Intussusception

Intussusception most commonly occurs in infants between the ages of 3 and 12 months, with a peak incidence between ages 5 and 9 months.

Patients typically present with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting, with blood in the stool in some cases.

When there is clinical suspicion, imaging plays a central role. Abdominal ultrasound will usually establish the diagnosis. Plain abdominal x-ray can be used to assess for obstruction and paucity of wind in the right lower quadrant; the presence or absence of free intra-abdominal gas will influence subsequent management, because pneumoperitoneum indicates bowel perforation and requires prompt surgical evaluation.

The anatomic location is typically ileocecal.

If the patient is clinically stable and perforation is not suspected, treatment involves reduction by image-guided enema (ultrasound or fluoroscopic contrast). Fluoroscopic air enema and ultrasound liquid enema are preferred as they are safer than fluoroscopic liquid enemas. Delayed repeat enemas are recommended where the first attempt fails.

Where reduction enemas are contraindicated or where peritonitis exists, urgent surgery is required. Open or laparoscopic surgery can be performed, but laparoscopic surgery may not be suitable for unstable patients. Intestinal resection of threatened nonviable bowel is necessary for cases complicated by bowel ischemia, necrosis and perforation.

Intussusception is a common cause of intestinal obstruction in young children and is defined as the prolapse or telescoping of one part of intestine into the lumen of an adjoining distal segment.[1]Marsicovetere P, Ivatury SJ, White B, et al. Intestinal intussusception: etiology, diagnosis, and treatment. Clin Colon Rectal Surg. 2017 Feb;30(1):30-9. https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0036-1593429 http://www.ncbi.nlm.nih.gov/pubmed/28144210?tool=bestpractice.com ​ This condition typically occurs in the ileocecal region. The lead point of the intussusception is most often an enlarged lymph node (Peyer patch) in the terminal ileum. Rarely, the lead point is an anatomic abnormality of the intestine (a “pathologic lead point”). Conditions resulting in pathologic lead points include congenital abnormalities of the digestive tract (e.g., Meckel diverticulum, enteric duplication), benign lesions (e.g., polyps, lipomata), malignant tumors (e.g., lymphoma), Henoch-Schonlein purpura, and cystic fibrosis.[1]Marsicovetere P, Ivatury SJ, White B, et al. Intestinal intussusception: etiology, diagnosis, and treatment. Clin Colon Rectal Surg. 2017 Feb;30(1):30-9. https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0036-1593429 http://www.ncbi.nlm.nih.gov/pubmed/28144210?tool=bestpractice.com

Intussusception results in venous obstruction and bowel-wall edema that can progress to bowel necrosis, perforation, and rarely death.[1]Marsicovetere P, Ivatury SJ, White B, et al. Intestinal intussusception: etiology, diagnosis, and treatment. Clin Colon Rectal Surg. 2017 Feb;30(1):30-9. https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0036-1593429 http://www.ncbi.nlm.nih.gov/pubmed/28144210?tool=bestpractice.com

This topic covers idiopathic intussusception in infants (intussusception without an established pathologic lead point). Intussusception in older children and adults is rare and is almost always caused by a pathologic lead point.[1]Marsicovetere P, Ivatury SJ, White B, et al. Intestinal intussusception: etiology, diagnosis, and treatment. Clin Colon Rectal Surg. 2017 Feb;30(1):30-9. https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0036-1593429 http://www.ncbi.nlm.nih.gov/pubmed/28144210?tool=bestpractice.com