Intussusception

• Intussusception is the most

frequent cause of bowel
obstruction in infants and
toddlers

• an acquired invagination of the

proximal bowel
(intussusceptum) into the distal
bowel (intussuscipiens)

• It was first described in 1674 by

Paul Barbette of Amsterdam,
defined by Treves in 1899, and
operated on successfully in
1873 by John Hutchinson
 Pathophysiology
• The intussusceptum telescopes into
the distal bowel by peristaltic activity

• may or may not be a lead point

• As the mesentery of the proximal

bowel is drawn into the distal bowel, it
is compressed,

• resulting in venous obstruction and

bowel wall edema

• If reduction does not occur >>

arterial insufficiency >> ischemia and
bowel wall necrosis
• PRIMARY INTUSSUSCEPTION

• A majority of cases, especially in infants, do not have a

lead point and are classified as primary or idiopathic
intussusceptions

• The cause is generally attributed to hypertrophied Peyer

patches within the bowel wall

• Intussusception occurs frequently in a course of an upper

respiratory tract infection or an episode of gastroenteritis,
providing an etiology or the hypertrophied lymphoid tissue

• Adenoviruses in children older than age 2 and rotaviruses,

have been historically implicated in up to 50% of cases
• PRIMARY INTUSSUSCEPTION

• viruses may play a role in intussusception includes the

rise in cases during seasonal respiratory viral illnesses and
the increased risk associated with rotavirus immunization

• The initial rotavirus vaccine was removed from the market

due to a significant increase in the incidence of
intussusception

• The current immunization formulas available in the United

States, RotaTeq and Rotarix, also have been associated
with a small increased risk, but these risks are widely
thought to be outweighed by the benefits of vaccination
• SECONDARY INTUSSUSCEPTION

• An intussusception can have an identifiable lesion that serves

as a lead point, drawing the proximal bowel into the distal
bowel by peristaltic activity

• The incidence of a lead point varies from 1.5–12%, and the

presence of a lead point increases in proportion with age

• The most common lead point is a Meckel diverticulum

followed by polyps and duplications

• Other benign lead points include the appendix, hemangiomas,

carcinoid tumors, foreign bodies, ectopic pancreas or gastric
mucosa, hamartomas from Peutz– Jeghers syndrome, and
lipomas
• SECONDARY INTUSSUSCEPTION

• Malignant causes, although rare, increase in incidence

with age and include lymphomas and small bowel tumors

• Systemic diseases, including Henoch–Schönlein purpura

and cystic fibrosis, have been associated with
intussusception

• Other diseases that may be related to intussusception

include celiac disease and Clostridium difficile colitis
 Incidence

• Idiopathic intussusception can occur at any age

• Most affected patients are well-nourished, healthy infants, and

approximately two-thirds are boys

• The highest incidence occurs in infants between ages 4 and 9

months, and it is the most common cause of small bowel
obstruction in this age group

• Intussusception is uncommon below 3 months and after 3 years

of age

• The condition has been described in premature infants and has

been postulated as the cause of small bowel atresia in some cases
 Clinical Presentation

• classic presentation is an infant or a young child with

intermittent, cramping abdominal pain associated with
“currant jelly” stools and a palpable mass on physical
examination,

• although this triad is seen in less than a fourth of children

• The abdominal pain is sudden, and the child may stiffen

and pull the legs up to the abdomen

• The pain also can be associated with hyperextension,

writhing , breath holding, and vomiting

• The attack often ceases as suddenly as it started

 Clinical Presentation

• Between attacks, the child may appear comfortable but eventually

will become lethargic

• Small or normal bowel movements will stop as the obstruction

progresses and becomes associated with bilious emesis and
increasing abdominal distention

• Stools may be blood tinged as impending ischemia causes mucosal

sloughing and compression of mucous glands leading to evacuation
of dark red mucoid clots or currant jelly stools

• This is often a late sign, as are laboratory derangements

• A pitfall is to wait for the currant jelly stool, leukocytosis, and electro
lyte abnormalities that are often the hallmarks of ischemic bowel
 Physical Examination

• The child’s vital signs are usually normal early in the

disease course

• During painless intervals, the child may appear comfortable

and the physical examination may be unremarkable

• However, the cramping episodes usually occur every 15–

30 minutes and reexamination may prove difficult.

