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Intussusception

Invagination of Intestines

Intussusception is the infolding of one part of the intestine into another. Most cases occur in children during the first year of life.


Presentation

Early symptoms of the condition include [6]:

  • Nausea 
  • Vomiting (often green in colour indicating bile stain)
  • Pulling of legs to the chest area
  • Intermittent and moderate to severe abdominal pain
  • Rectal bleeding
  • Stool mixed with blood and mucus
  • A sausage shaped mass can be felt in the abdomen following physical examinations 

In children who are too young to communicate symptoms, major presentations include constant crying and pulling up of knees to the chest and paroxysms of pain [7].

Fever is not a symptom of intussusception except when there is compression of arterial blood supply. This brings about perforation and sepsis and consequently, fever.

Fever
  • A 50-year-old woman of Chinese origin came to the emergency room with symptoms of high fever, nausea, vomiting and weight loss of 10 kg. Three months before, an episode with abdominal pain due to ileal invagination in the colon occurred.[ncbi.nlm.nih.gov]
  • It is normal during this time to have a fever and your child may be given Tylenol (Acetaminophen) to bring down the fever. For the first 12 hours after the enema, your child will not be allowed to eat or drink.[chop.edu]
  • Patients presented with intermittent abdominal pain (IAP, all five patients), alternate vomiting (three of five patients), alternate diarrhea (two of five patients), fever (two of five patients), and rectal bleeding (one of five patients).[ncbi.nlm.nih.gov]
  • Fever is not a symptom of intussusception except when there is compression of arterial blood supply. This brings about perforation and sepsis and consequently, fever.[symptoma.com]
Crying
  • […] comparing recurrent and non-recurrent intussusception cases using univariate analysis, it was determined that the factors associated with recurrent intussusception were age ( 1 year), duration of symptoms ( 12 hours), the lack of bloody stool, paroxysmal crying[ncbi.nlm.nih.gov]
  • Symptoms Children The first sign of intussusception in an otherwise healthy infant may be sudden, loud crying caused by abdominal pain. Infants who have abdominal pain may pull their knees to their chests when they cry.[mayoclinic.org]
  • Infants and children may strain, draw their knees up, act very irritable, and cry loudly. Your child may recover and become playful in-between bouts of pain, or may become tired and weak from crying.[stanfordchildrens.org]
  • An infant with severe abdominal pain may draw the knees to the chest while crying.[nlm.nih.gov]
Pallor
  • The most common presenting features are colicky abdominal pain, vomiting, pallor, lethargy and listlessness.[ncbi.nlm.nih.gov]
  • Vomiting (initially nonbilious) Lethargy , pallor, and other symptoms of shock or altered mental status may be present.[amboss.com]
  • Dehydration, pallor, shock. Irritability, sweating. Later, mucoid and bloody 'redcurrant' stools. Late pyrexia.[patient.info]
  • Patients with an intussusception may also present with lethargy/altered level of consciousness and pallor. The etiology of this lethargic presentation is not known, but it tends to occur in younger infants.[hawaii.edu]
Neonatal Intestinal Obstruction
  • intestinal obstructions classifiable to P76.- obstruction of duodenum ( K31.5 ) postprocedural intestinal obstruction ( K91.3- ) stenosis of anus or rectum ( K62.4 ) Paralytic ileus and intestinal obstruction without hernia Approximate Synonyms Intussusception[icd10data.com]
Abdominal Pain
  • KEYWORDS: Abdominal pain; Adult; Burkitt’s lymphoma; Early diagnosis; Intussusception[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A case of a 35-year-old male, who complaining a diffuse abdominal pain beginning three days earlier.[ncbi.nlm.nih.gov]
  • A 37-year-old man with abdominal pain 3 weeks after lumbar spine surgery following a motor vehicle accident.[web.archive.org]
  • CASE REPORT: An 8-year-old girl was admitted with abdominal pain lasting for 2 weeks. Clinical and radiologic findings suggested ileocecal intussusception initially.[ncbi.nlm.nih.gov]
  • CONCLUSION Although intussusception is a rare cause of abdominal pain in adults, it is an important diagnosis to consider in patients with recurrent abdominal pain because it may be a harbinger of malignancy.[ncbi.nlm.nih.gov]
Vomiting
  • The factors associated with recurrent intussusception with lead points present were vomiting and mass location in the right abdomen (P CONCLUSIONS: Age ( 1 year), symptom duration ( 12 hours), the absence of vomiting, mass location (right abdomen) and[ncbi.nlm.nih.gov]
  • Abstract We report a middle age man who presented with intermittent vomiting and loss of weight. Oesophagogastroduodenoscopy showed numerous antral hyperplastic polyps with inaccessible duodenum.[ncbi.nlm.nih.gov]
  • We present a case of 5-year-old girl admitted with non-bilious vomiting, watery diarrhoea and abdominal pain. She is a known patient of Glanzmann's thrombasthenia.[ncbi.nlm.nih.gov]
