INTUSSUSCEPTION
BY: Mohammad Adawi
DEFINITION
Intussusception is the invagination (telescoping) of one segment of intestine (intussusceptum) into the lumen of
an adjacent distal segment (intussuscipiens).
This causes bowel obstruction, vascular compromise, ischemia, and potential gangrene if untreated.
EPIDEMIOLOGY
Most common cause of intestinal obstruction in children aged 6 months–3 years.
Peak incidence: 4–36 months.
Age distribution:<3 months: ~1%
3–12 months: ~30%
1–2 years: ~20%
2–3 years: ~25%
3–4 years: ~10%~10%
>5 years; 3–4%
>10 years (often with lead point).
M:F ratio ~ 3:2.
Occurs in 1–4 per 1,000 live births.
Seasonal variation: increased incidence during viral gastroenteritis outbreaks (e.g., rotavirus, adenovirus).
Adult cases are rare (≈5% of all intussusceptions) and usually due to an underlying lead point (e.g., tumor, polyp, post-op
adhesions).
ETIOLOGY
1. Idiopathic (most common in infants)
Seasonal variation with viral gastroenteritis. Strongest association: adenovirus
(species C). Others: rotavirus (esp. old RRV-TV vaccine, withdrawn), HHV-6.
Mechanism: viral stimulation(adenovirus, rotavirus, enterovirus) → hypertrophy
of Peyer’s patches.
Acts as a temporary lead point.
Typical age: 3 months–5 years.
ETIOLOGY
2. Pathologic lead points (more common in older children & adults)
Meckel’s diverticulum
Polyps (juvenile polyps, Peutz–Jeghers syndrome)
Malignancies (lymphoma, adenocarcinoma in adults)
Duplication cysts
Henoch–Schönlein Purpura (HSP) (vasculitic involvement of bowel wall)
Postoperative Intussusception Usually small bowel. Causes: altered
peristalsis, traction from sutures/tubes. Mimics ileus; US/CT useful.
Contrast enema usually not helpful.
PATHOGENESIS
Invagination → compression of mesentery & vessels → venous
congestion → edema → arterial compromise.
Leads to:
Bowel ischemia
Necrosis
Gangrene → perforation → peritonitis
If untreated: shock, sepsis, death.
CLINICAL MANIFESTATIONS
Typical
Sudden, intermittent, severe crampy abdominal pain (child cries, flexes legs).
Episodes every 15–20 min; worsen over time.
Vomiting: initially nonbilious, may become bilious.
Sausage-shaped abdominal mass.
Bloody stool (currant jelly): late sign (<25%).
Between episodes: normal or lethargic.
CLINICAL MANIFESTATIONS
Atypical
Intermittent colicky abdominal pain (paroxysmal, severe crying,
drawing knees to chest)
Vomiting (initially non-bilious, later bilious if obstruction worsens)
"Currant jelly" stool (blood + mucus per rectum)
⅓ have no blood or palpable mass.
Some infants present with lethargy only (may mimic sepsis or
meningitis).
DIAGNOSIS
1. History & Physical Exam
Clinical suspicion is key.
Evaluation
• Key features: intermittent pain, vomiting, rectal bleeding, lethargy.
• Physical exam: sausage mass, empty RLQ (Dance sign), lethargy.
Differential
• Bloody stool/vomiting → Meckel, volvulus, colitis.
• Crampy pain → gastroenteritis, appendicitis, torsion, hernia, peritonitis.
• Lethargy/altered mental state → trauma, sepsis, metabolic derangement, intoxication, seizure.
•Gold standard: sensitivity &
specificity > 95%
•“Target sign” / “bull’s-eye” / “coiled
spring” / doughnut sign (transverse
view).
•Pseudokidney sign (longitudinal view)
•Detects lead points in ~⅔.
•Can monitor reduction.
DIAGNOSTIC TESTING
Ultrasound
•Used to rule out
perforation.
•Findings: obstruction,
target/crescent sign,
absent cecal gas,
pneumoperitoneum.
