Intussusception in Children

Intussusception is a term derived from the Latin intus (within) and suscipere (to receive). One segment of the bowel (intussusceptum) invaginates into another (intussuscipiens) just distal to it, leading to obstruction. The bowel may simply telescope on itself (non-pathological lead point), or some pathology may be the focus of the invagination (pathological lead point).
The mesentery of the intussuscepted bowel becomes compressed. The bowel wall distends and obstructs the lumen. Peristalsis is disrupted leading to colicky abdominal pain and vomiting. Lymphatic and venous obstruction occurs, causing ischaemia. In most children the intussusception is ileocaecal, though ileo-ileocolic and ileo-ileal or colocolic cases can occur.

• The male to female ratio is approximately 3:2.
• Two-thirds of patients are under one year old, the peak age being between 5-10 months.
• Intussusception is the most common cause of intestinal obstruction in patients aged 5 months-3 years and accounts for up to 25% of abdominal emergencies in children up to age 5.
• It is rare pre-term.
• One large Swiss study found an overall incidence of 38, 31 and 26 cases per 100,000 live births in the first, second and third year of life respectively.³

• Usually of sudden onset, maybe more insidious in the older child
• Paroxysms (about every 10-20 minutes) of colicky abdominal pain (>80%) ± crying
• May appear well between paroxysms initially
• Early vomiting – rapidly becoming bile-stained
• Neurological symptoms such as lethargy, hypotonia or sudden alterations of consciousness can occur⁵
• Palpable 'sausage-shaped' mass (often in right upper quadrant)
• Absence of bowel in right lower quadrant (Dance's sign)
• Dehydration, pallor, shock
• Irritability, sweating
• Later mucoid and bloody 'redcurrant stools'
• Late pyrexia

Non-pathological lead point (>90%)

• Viral 50% - rotavirus, adenovirus and human herpes virus 6 (HHV6)
• Amoebomata, shigella, yersinia^7,8
• Peyer's patch hypertrophy

Pathological lead point (<10%)

NB: older patients (may have longer history)

• Meckel's diverticulum (75%)
• Polyps and Peutz-Jeghers' syndrome (16%)⁹
• Henoch-Schönlein purpura (3%)
• Lymphoma and other tumours (3%)
• Reduplication (a process by which the bowel wall is duplicated) (2%)
• Cystic fibrosis
• An inflamed appendix ¹⁰
• Ascariasis¹¹
• Nephrotic syndrome¹²
• Foreign body¹³
• Postoperative¹⁴ - rarely, postoperative intussusception, following operative treatment of an intusussception, has been reported¹⁵
• Hyperperistalsis¹⁶
• Exclusive breast-feeding¹⁷
• Weight above average
• Rotavirus vaccine¹⁸
• Abdominal tuberculosis¹⁹

• Full blood count - may show neutrophilia
• Urea and electrolytes - may reflect dehydration
• Abdominal X-ray - may show dilated gas-filled proximal bowel, paucity of gas distally, multiple fluid levels (but may be normal in the early stages)
• Ultrasound - may show doughnut or target sign, pseudokidney/sandwich appearance.²⁰ It is a very effective modality and many consider it the investigation of choice.²¹
• Bowel enema - barium has been gold standard (crescent sign, filling defect) but air and water-soluble double-contrast now available; each has pros and cons - choice left to individual radiologist^1,22
• CT/MRI scanning - more often used in adults than children²³

• Early diagnosis reduced the need for open surgery.²¹
• Resuscitation - 'drip and suck' - nasogastric tube and IV fluids.
• Radiological - reduction (three tries for three minutes each) if no sign of peritonitis, perforation or shock.
• Air enema <120 mmHg of pressure or barium enema - the choice of enema usually left to radiologist (many now favour air enema).^18,21
• Laparotomy (reduction/resection) - indications:
  • Peritonitis
  • Perforation
  • Prolonged history (>24 hours)
  • High likelihood of pathological lead point
  • Failed enema
• Hospital admission has been recommended in the past because of the presumed high incidence of recurrence. However, a recent study of hospitalised children with enema-reduced intussusception found that they required minimal interventions, had a low rate of signs and symptoms requiring further radiographic studies and had no enema-reduced serious complications. They therefore advised outpatient management as an acceptable alternative.²⁴

• Missed diagnosis
• Ischaemia of the intussusceptum/intussuscipiens²⁵
• Necrosis
• Haemorrhage
• Perforation
• Infection and peritonitis
• Failure of enema reduction
• Chronic intussusception – rare cause of failure to thrive²⁶

• Prognosis - excellent with treatment
  • Post-reduction recurrence:
    • Radiological: 5%
    • Surgical: 1-4%
• Mortality: 1% with treatment, fatal if untreated