• There may be audible peristaltic rushes, and a sausage-

shaped or curved mass might be palpable anywhere in the
abdomen or even visualized if the child is relatively thin
 Physical Examination

• The right lower abdominal quadrant can appear flat or

empty (Dance sign) as the intussuscepted mass is drawn
cephalad

• On rectal examination, blood-stained mucus or blood

may be encountered as a later sign

• If the obstructive process worsens and bowel ischemia

occurs, dehydration, fever, tachycardia, and hypotension
can develop in quick succession as a result of bacteremia
and bowel necrosis
 Physical Examination

• Prolapse of the intussusceptum through the anus is a grave sign,

particularly when the intussusceptum is ischemic

• The greatest danger in a case of prolapsed intussusceptum is

that the examiner will misdiagnose the condition as a rectal
prolapse and attempt reduction

• Careful physical examination is mandatory and can be done by

inserting a lubricated tongue blade along the side of the
protruding mass before reduction

• If the blade can be inserted more than 1–2 cm into the anus
along the side of the mass, the diagnosis of intussusception
should be considered
 Diagnosis

ABDOMINAL RADIOGRAPHY

• In half of cases the diagnosis of intussusception can be

suspected on flat and upright abdominal radiographs

• Suggestive radiographic abnormalities include an

abdominal mass, abnormal distribution of gas and fecal
contents, and air-fluid levels in the presence of bowel
obstruction
• However, plain films have
limited value in confirming the
diagnosis
ULTRASONOGRAPHY

• The use of abdominal ultrasound (US) for the evaluation

of intussusception was first described in 1977

• Since then, most institutions have adopted it as a

screening tool because of the lack of radiation exposure,
ability to identify pathologic lead points, and low cost
ULTRASONOGRAPHY

• The characteristic finding

on US has been referred
to as a “target” or “dough-
nut” lesion , which
consists of alternating
rings of low and high
echogenicity representing
the bowel wall and
mesenteric fat within the
intussusceptum in a
transverse plane
ULTRASONOGRAPHY

• The “pseudo-kidney” sign is

seen on longitudinal section,
This pattern is secondary to the
edematous walls of the
intussusceptum within the
intussuscipiens

• US can also guide the

therapeutic reduction of an
intussusception
COMPUTED TOMOGRAPHY AND MAGNETIC
RESONANCE IMAGING

• Neither computed tomography (CT) nor (MRI) is routinely

used in the evaluation of a patient with intussusception,
although either may confirm this diagnosis and/or
pathologic causes for intussusception, such as a
malignancy (i.e., lymphoma)
• The characteristic CT finding is a target or doughnut sign

• Transient small bowel intussusceptions that are discovered

on CT or MRI are usually not clinically significant

• Radiographic or operative treatment should be based on

clinical findings in symptomatic patients

• Laparoscopy is an excellent means to evaluate these

patients if surgical intervention is needed
 Nonoperative Management
• If the diagnosis of intussusception is suspected, a nasogastric tube may
be helpful to decompress the stomach

• Bowel rest and intravenous fluid resuscitation should be initiated

• CBC and serum electrolytes are obtained

• There is no need for routine antibiotic administrations

• An air or contrast enema is first-line treatment as long as there are no

contraindications to nonoperative reduction

• Contraindications include intestinal perforation(free intraperitoneal air),

peritonitis, or persistent hypotension

• The advantages of nonoperative reduction are decreased morbidity, cost,

and length of hospitalization
• HYDROSTATIC AND PNEUMATIC REDUCTION

• The conceptual methodology for hydrostatic reduction has

not changed significantly since its first description in 1876

• Hydrostatic reduction with barium under fluoroscopic

guidance was historically used

• More recently, children’s hospitals have transitioned to air or

water-soluble isotonic contrast because of the potential
hazard of barium peritonitis in patients with intestinal
perforation

• Successful reduction in uncomplicated patients is seen in

about 85% of cases and ranges from 42–95%
• HYDROSTATIC REDUCTION
• HYDROSTATIC AND PNEUMATIC REDUCTION

• Although pneumatic reduction was first described in 1897,it began to gain

popularity only in the late 1980s

• Since then, many institutions have adopted pneumatic decompression because

it is quicker, safer, less messy, and decreases the exposure time to radiation.

