • Diarrhea: 7%

PHYSICAL EXAM

  • Lethargy (with longer duration of illness): 22%
  • Palpable mass, typically right lower quadrant: 16-41%
  • Prolapse through anus: 3%
  • Fever
  • Pallor
  • In postoperative patients, intussusception typically presents as a small bowel obstruction.
  • Abdominal distension, depending on the duration of symptoms and degree of obstruction
  • Dance sign: retraction of the right lower quadrant above the iliac fossa
  • Bowel sounds initially hyperactive; may be absent later in the course
  • Abdominal tenderness
  • Hemoccult positive stool

DIFFERENTIAL DIAGNOSIS

  • Adhesive-band small bowel obstruction
  • Appendicitis
  • Gastroenteritis
  • Rectal prolapse (if intussuscepted bowel protrudes from anus)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Electrolytes
  • CBC
  • Urinalysis
  • Stool guaiac
  • Abdominal US is the diagnostic test of choice in children (9)[A].
  • Abdominal CT scan is mandatory in adults (10)[C].
  • Plain film: flat and upright abdominal films for alternate diagnosis or to rule out perforation

Diagnostic Procedures/Other

  • Contrast enema (barium, water-soluble contrast material, or air)
  • Colonoscopy may be useful in adults presenting with subacute or chronic colonic obstruction (1)[B].

Test Interpretation

  • Hyperplasia of Peyer lymphatic patches of terminal ileum (92%), with or without mesenteric lymphadenopathy in children
  • Recognizable lead point, 2-12% in children; >90% in adults (70% caused by neoplasms)

TREATMENT

GENERAL MEASURES

  • IV fluid resuscitation
  • Foley catheter (if severely dehydrated)
  • Nasogastric tube
  • Antibiotics if necrotic bowel present
  • Surgical consultation prior to enema reduction attempt
  • Nonoperative care (2)[C],(9)[A]Hydrostatic/pneumatic reduction of intussusception (50-80% success)Pneumatic reduction is preferred over hydrostatic reduction (lower cost, safer if perforation occurs).Pneumatic reduction pressure should not exceed 120 mm Hg (16 kPa).Barium column should be 40- to 42-inches high.Enema is continued as long as progress is made. Contrast material may be drained and the enema repeated up to 3 times.Hydrostatic/pneumatic reduction of intussusception should be performed in hospitals with specialized pediatric care, if possible, especially in children >4 years of age (11)[C].

SURGERY/OTHER PROCEDURES

  • Right lower quadrant incision with direct manipulation
  • If unable to reduce nonviable bowel, segmental resection with reanastomosisThe rate of intestinal resection in children's hospitals is 1-9%, whereas the reported rate of intestinal resection in general (nonpediatric) hospitals is reported as 1-47%, with a rate of 38% in a recent review of 11 general hospitals (11)[C].
  • Enterotomy if lead point is suspected
  • Incidental appendectomy: Tertiary centers with adequate minimally invasive skills often have laparoscopy as the primary surgical technique.
  • Postoperative intussusception usually requires laparotomy and operative reduction (12)[C].
  • Many adults do not have preoperative diagnosis of intussusception (only 65% in one series) (13)[C].
  • In adults, segmental bowel resection is usually required.
  • In adults, low recurrence with ventral rectopexy (14)[A].

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Inpatient support until reduced or resolved
  • Consider admitting infants for observation after nonoperative reduction due to higher risk for recurrence within 48 hours.

Discharge Criteria

  • Normal bowel function
  • Tolerating regular diet
  • Resolution of abdominal pain

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Liquid diet may be started and diet can be advanced as tolerated after successful reduction.

Patient Monitoring

Office visit 1 to 2 weeks after discharge

DIET

Start liquids after abdominal distension resolves and bowel function returns.

PATIENT EDUCATION

Possibility of recurrence is 5-13%. 40% of recurrences occur in the first 48 hours after reduction.