1. Young L; Case Based Pediatrics For Medical Students and Residents Intussusception Case Based Pediatrics For Medical Students and Residents Department of Pediatrics, University of Hawaii John A. Burns School of Medicine Chapter X.4. 2002
2. Blanco FC, Chahine A; Intussusception. eMedicine, Nov 2009.
3. Buettcher M, Baer G, Bonhoeffer J, et al; Three-year surveillance of intussusception in children in Switzerland. Pediatrics. 2007 Sep;120(3):473-80. [abstract]
4. King L|; Pediatrics, Intussusception eMedicine.com 2009.
5. Kleizen KJ, Hunck A, Wijnen MH, et al; Neurological symptoms in children with intussusception. Acta Paediatr. 2009 Nov;98(11):1822-4. Epub 2009 Aug 10. [abstract]
6. Irish M, Shellnut, J; Intussusception, Surgical eMedicine.com 2009.
7. Patra SB, Giri DD, Shukla GN, et al; Amoebic granuloma--an unusual cause of caeco-colic intussusception. Postgrad Med J. 1984 Feb;60(700):168-70. [abstract]
8. Navaneethan U, Giannella RA; Mechanisms of infectious diarrhea. Nat Clin Pract Gastroenterol Hepatol. 2008 Nov;5(11):637-47. Epub 2008 Sep 23. [abstract]
9. Gammon A, Jasperson K, Kohlmann W, et al; Hamartomatous polyposis syndromes. Best Pract Res Clin Gastroenterol. 2009;23(2):219-31. [abstract]
10. Chaar CI, Wexelman B, Zuckerman K, et al; Intussusception of the appendix: comprehensive review of the literature. Am J Surg. 2009 Jul;198(1):122-8. Epub 2009 Feb 27. [abstract]
11. Yetim I, Ozkan OV, Semerci E, et al; Rare cause of intestinal obstruction, Ascaris lumbricoides infestation: two case reports. Cases J. 2009 Jun 17;2:7970. [abstract]
12. Asai K, Tanaka S, Tanaka N, et al; Intussusception of the small bowel associated with nephrotic syndrome. Pediatr Nephrol. 2005 Dec;20(12):1818-20. Epub 2005 Oct 25. [abstract]
13. Lynch KA, Feola PG, Guenther E; Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department. Pediatr Emerg Care. 2003 Oct;19(5):343-7. [abstract]
14. Turkyilmaz Z, Sonmez K, Demirogullari B, et al; Postoperative intussusception in children. Acta Chir Belg. 2005 Apr;105(2):187-9. [abstract]
15. Bai YZ, Chen H, Wang WL; A special type of postoperative intussusception: ileoileal intussusception after surgical reduction of ileocolic intussusception in infants and children. J Pediatr Surg. 2009 Apr;44(4):755-8. [abstract]
16. Akbayir N, Yildirim S, Sokmen HM, et al; Intussusception of vermiform appendix with microscopic melanosis coli: a case report. Turk J Gastroenterol. 2006 Sep;17(3):233-5. [abstract]
17. Pisacane A, Caracciolo G, de Luca U, et al; Infant feeding and idiopathic intussusception. J Pediatr. 1993 Oct;123(4):593-5. [abstract]
18. Justice FA, Auldist AW, Bines JE; Intussusception: Trends in clinical presentation and management. J Gastroenterol Hepatol. 2006 May;21(5):842-6. [abstract]
19. Mahajan D, Nigam S, Kohli K; Abdominal tuberculosis presenting as ileocolic intussusception in an infant. Pediatr Dev Pathol. 2007 Nov-Dec;10(6):477-80. [abstract]
20. Kim J; US Features of Transient Small Bowel Intussusception in Pediatric Patients Korean Journal of Radiology; 2004 September; 5(3):178-184
21. Lehnert T, Sorge I, Till H, et al; Intussusception in children--clinical presentation, diagnosis and management. Int J Colorectal Dis. 2009 Oct;24(10):1187-92. Epub 2009 May 6. [abstract]
22. Young, L , Yamamoto, L; The Stomach Flu? - The Target, Crescent, and Absent Liver Edge Signs Radiology Cases in Pediatric Emergency Medicine Volume 1, Case 2 1994
23. Byrne AT, Geoghegan T, Govender P, et al; The imaging of intussusception. Clin Radiol. 2005 Jan;60(1):39-46. [abstract]
24. Herwig K, Brenkert T, Losek JD; Enema-reduced intussusception management: is hospitalization necessary? Pediatr Emerg Care. 2009 Feb;25(2):74-7. [abstract]
25. Park SB, Ha HK, Kim AY, et al; The diagnostic role of abdominal CT imaging findings in adults intussusception: focused on the vascular compromise. Eur J Radiol. 2007 Jun;62(3):406-15. Epub 2007 Apr 6. [abstract]
26. Malakounides G, Thomas L, Lakhoo K; Just another case of diarrhea and vomiting? Pediatr Emerg Care. 2009 Jun;25(6):407-10. [abstract]

• Blanch AJ, Perel SB, Acworth JP; Paediatric intussusception: epidemiology and outcome. Emerg Med Australas. 2007 Feb;19(1):45-50. [abstract]