Intussusception: quick review

30 Jan
(scroll to bottom for 10-second version)
DEMOGRAPHICS
–most common cause of intestinal obstruction in kids 3 months-6 years of age.
male:female ratio is 4:1
–Seasonal variation with peaks after GI viral illness seasons.

PATHOPHYSIOLOGY
–In younger children, the ileum invaginates into the upper colon, bringing the mesentery with it (ileocolic).

–lead point is often lymphoid hyperplasia from viral gastroenteritis

–In older children, ileo-ileo intussusceptions are more common. 
–lead point causes include intestinal polyps, Meckel diverticulum, lymphosarcoma, or even HSP
–Constriction of the mesentery obstructs venous return, leading to bowel ischemia and bloody stools leading to the classic “currant jelly” stool, which is a late finding occurring in about 50% of cases

CLINICAL FEATURES

–Sudden colicky abdominal pain (child will stop, cry, draw up their legs, and then after a few minutes the child appears well). 
–As the condition progresses the time between episodes decreases.   
–Stool is generally guaiac positive even in the absence of gross blood. 
–A palpable sausage shaped mass can be found on the right side of the abdomen in about 2/3 of cases

DIAGNOSIS
–Diagnosis often made by history alone
KUB may suggest a filling defect in the right lower quadrant of the abdomen or can be normal
US can often show the classic target appearance of bowel within bowel (donut sign (transverse); sandwich sign (longitudinal)


TREATMENT
Air contrast enema is preferred over barium enema because it enables better control over colonic pressure and in the case of perforation prevents barium spillage into the peritoneum.
–Children generally admitted for observation because of the 5-10% recurrence rate.  A second attempt at air reduction is usually successful, but if further recurrences occur surgical reduction may be necessary.  

10-SECOND RECAP:
–most common in kids 3 mo-6 yrs old; male:female 4:1

ileocolic (younger), ileo-ileo (older), or wherever

–common lead points (lympoid hyperplasia from gastroenteritis, polyps, meckel’s, cancer, HSP, etc.)
–bowel ischemia -> guaiac+ stool -> occasionally currant jelly stool
history is key, palpable sausage in RLQ in 2/3, KUB maybe, ultrasound (donut/sandwich signs)
air contrast enema = diagnostic + therapeutic; surgery if that doesn’t work


Submitted by J. Grover.


Reference(s): Tintinalli’s Emergency Medicine, picture 1, KUB, donut, sandwich
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  1. adult intussusception « DAILYEM - November 2, 2012

    […] refresher via old post […]

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