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 age
- 5 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

Children
- Marked 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to 1/32,000 vaccinated children developed intussusception with previous versions of rotavirus vaccine which has been withdrawn (3)[C].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 intussusceptions
- Intussusception 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 purpura
- Intussusception is a rare but well-recognized complication.
Cystic fibrosis
- Intussusceptions occur in ~1% of cystic fibrosis patients.
Lymphoma (rare)
Polyps (rare)
Small bowel carcinoma

DIAGNOSIS

HISTORY

History of intermittent colicky abdominal pain
- Episodes lasting 5 to 10 minutes
- Often 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 reanastomosis
- The 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.

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).

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