  • He presented with nausea, vomiting, poor appetite, and intermittent, cramping abdominal pain for over 1 wk.[ncbi.nlm.nih.gov]
  • The most common presenting features are colicky abdominal pain, vomiting, pallor, lethargy and listlessness.[ncbi.nlm.nih.gov]
Diarrhea
  • Diarrhea was the presenting symptom in 119 (79%) cases. A total of 45 intussusceptions were detected in 37 (25%) children. Out of 45 intussusceptions, 95% involved small bowel. All but one had asymptomatic intussusception.[ncbi.nlm.nih.gov]
  • While most of the grossly bloody stools were not consistent with pure currant jelly, the most common terms used in describing the grossly bloody stools were "bloody," "mucus," "red," and "diarrhea."[ncbi.nlm.nih.gov]
  • An 88-year-old man was seen at the hospital because of diarrhea. There was a previous history of undergoing sigmoidectomy for retrograde intussusception due to a cancer of the sigmoid coin in the hospital 6 years earlier.[doi.org]
  • The symposium concluded that the regional rotavirus surveillance network has played a crucial role in pre-vaccine data through documenting burden and epidemiology of rotavirus diarrhea in Africa, seasonal trends and identifying common rotavirus genotypes[ncbi.nlm.nih.gov]
  • Patients presented with intermittent abdominal pain (IAP, all five patients), alternate vomiting (three of five patients), alternate diarrhea (two of five patients), fever (two of five patients), and rectal bleeding (one of five patients).[ncbi.nlm.nih.gov]
Colic
  • INTRODUCTION: Colo-colic intussusception is extremely rare in adults and few cases have been described secondary to a lypomatous polyp.[ncbi.nlm.nih.gov]
  • Abstract We present a rare cause of intestinal obstruction in an adult, due to ileo-colic intussusception by a lipoma of the ileo-cecal valve and its ultrasonographic presentation.[ncbi.nlm.nih.gov]
  • Ileo-colic. Ileo-colic. Ileo-ileal. Colo-colic. 7. Redcurrant jelly stool الكشمش الأحمر 8.[slideshare.net]
  • We performed laparoscopic segmental resection of the rectum (with preservation of the left colic artery [LCA]).[ncbi.nlm.nih.gov]
  • An exploratory laparotomy was carried out after resuscitation with per-operative findings of a prolapsed ileo- colic intussusception and a necrosed intussusceptum.[ncbi.nlm.nih.gov]
Nausea
  • He presented with nausea, vomiting, poor appetite, and intermittent, cramping abdominal pain for over 1 wk.[ncbi.nlm.nih.gov]
  • All patients presented with abdominal symptoms (pain: 10/10, nausea and vomiting: 3/10, diarrhoea: 2/10, "red-currant jelly stool": 2/10) during a median time of 8.3 months (2 days - 6 years) and with a trend for longer duration of symptoms for benign[ncbi.nlm.nih.gov]
  • On the third postoperative day (POD3), the patient complained of paroxysmal pain around the umbilicus, accompanied by nausea and vomiting.[ncbi.nlm.nih.gov]
  • A 50-year-old woman of Chinese origin came to the emergency room with symptoms of high fever, nausea, vomiting and weight loss of 10 kg. Three months before, an episode with abdominal pain due to ileal invagination in the colon occurred.[ncbi.nlm.nih.gov]
  • Other possible symptoms of intussusception include nausea, vomiting, and rectal bleeding (red jelly-like stools), sometimes mixed with mucus. These symptoms begin suddenly, usually one week after a non-specific viral illness.[my.clevelandclinic.org]
Lethargy
  • The most common presenting features are colicky abdominal pain, vomiting, pallor, lethargy and listlessness.[ncbi.nlm.nih.gov]
  • Additionally, significant somnolence and lethargy can be seen with intussusception! Numerous cases have been reported that highlight this fact. Cause of the lethargy is unclear.[pedemmorsels.com]
  • […] from profound dehydration; therefore, intussusception should always be in the differential for pediatric lethargy. 1,2 The imaging workup for suspected intussusception includes plain film radiography, ultrasound, and contrast enema.[appliedradiology.com]
Irritability
  • Clinical examinations and investigations may not be conclusive and another working diagnosis such as irritable bowel syndrome would be made.[ncbi.nlm.nih.gov]
  • A baby might also vomit several times or have blood in the stool, or could appear weak or very irritable.[cdc.gov]
  • The walls of the two sections of intestine press on each other, causing irritation and swelling. Eventually, the blood supply to that area is cut off, which can cause damage to the intestine.[childrenshospital.org]
  • The walls of the two "telescoped" sections of intestine press on each other, causing irritation and swelling. Eventually, the blood supply to that area is cut off, which can cause damage to the intestine.[luriechildrens.org]
Altered Mental Status
  • Along with the classic and common presentations, patients with intussusception may also present with altered mental status. This altered mental status is often thought of as the child being inconsolable .[pedemmorsels.com]
  • Vomiting (initially nonbilious) Lethargy , pallor, and other symptoms of shock or altered mental status may be present.[amboss.com]