• The procedure is fluoroscopically monitored as air is insufflated into the rectum

• The maximum safe air pressure is 80mmHg for younger infants and 110–
120mmHg for older infants

• Potential drawbacks of pneumatic reduction include the possibility of

developing tension pneumo- peritoneum, and poor visualization of lead points
and/or the intussusception reduction process, resulting in false- positive
reductions

• Rates of perforation range from 0.4–2.5%, with the most recent publications
citing an average rate of 0.8%
• อัจฉรา มหายศนันท์, เอกพล เศรษฐ์สกล, ปานฤทัย ตรีนวรัตน์, สุดี ชมเดช, สมบูรณ์ ฤกษ์วิบูลย์ศรี. การ
รักษาโรคลําไส้กลืนกันด้วยวิธีสวนทวารหนักด้วยลม โดยสังเกตุด้วย อัลตร้าโซโนกราฟี : รายงานผู้
ป่วยรายแรกในโรงพยาบาลจุฬาลงกรณ์. จุฬาลงกรณ์เวชสาร 2547 พ.ค; 48(5) : 299 - 308
• PNEUMATIC REDUCTION
• HYDROSTATIC AND PNEUMATIC REDUCTION

• Tension pneumoperitoneum is best treated with immediate cessation

of the procedure and immediate release of the pneumoperitoneum
using a 14-, 16-, or 18-gauge needle or angiocatheter above or below
the umbilicus

• This should be followed by immediate operative exploration

• For unsuccessful reduction, several studies have shown improved

reduction rates using a second attempt after waiting 30 minutes to 24
hours after the initial attempt

• In some instances, this is done in the operating room prior to

laparoscopy or in conjunction with laparoscopic reduction

• Premedication with midazolam may increase the chances of

successful reduction
• HYDROSTATIC AND PNEUMATIC REDUCTION

• Although traditionally patients were admitted following

successful reduction, numerous recent studies have
documented safe discharge home of select patients after a
brief observation period in the emergency department

• The parents/caregivers of these patients should be

counseled about the risk of recurrence over the next few
days after the initial intussusception and warning signs that
should prompt return

• Any clinical signs of abdominal pain after reduction could

be a sign of ischemic bowel or recurrent intussusception,
and repeat US is needed
 Operative Management

• An operation is needed when nonoperative reduction is

unsuccessful or incomplete, for signs of peritonitis, in the
presence of a lead point, or with radiographic evidence of
pneumoperitoneum

• Preoperative preparation includes administration of

broad-spectrum antibiotics, intravenous fluid
resuscitation, insertion of a urinary catheter, and
placement of a nasogastric tube for gastric
decompression
• LAPAROSCOPIC APPROACH

• Initially, the use of laparoscopy in the operative management of

intussusception was strictly diagnostic, was used in cases with
equivocal radiographic studies or in patients with suspected lead
points, and was associated with conversion rates in up to 70% of
cases

• As surgeons have become more comfortable with laparoscopy, the

laparoscopic approach has become the initial operation of choice in
many centers

• More recent studies have shown improved postoperative pain and

shorter time to full feeds and length of stay with laparoscopic reduction

• Reported rates of conversion to open are variable (12–40%), but most

report around 30% with a low overall complication rate
• LAPAROSCOPIC APPROACH

• Contraindications to laparoscopy include hemodynamic instability,

peritonitis or evidence of pneumoperitoneum, and severe bowel
distention that limits visualization

• Risk factors for increased conversion rates to an open procedure have

included an intussusceptum extending beyond the ascending colon as
well as presence of known pathologic lead points

• A retrospective analysis of 65 cases found that in patients unable to be

reduced laparoscopically, 33% had a lead point that necessitated
conversion to open

• The majority of minimally invasive approaches describe the use of

three abdominal ports: one in the infra- umbilical region, with two other
ports along the left side of the abdomen
• LAPAROSCOPIC APPROACH

