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Intussusception, Emergency Medicine

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Intussusception, Emergency Medicine

Basics

Description

Patients, particularly those in the pediatric age group, with a picture of potential intestinal obstruction, especially with hematest-positive stool or altered mental status, need to have intussusception considered.

If enema is unsuccessful in reducing, surgery is required on an emergent basis.

Surgeon should be aware of patients with potential diagnosis of intussusception.

Infants with intermittent abdominal pain, impaired mental status, and blood in stools should generally have intussusception considered.

  • The proximal bowel invaginates into the distal bowel, producing infarction and gangrene of the inner bowel:>80% involve the ileocecal region.
  • Often occurs with a pathologic lead point in children >2 yr:Hypertrophied lymphoid patches may be present in infants.Children >2 yr: 1/3 of patients have pathologic lead point.Children >6 yr: Lymphoma is the most common lead point.Adults usually have a pathologic lead point.
  • The most common cause of intestinal obstruction within the 1st 2 yr of life
  • Epidemiology in US:Most frequently between 5 and 9 mo of ageIncidence is 2.4 cases per 1,000 live births.Male > female predominance of 2:1Mortality <1%
  • Morbidity increases with delayed diagnosis.
  • >80% involve the ileocecal region.
  • Hypertrophied lymphoid patches may be present in infants.
  • Children >2 yr: 1/3 of patients have pathologic lead point.
  • Children >6 yr: Lymphoma is the most common lead point.
  • Adults usually have a pathologic lead point.
  • Most frequently between 5 and 9 mo of age
  • Incidence is 2.4 cases per 1,000 live births.
  • Male > female predominance of 2:1
  • Mortality <1%

Etiology

  • Most cases (85%) have no apparent underlying pathology.
  • Predisposing conditions that create a lead point for invagination, esp. in older children and adults:Masses/tumors:LymphomaLipomaPolypHypertrophied lymphoid patchesMeckel diverticulumInfection:Adenovirus or rotavirus infectionParasitesForeign bodyHenoch-Sch ¶nlein purpuraCeliac disease and cystic fibrosis (small intestine intussusception)
  • Masses/tumors:LymphomaLipomaPolypHypertrophied lymphoid patchesMeckel diverticulum
  • Infection:Adenovirus or rotavirus infectionParasites
  • Foreign body
  • Henoch-Sch ¶nlein purpura
  • Celiac disease and cystic fibrosis (small intestine intussusception)
  • Lymphoma
  • Lipoma
  • Polyp
  • Hypertrophied lymphoid patches
  • Meckel diverticulum
  • Adenovirus or rotavirus infection
  • Parasites

Diagnosis

Signs and Symptoms

  • Classic triad (present in <50% of patients):Abdominal painVomiting, often biliousStools have blood and mucus ("currant jelly"¯ stools)
  • Recurrent painful episodes accompanied by pallor and drawing up of the legs; intermittent fits of sudden intense pain with screaming and flexion of legs:Occur in 5-20 min intervals
  • Mental status changes:IrritabilityLethargy or listlessness; child can be limp or have a rag doll appearance.May precede abdominal findings.
  • Stool variable:Heme-positive (occult), bloody, or "currant jelly"¯
  • Preceding illness several days or weeks prior to the onset of abdominal pain:DiarrheaViral syndromeHenoch-Sch ¶nlein purpura
  • Recurrent intussusception occurs in <10% of patients.
  • Abdominal pain
  • Vomiting, often bilious
  • Stools have blood and mucus ("currant jelly"¯ stools)
  • Occur in 5-20 min intervals
  • Irritability
  • Lethargy or listlessness; child can be limp or have a rag doll appearance.
  • May precede abdominal findings.
  • Heme-positive (occult), bloody, or "currant jelly"¯
  • Diarrhea
  • Viral syndrome
  • Henoch-Sch ¶nlein purpura
  • Fever
  • Abdomen distended and swollen:A "sausage"¯ mass may be palpated in the right upper quadrant.May have absent cecum in right iliac fossa.Peristaltic wave may be present.Rectal exam may reveal bloody stool and palpable mass.
  • Dependent on the time from onset to diagnosis; perforation with peritonitis and sepsis may be present.
  • A "sausage"¯ mass may be palpated in the right upper quadrant.
  • May have absent cecum in right iliac fossa.
  • Peristaltic wave may be present.
  • Rectal exam may reveal bloody stool and palpable mass.