PROGNOSIS

  • Mortality <1-2%
  • Recurrence after hydrostatic reduction: 5-13%; recurrence after operative reduction: 1-3%

COMPLICATIONS

  • Bowel perforation (0.1% with barium enema, 0.4% with liquid enema, 0.6% with pneumatic reduction)
  • Prolonged ileus
  • Adhesions; intestinal obstruction (surgical reduction)
  • Incisional hernia with surgical reduction
  • Ischemic intestine requiring second operation
  • Recurrence

REFERENCES

11 Marinis A, Yiallourou A, Samanides L, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol. 2009;15(4):407-411.22 Sorantin E, Lindbichler F. Management of intussusception. Eur Radiol. 2004;14(Suppl 4):L146-L154.33 Bines JE. Rotavirus vaccines and intussusception risk. Curr Opin Gastroenterol. 2005;21(1):20-25.44 Ruiz-Palacios GM, P Šrez-Schael I, Vel Ązquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. 2006;354(1):11-22.55 Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med. 2006;354(1):23-33.66 Rha B, Tate JE, Weintraub E, et al. Intussusception following rotavirus vaccination: an updated review of the available evidence. Expert Rev Vaccines. 2014;13(11):1339-1348.77 Weintraub ES, Baggs J, Duffy J, et al. Risk of intussusceptions after monovalent rotavirus vaccination. N Engl J Med. 2014;370(6):513-519.88 Yih WK, Lieu TA, Kulldorff M, et al. Intussusception risk after rotavirus vaccination in U.S. infants. N Engl J Med. 2014;370(6):503-512.99 Ito Y, Kusakawa I, Murata Y, et al. Japanese guidelines for the management of intussusception in children, 2011. Pediatr Int. 2012;54(6):948-958.1010 Baleato-Gonz Ąles S, Vilanova JC, Garc a-Figueiras R, et al. Intussusception in adults: what radiologists should know. Emerg Radiol. 2012;19(2):89-101.1111 Shekherdimian S, Lee SL. Management of pediatric intussusception in general hospitals: diagnosis, treatment, and differences based on age. World J Pediatr. 2011;7(1):70-73.1212 Holcomb GWIII, Ross AJIII, O'Neill JAJr. Postoperative intussusception: increasing frequency or increasing awareness? South Med J. 1991;84(11):1334-1339.1313 Wang N, Cui X, Liu Y, et al. Adult intussusception: a retrospective review of 41 cases. World J Gastroenterol. 2009;15(26):3303-3308.1414 Samaranayake CB, Luo C, Plank AW, et al. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis. 2010;12(6):504-512.

ADDITIONAL READING

  • Apelt N, Featherstone N, Giuliani S. Laparoscopic treatment of intussusception in children: a systematic review. J Pediatr Surg. 2013;48(8):1789-1793.
  • Applegate KE. Intussusception in children: evidence-based diagnosis and treatment. Pediatr Radiol. 2009;39(Suppl 2):S140-S143.
  • Charles T, Penninga L, Reurings JC, et al. Intussusception in children: a clinical review. Acta Chir Bleg. 2015;115(5):327-333.
  • Soares-Weiser K, Maclehose H, Bergman H, et al. Vaccines for preventing rotavirus diarrhea: vaccines in use. Cochrane Database Syst Rev. 2012;(11):CD008521.

SEE ALSO

Cystic Fibrosis; Henoch-Sch śnlein Purpura; Intestinal Obstruction

CODES

ICD10

K56.1 Intussusception

ICD9

560.0 Intussusception

SNOMED

  • Intussusception of intestine (disorder)
  • Ileocolic intussusception
  • Intussusception of colon

CLINICAL PEARLS

  • The classic presentation for intussusception is intermittent infantile abdominal pain, vomiting, and currant jelly stools with a palpable right lower quadrant mass following an upper respiratory (adenovirus) infection.
  • Abdominal ultrasound is the diagnostic test of choice for pediatric intussusception.
  • Abdominal CT is preferred for adults
  • A lead point is present in ~10% of children <1 year of age (most commonly Meckel's diverticulum).
  • Pathologic lead points are present in >90% of adults, (most commonly a neoplasm).