• Laparoscopic reduction is accomplished by applying

gentle pressure distal to the intussusceptum using
atraumatic graspers

• Although counterintuitive to the conventional open

method, traction is usually required proximal to the
intussuscipiens to complete the reduction
• LAPAROSCOPIC APPROACH

• Excessive force should be discouraged, and if the bowel reduces to a point at

which there is dusky-appearing bowel or the surgeon is noticing more serosal
tears, the procedure should be converted to open

• Appendectomy is not routinely performed with laparoscopic reduction unless it is

felt to be the lead point

• Careful inspection of the bowel is performed to evaluate for any signs of

ischemia, necrosis, or perforation

• A criticism of laparoscopic reduction is the loss of tactile sense that can lead to
missed pathology

• If resection is required, this often can be accomplished by exteriorizing the bowel

through an enlarged periumbilical incision

• If this is not possible, the operation is usually converted to a laparotomy

• OPEN APPROACH

• Most commonly, the cecum and terminal ileum are involved

and can be delivered through the traditional right lower
abdominal incision

• It is important to evaluate the extent of the intussusceptum

before delivering it as it can extend into the rectosigmoid
region in severe cases, which usually requires extension of
the incision

• Once the leading edge of the intussusceptum is identified, it

is gently manipulated back toward its normal position in the
terminal ileum

• Excessive force or pulling is avoided to prevent injury or

perforation of the bowel
• OPEN APPROACH

• Inability to manually reduce the intussusception, the

finding of ischemic bowel, or identification of a lead point
requires resection and bowel anastomosis or diversion,
depending on the condition of the bowel and child

• Although ileopexy has been described in patients with

recurrent intussusception after operative reduction,

• in a series of 278 patients, this technique was not shown

to reduce reintussusception rates when compared with
operative reduction and resection of the affected area
• OPEN APPROACH

• If surgical reduction is possible, the bowel is evaluated for

viability, perforation, or a lead point

• An edematous ileocecal junction is commonly palpable after

ileocecal or ileocolic intussusception and should not be
confused with a lead point

• Questionable ischemic bowel can be warmed with saline-soaked

laparotomy pads and reevaluated

• After complete reduction of the intussusception, an incidental

appendectomy is often performed because the location of the
abdominal scar is similar to that in an open appendectomy
incision
 Recurrent Intussusception

• Recurrent intussusception has been described in association

with nonoperative intervention in approximately 10% of cases,
with about one-third occurring within 24 hours and the majority
within 6 months of the initial episode

• Recurrences are less likely to occur after operative reduction or

resection.

• After laparoscopic reduction, a recurrence rate as high as 10%

has been reported, although a recent systematic review showed
it to be much lower at 4%

• When this occurs, it is reasonable to attempt pneumatic

reduction again
 Recurrent Intussusception

• Patients with recurrent intussusception tend to be seen

earlier in their course because their parents are more aware
of how to recognize the signs and symptoms

• Success rates with enema reduction after one recurrence

are comparable to those with the first episode

• Success rates are better if the child did not previously require
operative reduction

• This finding has led to a nonoperative approach for initial

management of recurrence in most patients as long as they
are not toxic or show signs of peritonitis or hemodynamic
instability.
 Recurrent Intussusception

• A concern in recurrent intussusception is occult

malignancy

• Unfortunately, the clinical findings or pattern of recurrence

do not predict the presence of a malignant lead point and
radiographic reduction with follow-up US is
recommended to look for an occult pathology

• There is limited guidance on follow-up imaging, but it

should be delayed until the expected swelling and
potential reactive lymphadenopathy associated with the
intussusception has resolved
 Postoperative Intussusception

• Postoperative intussusception is a rare clinical entity that has been

described after ileocolic intussusception reduction and resection,
retroperitoneal dissections, long intra-abdominal procedures, a
Ladd procedure, or extra-abdominal operation

• It accounts for 3–10% of cases of postoperative bowel obstruction

and most often occurs in the initial 10days following a procedure

• Ileus and adhesive obstruction are more frequently encountered

as a cause for intestinal obstruction in the postoperative patient.

• Thus, an index of suspicion is needed, and US is a useful

diagnostic tool. Most postoperative intussusceptions are ileoileal
and respond to operative reduction without resection