Essential Workup

  • The diagnosis is suggested by the history and is proven radiographically.
  • A heme-positive stool may aid in the diagnosis, particularly in the presence of lethargy or listlessness.

Diagnosis Tests & Interpretation

  • CBC
  • Serum electrolytes, BUN
  • Type and cross-match
  • Abdominal radiograph:Abnormal in 35-40% of patientsDecreased bowel gas and fecal material in the right colonAbdominal massApex of intussusceptum outlined by gasSmall bowel distention and air-fluid levels secondary to mechanical obstructionMay aid in excluding intestinal perforation.
  • Enema:Often both diagnostic and therapeutic. Reoccurrences do happen.74% successful if intussusception present ā‰¤24 hr32% effective when present >24 hrThe more distal the intussusception, the lower is the ability to reduce it radiographically.Recurrent disease (up to 10%) has similar success to initial episode.Complications include bowel perforation, reduction of necrotic bowel, incomplete reduction with delay in surgery, and overlooking pathologic lead point.Hypovolemic shock reported following reduction secondary to endotoxins and cytokines.Barium:Traditional standard for diagnosis and treatmentCharacteristic coiled-spring appearanceAir:Fluoroscopic guidanceAvoids peritoneal contamination if perforationIncreasingly used for diagnosis and treatmentContraindications:PeritonitisPerforationUnstable patients secondary to sepsis or shock
  • US is highly accurate and may be useful as a screening technique; operator dependent:Typical appearance is a "donut"¯ or "bulls eye"¯ structure, with hyperechoic core surrounded by hypoechoic rim of homogeneous thickness.
  • Abnormal in 35-40% of patients
  • Decreased bowel gas and fecal material in the right colon
  • Abdominal mass
  • Apex of intussusceptum outlined by gas
  • Small bowel distention and air-fluid levels secondary to mechanical obstruction
  • May aid in excluding intestinal perforation.
  • Often both diagnostic and therapeutic. Reoccurrences do happen.74% successful if intussusception present ā‰¤24 hr32% effective when present >24 hrThe more distal the intussusception, the lower is the ability to reduce it radiographically.Recurrent disease (up to 10%) has similar success to initial episode.
  • Complications include bowel perforation, reduction of necrotic bowel, incomplete reduction with delay in surgery, and overlooking pathologic lead point.
  • Hypovolemic shock reported following reduction secondary to endotoxins and cytokines.
  • Barium:Traditional standard for diagnosis and treatmentCharacteristic coiled-spring appearance
  • Air:Fluoroscopic guidanceAvoids peritoneal contamination if perforationIncreasingly used for diagnosis and treatment
  • Contraindications:PeritonitisPerforationUnstable patients secondary to sepsis or shock
  • 74% successful if intussusception present ā‰¤24 hr
  • 32% effective when present >24 hr
  • The more distal the intussusception, the lower is the ability to reduce it radiographically.
  • Recurrent disease (up to 10%) has similar success to initial episode.
  • Traditional standard for diagnosis and treatment
  • Characteristic coiled-spring appearance
  • Fluoroscopic guidance
  • Avoids peritoneal contamination if perforation
  • Increasingly used for diagnosis and treatment
  • Peritonitis
  • Perforation
  • Unstable patients secondary to sepsis or shock
  • Typical appearance is a "donut"¯ or "bulls eye"¯ structure, with hyperechoic core surrounded by hypoechoic rim of homogeneous thickness.

