Small Intestine: Intussusception

Intussusception

Basics

  • Definition: Loop of Bowel Invaginates/Telescopes into Itself
  • Segments:
    • Intussusceptum – Prolapsed Bowel
    • Intussuscipiens – Recipient Bowel
  • Most Common in Peds, Rare in Adults

Lead Points

  • Hypertrophied Peyer Patches (Viral Infection) – Most Common Lead Point in Peds
  • Meckel’s Diverticulum – Most Common Pathologic Lead Point in Peds
  • Cancer – Most Common Lead Point in Adults
  • Inspissated Stool of Cystic Fibrosis
  • Bowel Wall Hematoma
  • Idiopathic
  • Pediatric Postoperative Ileus
    • Classically After A Prolonged Laparotomy but Can Occur After Any Surgery, Even Nonabdominal Procedures
    • Most Common Site: Ileoileal

Intussusception 1

Location

  • Enteroenteric – Small Bowel into Small Bowel
  • Ileocolic – Terminal Ileum into Colon
    • The Most Common Site (90%)
  • Colocolic – Large Bowel into Large Bowel

Symptoms

  • Intermittent Abdominal Pain
  • Sausage-Shaped Abdominal Mass in Peds
  • Currant Jelly Stools (Blood & Mucous from Vascular Congestion)
  • SBO – Nausea, Vomiting & Obstipation

Diagnosis

  • Peds: US (Target Sign)
  • Adults: CT

Intussusception on US 2

Intussusception on CT 3

Treatment – Pediatrics

  • Primary Treatment: Air-Contrast Enema to Reduce
    • Both Pneumatic (Air) or Hydrostatic (Saline/Contrast) are Acceptable
      • Max Pneumatic Pressure: 120 mm Hg
      • Max Barium Enema Column Height: 1 Meter/3 Feet
    • Do Not Attempt Air-Contrast Enema if After a GI Surgery – Will Require Operative Reduction
    • 70-85% Success; 10-20% Recur
  • If Successful: Observe for 4 Hours & Discharge
  • If Fails: Repeat Enema
    • Can Repeat Multiple Times if Needed
  • Risk for Perforation with Radiographic Reduction (< 1%)
    • Perforation More Common in Intussuscipiens than the Intussusceptum
    • Risk Similar for Pneumatic & Hydrostatic
    • Increased Risk if Young (< 6 Months) & Long Duration of Symptoms (> 36 Hours)
  • Surgery:
    • Indications:
      • Hemodynamically Unstable
      • Peritonitis or Perforation
      • Complete Failure of Air-Contrast Enema
    • Procedure: Reduction & Resection of Any Necrotic Bowel
      • Reduction: Apply Pressure to Distal End (Intussuscipiens) & Milk
        • Do Not Apply Traction to the Proximal End

Treatment – Adults

  • Primary Treatment: Resection & Lymphadenectomy
  • *There is Some Newer Evidence that Not All Patients Require Surgery, Some Present with Frequent Intussusception that May be Due to Peristalsis without Lead Point – “Safe Answer” at this Time is Surgery

References

  1. Joyce KM, Waters PS, Waldron RM, Khan I, Orosz ZS, Németh T, Barry K. Recurrent adult jejuno-jejunal intussusception due to inflammatory fibroid polyp – Vanek’s tumour: a case report. Diagn Pathol. 2014 Jun 27;9:127. (License: CC BY-4.0)
  2. Zavras N, Tsilikas K, Vaos G. Chronic Intussusception Associated with Malrotation in a Child: A Variation of Waugh’s Syndrome? Case Rep Surg. 2016;2016:5638451. (License: CC BY-4.0)
  3. Kee HM, Park JY, Yi DY, Lim IS. A Case of Intussusception with Acute Appendicitis. Pediatr Gastroenterol Hepatol Nutr. 2015 Jun;18(2):134-7. (License: CC BY-NC-3.0)