11/14/24, 10\:59 AM Intussusception

Intussusception

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Intussusception\: a paediatric surgical emergency where a section of the bowel telescopes into its distal section, causing
bowel obstruction. Most common at the ileocaecal valve.
Complications\: can lead to bowel necrosis, perforation, and peritonitis if untreated.
Aetiology\: often no clear cause; associated with preceding viral infection and enlarged Peyer’s patches. Pathological lead
points (10% cases) include Meckel’s diverticula, intestinal polyps, lymphomas, leukaemias, and HSP.
Risk factors\: children aged 4-18 months, more common in boys.
Symptoms\:
Intermittent, severe abdominal pain (screaming episodes, knees drawn to chest).
Vomiting (becomes bilious in later stages).
Redcurrant jelly stool (late feature with ischaemic mucosal tissue).
Lethargy, odd posturing (may be mistaken for seizures).
History\: birth/developmental history, systemic enquiry for underlying causes (e.g., HSP).
Examination\:
ABCDE approach to identify unwell, dehydrated child.
Observation\: dehydration signs, screaming episodes, lethargy, rashes.
Abdominal exam\: sausage-shaped mass in right upper quadrant, tenderness, reduced bowel sounds, distension, peritonitis
(late stage).
Di
obstruction, testicular torsion, appendicitis.
Investigations\:
Bedside\: vital signs, capillary blood gas, urinalysis, stool sample for culture.
Laboratory\: FBC, U&E, LFTs, CRP.
Imaging\:
Abdominal ultrasound (gold-standard)\: shows ‘target sign’
.
Abdominal X-ray\: less sensitive/speci
Initial management\:
Fluid resuscitation.
Analgesia (IV paracetamol or opioids).
Nasogastric tube insertion.
Nil-by-mouth.
De
Non-surgical\: air or water enema (successful in 80% cases, 10% recurrence).
Surgical\: for unsuccessful non-surgical reduction, perforation, or peritonitis; involves manual reduction or bowel resection.
Complications\: late presentation, sepsis, delayed
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Introduction

Intussusception is a paediatric surgical emergency that occurs when a section of the bowel telescopes into its
neighbouring distal section, causing bowel obstruction. The most common site is the ileocaecal valve (ileocolic
intussusception).
1,2
If left untreated, intussusception can result in serious complications including bowel necrosis, perforation and peritonitis.

Aetiology

In most cases of intussusception, there is no clear cause. It can be associated with a preceding viral infection and may
occur due to an enlarged Peyer’s patch acting as a ‘lead point’
, facilitating the telescoping of the ileum through the
ileocaecal valve.
3
Around 10% of cases occur due to the presence of a pathological lead point. This is an abnormal area in the bowel which is
caught and pulled by peristalsis, thus leading the intussusception.
2
Intussusception due to a pathological lead point is more likely in patients presenting outside the typical age range or where
intussusception occurs away from the ileocaecal valve.
Examples of pathological lead points and other secondary causes of intussusception include\:
4
Meckel’s diverticula (and other congenital bowel defects)
Intestinal polys
Lymphomas and leukaemias
Henoch-Schonlein purpura (HSP)
Figure 1. Intussusception occurs when a
segment of bowel telescopes into its
distal neighbouring segment.

Risk factors

Intussusception most frequently occurs in children aged four to eighteen months and is slightly more common in boys.
1

Clinical features

History

The typical triad of symptoms of intussusception include\:
2
Intermittent, severe abdominal pain\: may present as screaming episodes during which the child is inconsolable and
draws their knees up to their chest. The child may appear well between episodes but will become more lethargic over
time as dehydration worsens.
Vomiting\: becomes bilious in later stages when bowel obstruction occurs
Redcurrant jelly stool\: a late feature that occurs when ischaemic mucosal tissue is sloughed o
stool, mixed with blood and mucus (it is a rare presenting feature).
In clinical practice, only one-third of patients present with all three of these symptoms. Other symptoms may include
lethargy or episodes of pain with odd posturing which may be mistaken for seizure activity.
4,5
Other important areas to cover in the history include\:
Birth and developmental history\: including antenatal scans and neonatal problems
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Systemic enquiry\: to identify cases where there is an underlying secondary cause, such as HSP

Clinical examination

An ABCDE approach should be adopted in order to quickly identify the unwell, dehydrated child who requires early
resuscitation. This type of systematic examination is also important to identify signs of an underlying cause of
intussusception.
Observation is an important part of the initial clinical assessment. Typical
Signs of dehydration, such as sunken eyes and dry lips
Episodes of screaming +/- drawing knees up to their chest
Lethargy or excessive sleepiness
Rashes or other features of secondary causes
The hallmark sign of intussusception is a sausage-shaped mass palpable in the right upper quadrant of the abdomen.
2
Other signs on abdominal examination may include tenderness, reduced/absent bowel sounds, distension (secondary to
bowel obstruction) and, in the late stages, peritonitis (secondary to perforation).
2