Workup

Laboratory studies are often not helpful in the evaluation of patients with intussusception [8]. However, leukocytosis may be present with gangrene in advanced cases of intussusception. Following persistent vomiting and fluid sequestration in obstructed bowels, dehydration and electrolyte imbalance often occur.

Ultrasonographic imaging has also been found to have a relatively high sensitivity and specificity when it comes to detection of ileocolic intussusception. Abdominal radiographs may also show diagnostic characteristics of intussusception but their specificity and sensitivity is still in doubt.

Bowel Distention
  • Ultrasound examination found a normally evolving pregnancy and a bowel obstacle, without bowel distention. Because it was not a surgical emergency at the time of evaluation, she was sent to the hospital's Obstetrics Department.[ncbi.nlm.nih.gov]
  • If left untreated, it will progress to bowel distention, damage, necrosis and rupture, followed by peritonitis (inflammation of the abdominal cavity), severe infection and shock.[lifespan.org]

Treatment

The treatment often recommended in this condition includes a barium or air enema and in some cases surgery [9].

A barium or air enema can be a diagnostic procedure and also a treatment. When this procedure works, there is usually no need to continue with further treatment. It is the treatment of choice in children as it is highly effective with them. It is rarely used in adults. Recurrence following barium or air enema is seen 15-20% of the time and when it happens, the treatment is often repeated.

Surgery is recommended when the intestine is torn or a lead point is suspected [10]. Portion of the trapped intestine is freed, obstruction is cleared and dead intestinal tissues are also removed. This is the treatment used for most adult cases. In rare scenarios, intussusception is temporary without requiring medical intervention.

Prognosis

Prognosis is excellent in patients with this condition as long as it is diagnosed and treated early [5]. Otherwise, severe complications and death may occur.

After non-operative reduction, the recurrence rate of intussusception is often less than 10% however it has been reported to be as high as 15% in other cases. Most intussusceptions recurrences happen after 72 hours of correction but there have been cases where it occurred 3 years down the line. When there is more than 1 recurrence, a lead point is suspected. A recurrence often starts with the same symptoms as the initial event. Except when lead point suggestion is very strong, treatment for recurrence is often same as treatment for initial event.

Etiology

In a few cases, the condition is caused by abnormal growth in the intestine such as polyp or a tumor [2]. This is known as the lead point. The normal wave-like contractions of the intestine may grab this lead point, pulling it into the lining of the intestine and then into the bowel that is ahead of it. In many cases however, there is no clear cause of intussusception.

Epidemiology

It is difficult to determine the true prevalence of this disease due to the wide geographic variation in the incidence of the condition among countries and also in cities within countries [3]. There are no official documents showing the prevalence of intussusception in the United States. It is believed though that incidence is 1 case for every 2000 live births. In Great Britain, incidence varies from 1.6 to 4 cases per 1000 live births.

