intussusception
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Introduction
Telescoping of one segment of the bowel into the lumen of an adjacent segment.
Etiology
- idiopathic
- 90% of cases in children are idiopathic
- viral-induced hypertrophy of Peyer's patches may play a role
- malignant tumors
- benign tumors
- other predisposing factors
Epidemiology
- in children, intussusception is the most common cause of intestinal obstruction & the 2nd most common cause acute abdominal pain after appendicitis
- peak incidence in children 3-9 months of age,
- 80% of patients are < 2 years of age
- 5-10% of cases occur in adults
- male/female ratio 2/1
- 2-4 cases/1000 live births
Pathology
- peristalsis subsequent to intussusception results in further telescoping of bowel
- mesentery & vasculature accompany telescoped bowel
- bowel infarction may result
- most common at or proximal to the ileocecal valve
Clinical manifestations
- paroxysms of abdominal pain
- duration 4-5 minutes
- interval 5-30 minutes
- localizes to the umbilicus
- loud crying in infants
- flexing at hips
- progressive lethargy
- nausea, vomiting
- diarrhea
- dehydration
- hematochezia may occur with prolonged obstruction
- a sign of vascular compromise
- mucus in stool
- abdominal tenderness
- abdominal mass
- palpable mass in right upper quadrant may occur with leocolic intussusception
- hyperactive or hypoactive bowel sounds
- physical examination is normal in 25% of cases
Laboratory
Radiology
- plain abdominal radiograph
- dilated loops of bowel
- soft tissue mass
- bowel obstruction
- abdominal films may be normal in 25% of cases
- contrast enema
- may be both diagnostic & therapeutic
- cervix-like mass
- coiled-spring appearance of contrast between 2 segments of bowel
- contraindicated in patients with peritonitis, bowel perforation or hypovolemic shock
- computed tomography imaging modality of choice
- target sign[3]
- abdominal ultrasound
Differential diagnosis
- neonates
- congenital intestinal atresia or stenosis
- disorders of motility
- necrotizing enterocolitis
- infants & children
- adolescents & adults: as for infants & children plus:
- testicular or ovarian disorders
- pelvic inflammatory disease (PID)
- ectopic pregnancy
- ruptured GI tumor
- misdiagnosis: 55-60% with gastroenteritis being most common incorrect diagnosis
Management
- morbidity & mortality increase markedly if intussusception is not reduced in the 1st 24-48 hours
- supportive therapy
- nasogastric decompression of bowel
- intravenous hydration & electrolyte balance
- broad spectrum antibiotics if bowel perforation or necrosis suspected
- nothing by mouth until intussusception reduced
- may begin refeeding after return of normal bowel sounds
- hydrostatic reduction under fluoroscopy
- infants & young children
- contraindicated in adults
- relatively contraindicated in neonates & older children
- 85-90% success rate
- recurrence rate <10%
- risk of bowel perforation <0.5%
- surgical reduction
- indicated in patients with contraindications to hydrostatic reduction or failed reduction
- manual reduction contraindicated if:
- evidence of bowel ischemia
- long loop of bowel to be resected
- resection of involved segment of bowel if manual reduction is unsuccessful or contraindicated
- 100% success rate
- recurrence 2-5%
More general terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 339-40
- ↑ Medical Knowledge Self Assessment Program (MKSAP) 16 American College of Physicians, Philadelphia 2012
- ↑ 3.0 3.1 3.2 3.3 Burgers P, Dawson I Enteroenteric Intussusception. N Engl J Med 2014; 371:2217. December 4, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25470697 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMicm1313388