Critical Care Medicine

Gastrointestinal Emergencies: Intussusception

Intussusception

1. Description of the problem

What every clinician needs to know

Intussusception is defined as a "telescoping" of the intestine into itself. Idiopathic intussusception occurs predominantly in children under the age of 3 years and is rare after the age of 6. However, if there is a pathologic cause intussusception can occur at any age, including in adults.

Clinical features

Sudden onset of severe crampy episodic abdominal pain

Vomiting (can become bilious)

Often asymptomatic between episodes

Currant-jelly stools (classic description but found in less than 10% of children)

Key management points

Fluid resuscitation

Trial of non-operative reduction of intussusception - contrast or air enema

Surgical reduction of intussusception

2. Emergency Management

Stabilize the hemodynamic status of the child - due to significant vomiting and anorexia due to pain, many children are at least moderately dehydrated when presenting for possible intussusception. Aggressive fluid resuscitation is often necessary followed by a high index of suspicion and early identification with abdominal ultrasound.

3. Diagnosis

Ultrasound - classic imaging modality identifying a "bull's eye" lesion. Can also detect the possibility of a lead point.

CT scan - can be used if US cannot be performed or cannot detect a lesion and is able to detect a possible lead point; however, given the risks of CT scan, including radiation exposure and time/sedation, it is not the preferred method of diagnosis.

4. Specific Treatment

Non-surgical reduction: Studies have demonstrated an 80-95% reduction rate of ileo-colonic intussusceptions with non-surgical methods, most commonly a contrast or air enema performed by radiology. Small bowel intussusceptions (ileo-ileal, jejuno-ileal, jejuno-jejunal) can be reduced non-surgically but are more likely to require surgical intervention. Sigmoid intussusceptions can often be reduced endoscopically with a colonoscope.

Surgical reduction: Surgical reduction is necessary if non-surgical reduction is unsuccessful or if there are signs of perforation.

5. Disease monitoring, follow-up and disposition

Idiopathic intussusception requires no disease monitoring and the long-term outcome is excellent.

The outcome of intussusception with an identified lead point depends on the underlying disorder.

Pathophysiology

Intussusception can be divided into idiopathic intussusception and intussusception with a lead point. Idiopathic intussusception is predominantly limited to children under the age of 6 and is most common between 3-36 months of age. Lead point intussusception can occur at any age and varies with the underlying condition.

Idiopathic intussusception may be triggered by a virus or other infection. A true cause-and-effect relationship is difficult to prove, although an abundance of evidence suggests a viral trigger, including seasonal variation, associated with early form of rotavirus vaccine, association with a known viral illness prior to intussusception in up to 40% of cases in multiple populations. Adenovirus may have the strongest association with intussusception.

Lead Point Differential Diagnosis:

Polyp

Intestinal duplication

Meckel's diverticulum (most common)

Henoch-Schonlein purpura

Stool (typically in cystic fibrosis with inspissated stool)

Inflammatory disorders (Crohn's, celiac)

Lymphoma

Parasites (Ascaris)

Vascular malformation

Hemolytic-uremic syndrome

Lymphatic hypertrophy

Arterial-venous malformations

Hematoma (trauma)

Epidemiology

Idiopathic intussusception: Appromately 75% of childhood intussusception cases are idiopathic or believed to be caused by a viral etiology.

Lead point intussusception: The remaining 25% of intussusceptions are due to a specific lead point.

Recurrent intussusception: Up to 10% of children may have a recurrence of intussusception after reduction. Any child with 2 occurrences of intussusception should undergo a complete work-up as a lead point is commonly identified in recurrent intussusception.

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