On average, the male-female ratio is set at approximate 3:1. With advancing age, the gender difference becomes further clear. In patients older than 4 years, male-to-female ratio is 8:1. Two out of three children with intussusception are < 1 year old and the most common occurrence is in people aged 5 to 10 months. It is also the most common cause of intestinal obstruction in patients within the ages of 5 months to 3 years.

Sex distribution
Age distribution

Pathophysiology

The pathogenesis of idiopathic intussusception is not clear [4]. It is however, believed to follow an imbalance in the longitudinal forces along the walls of the intestine. 

As a result of imbalance in the intestinal wall forces, an area of the intestine enters into the lumen of adjacent bowel. The invaginating portion of the intestine or the intussusceptum collapses into the receiving portion or the intussuscipiens. The process goes on and more proximal areas get involved. 

The intussusceptum may proceed to the distal colon or sigmoid and even prolapse out of the anus in rare cases. The classic pathologic process seen with most bowel obstruction cases arises when the mesentery of the intussusceptum gets invaginated with the intestine.

Prevention

There is no clear prevention path for this condition.

Summary

Intussusception refers to a situation where a part of the intestine invaginates into the bordering intestinal lumen bringing about an obstruction in the bowel [1]. It is a well-known cause of abdominal pain in children. Intussusception is suspected in pediatric medicine when the 3 main symptoms (vomiting, abdominal pain, and passage of blood) are present.

There are two variants of intussusception, the idiopathic intussusception which often starts at the ileocolic junction (affects infants and toddlers mostly) and the enteroenteral intussusception which is jejunojejunal, jejunoileal or ileoileal (occurs in older children). The latter condition is seen in people with special medical conditions such as Henoch-Schönlein purpura (HSP), cystic fibrosis and hematologic dyscrasia. It may also be secondary to a lead point and often occurs in the postoperative period.

Patient Information

Intussusception refers to a serious disorder where part of the intestine enters into a nearby part of the intestine in a manner seen with the folding of a telescope. This mechanism leads to the blockage of food and fluid from getting through. The part of the intestine that is affected is also deprived of blood supply. The condition can bring about a tear in the bowel, infection, and death to tissues in the bowel.

It is the most common cause of intestinal obstruction in children younger than 3 years of age and it is rarely seen in adults. When it is seen in an adult, there is a high chance that it is as a result of a medical condition such as a tumor. In children on the other hand, there is no clear indication of what causes intussusception.

Treatment in children doesn’t require surgery most of the time but surgery is required to treat the condition in adults.

References

Article

  1. Bonnard A, Demarche M, Dimitriu C, et al. Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI). J Pediatr Surg. Jul 2008;43(7):1249-53.
  2. Fraser JD, Aguayo P, Ho B, et al. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A. Aug 2009;19(4):563-5.
  3. Milbrandt K, Sigalet D. Intussusception associated with a Meckel's diverticulum and a duplication cyst. J Pediatr Surg. Dec 2008;43(12):e21-3.
  4. Soccorso G, Puls F, Richards C, Pringle H, Nour S. A ganglioneuroma of the sigmoid colon presenting as leading point of intussusception in a child: a case report. J Pediatr Surg. Jan 2009;44(1):e17-20. 
  5. Sanni RB, Nandiolo R, Coulibaly Diaoudia MT, Vodi L, Mobiot ML. Acute intussusception due to intestinal Kaposi's sarcoma in an infant. Afr J Paediatr Surg. Jul-Dec 2009;6(2):131.
  6. Lloyd DA, Kenny SE. The surgical abdomen. In: Pediatric Gastrointestinal Disease: Pathopsychology, Diagnosis, Management, 4th, Walker WA, Goulet O, Kleinman RE, et al (Eds), BC Decker, Ontario 2004. p.604.
  7. Erkan N, Haciyanli M, Yildirim M, et al. Intussusception in adults: an unusual and challenging condition for surgeons. Int J Colorectal Dis 2005; 20:452.
  8. Mandeville K, Chien M, Willyerd FA, et al. Intussusception: clinical presentations and imaging characteristics. Pediatr Emerg Care 2012; 28:842.
  9. Buettcher M, Baer G, Bonhoeffer J, et al. Three-year surveillance of intussusception in children in Switzerland. Pediatrics 2007; 120:473.
  10. West KW, Grosfeld JL. Intussusception. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, Wyllie R, Hyams JS (Eds), WB Saunders, Philadelphia 1999. p.427.

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Last updated: 2018-06-22 09:21