Differential Diagnosis

  • Infection
  • Acute gastroenteritis
  • Appendicitis
  • Inflammatory bowel disease
  • Infectious mononucleosis
  • Pneumonia
  • Pharyngitis/group A streptococcal
  • Pyelonephritis
  • Colic
  • Intestinal obstruction/peritonitis
  • Strangulated hernia
  • Malrotation/volvulus
  • Hirschsprung disease
  • Trauma
  • Intestinal vascular/hemorrhagic disorder
  • Anal fissure/hemorrhoids
  • Ulcer disease
  • Vascular malformations
  • Henoch-Sch ¶nlein purpura
  • Polyp
  • Protein-sensitive enterocolitis
  • Diabetes mellitus
  • Coagulopathy

Treatment

Pre-Hospital

  • IV access
  • IV bolus of 20 mL/kg of 0.9% NS or lactated Ringer (LR) if evidence of hypovolemia, abdominal distention, peritonitis, sepsis
  • Diagnosis rarely confirmed in pre-hospital setting

Initial Stabilization/Therapy

  • IV access and initiation of 0.9% NS or LR at 20 mL/kg bolus
  • Nasogastric tube

Ed Treatment/Procedures

  • Stabilize patient hemodynamically.
  • Surgical consultation
  • Abdominal radiograph film series
  • Interventional radiography for reduction if no contraindications:Enemas are 75-80% successful at reduction, reflecting duration of condition.Recurrences may also be reduced radiographically.
  • Antibiotics:Initiate if evidence of peritonitis, perforation, or sepsis.Ampicillin, clindamycin, and gentamicinAmpicillin/sulbactam
  • Laparotomy:Indications:Enema is unsuccessful.Enema is contraindicated.Pathologic lead pointMultiple recurrencesProcedure:Gentle milking of the intussusceptumResection of any nonviable bowel as well as any lead points that are identified
  • Enemas are 75-80% successful at reduction, reflecting duration of condition.
  • Recurrences may also be reduced radiographically.
  • Initiate if evidence of peritonitis, perforation, or sepsis.
  • Ampicillin, clindamycin, and gentamicin
  • Ampicillin/sulbactam
  • Indications:Enema is unsuccessful.Enema is contraindicated.Pathologic lead pointMultiple recurrences
  • Procedure:Gentle milking of the intussusceptumResection of any nonviable bowel as well as any lead points that are identified
  • Enema is unsuccessful.
  • Enema is contraindicated.
  • Pathologic lead point
  • Multiple recurrences
  • Gentle milking of the intussusceptum
  • Resection of any nonviable bowel as well as any lead points that are identified

Medication

  • Ampicillin: 100-200 mg/kg/d q4h IV
  • Clindamycin: 30-40 mg/kg/d q6h IV
  • Gentamicin: 5-7.5 mg/kg/d q8h IV
  • Ampicillin/sulbactam 100-200 mg/kg/d q6h IV

Follow-Up

Disposition

  • Patients undergoing successful enema reduction should be observed for complications or recurrence.
  • Patients undergoing surgery
  • May be considered after a very prolonged period of observation following successful enema reduction:Stable patient with normal mental statusSymptomatic relief of abdominal pain during the postreduction periodParents have appropriate understanding to watch for potential reoccurrence, even after prolonged period observation
  • Stable patient with normal mental status
  • Symptomatic relief of abdominal pain during the postreduction period
  • Parents have appropriate understanding to watch for potential reoccurrence, even after prolonged period observation

Pearls and Pitfalls

Additional Reading

  • Bajaj L, Roback MG. Postreduction management of intussusception in a childrens hospital emergency department. Pediatrics. 2003;112:1302-1307.
  • Hryhorczuk AL, Strouse PJ. Validatiion of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radiol. 2009;39:1075-1079.
  • Kleizen KJ, Hunck A, Wijnen MH, et al. Neurological symptoms in children with intussusception. Acta Paediatr. 2009;98:1822-1824.
  • Saverino BP, Lava C, Lowe LH, et al. Radiographic findings in the diagnosis of pediatric ileocolic intussusception: Comparison to a control population. Pediatr Emerg Care. 2010;26:281-284.
  • Willetts IE, Kite P, Barclay GR, et al. Endotoxin, cytokines and lipid peroxides in children with intussusception. Br J Surg. 2001;88:878-883.

Codes

ICD9

ICD10

SNOMED

  • 49723003 Intussusception of intestine (disorder)
  • 197049005 ileocecal intussusception (disorder)
  • 197054001 Secondary intussusception (disorder)