INTUSSUSCEPTION

WHAT IS INTUSSUSCEPTION?
◦ Intussusception occurs when a portion of the alimentary tract is
telescoped into an adjacent segment
◦ It is the most common cause of intestinal obstruction between
5 mo and 3 yr of age and the most common abdominal
emergency in children younger than 2 years
◦ If left untreated, it may lead to intestinal infarction, perforation,
peritonitis, and death
Risk Factors
◦ prior or concurrent respiratory adenovirus (type C) infection
◦ after receiving a tetravalent rhesus-human reassortant rotavirus vaccine within 2 wk of
immunization (no longer available)
◦ Lymphoid nodular hyperplasia - lead to mucosal prolapse of the
ileum into the colon, thus causing an intussusception.
Anatomical Lead Points
◦ A piece of intestinal tissue that protruded into the
bowel lumen
◦ Recognizable anatomic abnormality that
obstructs the bowel, thus initiating the process of
intussusception
◦ Found in 2-8% of cases
◦ This includes: Meckel diverticulum, intestinal
polyp, neurofibroma, intestinal duplication cysts,
inverted appendix stump, leiomyomas,
hamartomas, ectopic pancreatic tissue, etc.

Intussusception caused by a tumor. The outermost layer of

intestine with external serosa has been removed, leaving the
mucosa of the second layer exposed. The serosa of the second
layer is apposed to the serosa of the intussuscepted intestine. A
tumor mass (right, labeled tumor) is present at the leading edge
of the intussusception.
 PATHOLOGY
◦ May be ileocolic (most common), cecocolic, or ileal
◦ The upper portion of bowel, the intussusceptum, invaginates into the
lower, the intussuscipiens, pulling its mesentery along with it into the
enveloping loop
◦ obstructs venous return  engorgement of the intussusceptum (w/
edema and mucosal bleeding)  bloody stool with mucus
 CLINICAL MANIFESTATIONS
◦ severe paroxysmal colicky pain that recurs at frequent intervals
and is accompanied by straining efforts with legs and knees
flexed and loud cries.
◦ becomes progressively weaker and lethargic.
◦ a shock-like state, with fever and peritonitis, can develop
◦ respirations become shallow and grunting, and the pain may be
manifested only by moaning sounds
◦ vomitus becomes bile stained.
CLINICAL MANIFESTATIONS
◦ The classic triad: (<30% of patients)
◦ Pain
◦ Palpable sausage-shaped abdominal mass (RUQ)
◦ Bloody or currant jelly stool
◦ The combination of paroxysmal pain, vomiting and a palpable
abdominal mass has a positive predictive value of >90%; the
presence of rectal bleeding increases this to approximately 100%.
CLINICAL MANIFESTATIONS
◦ On rare occasions, the advancing Milder forms:
intestine prolapses through the • Ileoileal intussusception
anus. This prolapse can be • Recurrent
distinguished from prolapse of the intussusception
rectum by the separation • Recurrent
between the protruding intestine intussusception
and the rectal wall, which does
not exist in prolapse of the rectum.
DIAGNOSIS:
Abdominal Ultrasound – will show a
tubular mass in longitudinal views
and a doughnut or target
appearance in transverse images

Contrast enemas - demonstrate

a filling defect or cupping in
the head of the contrast media
where its advance is
obstructed by the
intussusceptum Intussusception in an infant. The obstruction is
evident in the proximal transverse colon.
Contrast material between the
intussusceptum and the intussuscipiens is
Transverse image of an ileocolic responsible for the coiled-spring appearance.
intussusception. Note the loops
within the loops of bowel.
Treatment
◦ Emergency procedure and should be performed immediately after diagnosis
◦ Radiologic hydrostatic reduction under fluoroscopic or ultrasonic guidance (80-95%
success rate)
◦ Spontaneous reduction of intussusception occurs in approximately 4-10% of patients
◦ Surgical reduction is indicated in the presence of refractory shock, suspected bowel
necrosis or perforation, peritonitis, and multiple recurrences (suspected lead point).
Treatment
◦ Ileoileal intussusception - can develop insidiously after bowel surgery and require
reoperation if they do not spontaneously reduce.
◦ If manual operative reduction is impossible or the bowel is not viable, resection of the
intussusception is necessary, with end-to-end anastomosis.
Prognosis
◦ Untreated intussusception in infants is usually fatal
◦ Infants recover if the intussusception is reduced in the 1st 24 hr
◦ Mortality rate rises rapidly after this time, especially after the 2nd day
◦ The recurrence rate after reduction of intussusceptions = 10%
◦ After surgical reduction it is 2-5%; none has recurred after surgical resection.
◦ Corticosteroids may reduce the frequency of recurrent intussusception.
◦ Lymphonodular hyperplasia may respond to treatment of identifiable food allergies if
present.
◦ In patients with multiple ileal–colonic recurrences, a lead point should be suspected
and laparoscopic surgery considered
References:

◦ Nelson Textbook of Pediatrics, 20thed

◦ Robbins and Cotran Pathologic Basis of Disease 9thed