•Limited sensitivity.
DIAGNOSTIC TESTING Radiographs
Detects cause/lead point.
Not first-line; radiation + cannot reduce.
Useful in atypical or persistent cases.
DIAGNOSTIC TESTING
CT
MANAGEMENT
Initial management
NPO (nothing by mouth)
NG tube decompression
IV fluids and electrolyte correction
Broad-spectrum antibiotics (if perforation suspected)
General Principles
Stable, no perforation → nonoperative reduction.
Unstable/perforated → surgery.
Lead point or failed reduction → surgery.
Small bowel intussusception → often resolves spontaneously.
DEFINITIVE TREATMENT
Non-surgical (preferred if no peritonitis or perforation)
Air enema reduction (pneumatic reduction): Preferred in many centers. Higher
success (83% vs 70%). Safer if perforation occurs. Requires rectal tube, sealed
system, controlled pressure (<120 mmHg). Success: reflux of air into ileum +
symptom relief.
Hydrostatic reduction: Contrast enema (fluoroscopy) – water-soluble
preferred. Saline enema (ultrasound-guided) – avoids radiation.
Contraindicated if: peritonitis, perforation, shock
Perforation risk: 1–4% .No antibiotics unless unstable. Must have surgical
backup.
SURGERY
Indications for urgent surgery:
Unstable patient (after stabilization/resuscitation).
Peritonitis or perforation.
Failed nonoperative reduction (if only partially successful, can repeat once).
Persistent focal filling defect (mass lesion).
Open or laparoscopic reduction by “milking” intussusceptum back out
Resection with anastomosis if necrosis present
Appendectomy often performed due to compromised blood supply
Special considerations:
•Residual filling defect post-reduction:
• If consistent with edematous ileocecal valve → observe + repeat US in
12–24h.
• If diffuse (eg, IgA vasculitis) → may repeat enema if reductions succeed.
•Pre-op: IV fluids, antibiotics (enteric flora coverage), NG tube if obstruction.
•Minimally invasive laparoscopy preferred: safe, accurate, faster recovery,
less narcotic use.
•Intra-op:
• Attempt manual reduction.
• If unsuccessful or lead point present → resection + anastomosis.
•Recurrence risk:
• 1–8% after manual reduction.
• Virtually none after surgical resection.
Small Bowel Intussusception
•More likely to resolve spontaneously.
•Nonoperative reduction rarely successful.
•Management:
• Incidental, short (<2.3–3.5 cm), asymptomatic →
likely spontaneous resolution.
• Symptomatic or long segment → attempt
nonoperative reduction (often fails) → surgery if not
resolved.
Spontaneous Reduction (SROI)
•Seen incidentally, often during US.
•No further evaluation/intervention if:
• Mild/no symptoms,
• No lead point,
• Normal bowel wall thickness,
• No proximal dilatation,
• No colonic involvement.
•~17% in some series; ~50% asymptomatic.
Recurrence
•~10% overall.
•4% recur within 48h.
•Stable patients: treat recurrence with repeat
enema.
•Multiple recurrences → consider lead point.
Prognosis
•Nonoperative reduction successful in 70–85%.
•Pneumatic > hydrostatic success.
•Complications rare if done by experienced teams.
•Surgery safe, especially laparoscopic.
Patient Education
“The Basics” (simple overview, 5th–6th grade level).
“Beyond the Basics” (detailed, 10th–12th grade level).
Key Summary Points
•Intussusception = telescoping bowel, most common in infants 6–36
months.
•Causes: 75% idiopathic, 25% with lead point (Meckel most
common).
•Classic triad (pain, mass, currant jelly stool) <15%.
•US = diagnostic test of choice.
•Nonoperative enema reduction = first-line if stable.
•Surgery if unstable, perforated, failed reduction, or lead point
suspected.
•Recurrence in ~10%; repeat enema usually safe.
•Small bowel intussusceptions often transient and self-limited.