Intussusception in Children

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Intussusception is much more common in children than in adults. There is a separate article on Intussusception in Adults.

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, although ileo-ileocolic and ileo-ileal or colocolic cases can occur.

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  • 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 preterm.
  • 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]
  • It is usually of sudden onset, and may be more insidious in the older child.
  • There are paroxysms (about every 10-20 minutes) of colicky abdominal pain (>80%) ± crying.
  • The child may appear well between paroxysms initially.
  • There is early vomiting - rapidly becoming bile-stained.
  • Neurological symptoms such as lethargy, hypotonia or sudden alterations of consciousness can occur.[4]
  • There may be a palpable 'sausage-shaped' mass (often in the right upper quadrant).
  • There may be absence of bowel in the 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 herpesvirus 6 (HHV6).
  • Amoebomata, shigella, yersinia.
  • Peyer's patch hypertrophy.

Pathological lead point (<10%)

NB: older patients (may have longer history):

  • FBC - may show neutrophilia.
  • U&Es - 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.[6] It is a very effective modality and many consider it the investigation of choice.[7]
  • 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 - the choice is left to the individual radiologist.[1]
  • CT/MRI scanning - more often used in adults than in children.[8]
  • Any child with possible intussusception or other serious cause of abdominal pain should be referred urgently to hospital for further assessment.
  • Early diagnosis reduces the need for open surgery.[7]
  • Resuscitation - 'drip and suck' - nasogastric tube and IV fluids.
  • Radiological:
    • Reduction (three tries for three minutes each) if there is no sign of peritonitis, perforation or shock.
    • Air enema <120 mm Hg of pressure or barium enema.
    • The choice of enema is usually left to the radiologist (many now favour air enema).[7][9]
  • Laparotomy (reduction/resection) - indications:
    • Peritonitis
    • Perforation
    • Prolonged history (>24 hours)
    • High likelihood of pathological lead point
    • Failed enema
  • Hospital admission is usually required but outpatient management may on occasions be an acceptable alternative.[10]
  • Missed diagnosis
  • Ischaemia of the intussusceptum/intussuscipiens[11]
  • Necrosis
  • Haemorrhage
  • Perforation
  • Infection and peritonitis
  • Failure of enema reduction
  • Chronic intussusception - rare cause of failure to thrive[12]

With treatment, prognosis is excellent.

  • Post-reduction recurrence:
    • Radiological: 5%
    • Surgical: 1-4%
  • Mortality:
    • 1% with treatment
    • Fatal if untreated

Further reading & references

  1. Young L; 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 et al; Intussusception, Medscape, May 2012
  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.
  4. 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.
  5. Irish MS et al; Pediatric Intussusception Surgery, Medscape, Apr 2011
  6. Kim J; US Features of Transient Small Bowel Intussusception in Pediatric Patients Korean Journal of Radiology; 2004 September; 5(3):178-184
  7. 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.
  8. Byrne AT, Geoghegan T, Govender P, et al; The imaging of intussusception. Clin Radiol. 2005 Jan;60(1):39-46.
  9. Justice FA, Auldist AW, Bines JE; Intussusception: Trends in clinical presentation and management. J Gastroenterol Hepatol. 2006 May;21(5):842-6.
  10. Herwig K, Brenkert T, Losek JD; Enema-reduced intussusception management: is hospitalization necessary? Pediatr Emerg Care. 2009 Feb;25(2):74-7.
  11. 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.
  12. Malakounides G, Thomas L, Lakhoo K; Just another case of diarrhea and vomiting? Pediatr Emerg Care. 2009 Jun;25(6):407-10.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Laurence Knott
Current Version:
Peer Reviewer:
Dr Adrian Bonsall
Last Checked:
28/03/2013
Document ID:
2337 (v22)
© EMIS