Di

Due to the non-speci
1
Constipation
Gastroenteritis
Malrotation volvulus
Incarcerated hernia
Adhesional bowel obstruction
Testicular torsion
Appendicitis

Investigations

Bedside investigations

Relevant bedside investigations include\:
Basic observations (vital signs)\: especially heart rate and blood pressure, which may be abnormal if the child is
dehydrated and unwell
Capillary blood gas\: signi
Urinalysis\: to look for evidence of a urinary tract infection, which is a cause of abdominal pain in children
Stool sample for microscopy, culture and sensitivities\: to look for evidence of gastroenteritis

Laboratory investigations

Relevant laboratory investigations include\:
Full blood count\: neutrophilia may be present in later stages
Urea & electrolytes\: dehydration and vomiting may cause electrolyte disturbances
Liver function tests\: to exclude a hepatobiliary cause
CRP\: may be elevated in later stages

Imaging investigations

The gold-standard investigation for suspected intussusception is an abdominal ultrasound.
6
This classically shows a ‘target sign’ and has a sensitivity and speci
give important information about the likely success of subsequent reduction.
3,7
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An abdominal X-ray can also be performed. However, this is less sensitive and speci
commonly requested. 8
Abdominal X-ray may show a typical picture of bowel obstruction, with distended proximal loops of
bowel and paucity of distal bowel gas.
Figure 2. The target sign of
intussusception on abdominal
ultrasound.

Management

Initial management

Prompt and adequate
one of the main causes of mortality in intussusception.
6
Additional initial management should include\:
3
Analgesia\: this might be in the form of intravenous paracetamol or opioids
Inserting a nasogastric tube to decompress the stomach
Making the child nil-by-mouth

De

Non-surgical
For most cases, the
Enemas are successful in over 80% of cases and have around a 10% recurrence rate. 9
The procedure is carried out under

intussusception.
This approach is less likely to be successful in children who have a pathological lead-point and is contraindicated if there
is evidence of shock, perforation or peritonitis.
3,9
Surgical
Where non-surgical reduction is unsuccessful, or there is evidence of perforation or peritonitis, surgery is required to
manually reduce the intussusception. 6
This can be performed laparoscopically but is often converted to an open
procedure. If this is unsuccessful, bowel resection may be required.

Complications

The main causes of mortality are late presentation, sepsis and a failure to instigate appropriate
6
Serious complications are uncommon when intussusception is identi
de
6

References

Jain S, Haydel MJ. Child Intussusception. StatPearls [Internet]. Treasure Island (FL)\: StatPearls Publishing; 2022 Jan. Available
from\: [LINK]
Marsicovetere P, Ivatury SJ, White B, Holubar SD. Intestinal Intussusception\: Etiology, Diagnosis, and Treatment. Clin Colon
Rectal Surg. 2017 Feb;30(1)\:30-39. Available from\: [LINK]
https\://app.geekymedics.com/notebook/2710/ 4/611/14/24, 10\:59 AM Intussusception
s t
ID, Sugarman., VA, Lane. (2014) Intussusception. In\: Max Pachl et. al. K e y C l i n i c a l T o p i c s i n P a e d i a t r i c S u r ge r y . 1 JP Medical
LTD.2013. Chapter 54 (p181-184).
Patient.info. Intussusception in Children. Updated 2016. Available from\: [LINK]
Park IK, Cho MJ. Clinical Characteristics According to Age and Duration of Symptoms to Be Considered for Rapid Diagnosis
of Paediatric Intussusception. Front Pediatr. 2021; 9\:651297. Available from\: [LINK]
Mendiratta P, Yadav A, Borse N. Paediatric small-bowel intussusception on ultrasound – a case report with di
features from the ileocolic subtype. J Ultrason. 2021; 21(84)\: 70-73. Available from\: [LINK]
Henderson AA, Anupindi SA, Servaes S, Markowitz RI, Aronson PL, McLoughlin RJ et al. Comparison of 2-view abdominal
radiographs with ultrasound in children with suspected intussusception. Pediatr Emerg Care. 2013; 29(2)\:145-50. Available
from\: [LINK]
BMJ Best Practice. Intussusception. Available from\: [LINK]
Daneman A, Navarro O. Intussusception Part 2\: An update on the evolution of management. Paediatr Radiol. 2004. 34;97-
108. Available from\: [LINK]

Image references

Figure 1. Orem. D r a w i n g o f i n t u s s u s c e p t i o n . License\: [CC BY-SA]
Figure 2. Benutzer\:Kalumet. S o n o g r a p h i c i m a g e o f a n i n t e s t i n e-i n v a g i n a t i o n . License\: [CC BY-SA]

Reviewer

Dr Cameron Kuronen-Stewart
Core Surgical Trainee

Related notes

Attention De
Autism Spectrum Disorder (ASD)
Biliary Atresia
Bronchiolitis
Cerebral Palsy

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Contents

Introduction
Aetiology
Risk factors
Clinical features
Di
Investigations
Management
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