Updated: 8/6/2018

Intussusception

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Snapshot
  • UltrasoundA young mother brings her 2-year-old son to the pediatrician reporting that he has had recurrent "belly aches" for the past two weeks. The child experiences sudden, intermittent vomiting interspersed with periods of no complaints. The mother reports that she has seen him squatting with his knees to his chest, which seems to relieve him of his symptoms.
Introduction
  • Most common form of bowel obstruction in children
  • Luminal lesion usually serves as focus point for looping bowels
  • Involves the terminal ileum telescoping into the proximal large bowel in most cases
  • Etiology unknown 
  • Associated with 
    • gastroenteritis
    • Meckel's diverticulum
    • gastric polyps
    • adenovirus infection
    • intestinal lymphoma
    • hyperplasia of Peyers patches
  • Epidemiology
    • most common in children 3 mos to 3 years of age
    • uncommon in adults
    • occurs in the large bowel
Presentation
  • Symptoms
    • abrupt onset of classic triad (only observed in 1/3 of patients)
      • colicky abdominal pain
      • emesis
      • currant jelly stool
    • child may flex knees to chest to relieve pain
    • infants may present with paleness and abdominal distention
    • lethargy
    • fever
  • Physical exam
    • abdominal distention and tenderness
    • positive stool guiaic indicative of intestinal bleed
    • sausage-shaped abdominal mass may be palpated in RUQ
    • signs of shock may be evident
Evaluation
  • Labs
    • show leukocytosis
  • Imaging
    • abdominal radiography
      • may show small bowel obstruction (air fluid levels)
      • rule out free air under the diaphragm (perforated viscus, surgical emergency)
    • ultrasound  
      • may show small bowel obstruction
      • donut sign
  • Pneumatic decompression enema via fluoroscopy
    • using air or carbon dioxide to push back intussusception
    • now preferred over contrast-based enemas as risk of perforation lower, and lower radiation exposure needed
    • additionally therapeutic
  • Hydrostatic decompression enema via fluoroscopy 
    • traditionally used barium (can cause peritonitis), but now gastrografin or other water-soluble agents used instead
    • reveals coil-spring sign
    • additionally therapeutic
    • can use saline with ultrasound guidance (no radiation exposure), unlike pneumatic technique
Differential
  •  Small bowel obstruction, upper or lower GI bleed, mesenteric ischemia
Treatment
  • Non-surgical management
    • Pneumatic decompression enema via fluoroscopy
      • now preferred over hydrostatic (contrast-based) techniques, see above
    • Hydrostatic decompression enema via fluoroscopy  
      • both diagnostic and therapeutic in many cases
      • after successful reduction, child should be admitted for 24 hrs to monitor for recurrence or complications 
  • Surgical intervention
    • surgical reduction
      • only indicated when barium enema does not relieve obstruction
      • must resect gangrenous/necrotic segments
      • appendix usually removed
        • to prevent confusion in the future
Prognosis, Prevention, and Complications
  • Prognosis
    • very good to excellent if identified and treated early
  • Prevention
    • there are no preventive measures available at this time
  • Complications 
    • bowel necrosis, followed by sepsis and death if left untreated

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Questions (7)
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(M2.PD.17.4688) A 2-year-old male is brought to the emergency department by his mother. The patient awoke in the night screaming, and when the mother changed his diaper she found thick, bloody stool. The child was born at 35 weeks, via c-section, and required an overnight stay in the NICU for tachypnea. Developmentally, the child is at the 38th percentile for weight and has met all milestones. The child's pulse is 110/min, blood pressure is 90/60 mmHg, and respirations are 20/min. An abdominal ultrasound is obtained, and shown in Figure A. What is the next best step in management?

QID: 107538
FIGURES:
1

Transanal mucosal biopsy

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Oral vancomycin

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(0/7)

3

Emergent exploratory laparoscopy

0%

(0/7)

4

Pneumatic enema

86%

(6/7)

5

Barium swallow

14%

(1/7)

M 5 D

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(M3.PD.16.61) A 7-month-old boy presents to the emergency room with three episodes of vomiting and severe abdominal pain that comes and goes for the past two hours. The patient's most recent vomit in the hospital appears bilious, and the patient had one stool that appears bloody and full of mucous. The mother explains that one stool at home appear to be "jelly-like." On physical exam, a palpable mass is felt in the right lower quadrant of the abdomen. What is the next best diagnostic test for this patient?

QID: 103551
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Peripheral blood culture

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Kidney, ureter, bladder radiograph

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Complete blood count with differential

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Abdominal ultrasound

67%

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Exploratory laparotomy

33%

(1/3)

M 11 D

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(M3.PD.16.67) A 2-year-old is brought to the emergency department by his mother for intermittent abdominal pain. She states the pain seems to be relieved by flexing his knees to his chest. The mother states that she noticed this morning that he passed stool mixed with blood and mucus. On exam, you note abdominal tenderness. An abdominal ultrasound is performed, and the results are shown in Figure A. What is the most common underlying cause of this patient's condition?

QID: 103358
FIGURES:
1

Idiopathic

50%

(3/6)

2

Gastric polyp

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(0/6)

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Meckel's diverticulum

50%

(3/6)

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Parasitic infection

0%

(0/6)

5

Intestinal lymphoma

0%

(0/6)

M 10 C

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Evidence (8)
VIDEOS & PODCASTS (2)
EXPERT COMMENTS (9)
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