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eMedicine Journal
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Pediatric
Pediatrics, Intussusception Synonyms, Key Words, and Related Terms: intussusception, telescoping of the bowel, prolapse of the bowel, intussusceptum, intussuscipiens, red currant jelly stool, upper respiratory illness, diarrheal illness, Henoch-Schönlein purpura, cystic fibrosis, Meckel diverticulum, intestinal polyp, intestinal lymphosarcoma, intestinal hematomas, mesenteric hematomas, hemangioma |
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 | AUTHOR INFORMATION | Section 1 of 11    |
Authored by Lonnie King, MD, Consulting Staff, Department of Emergency Medicine, Children's Healthcare of Atlanta at Scottish Rite
Lonnie King, MD, is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Academy of Pediatrics, and American College of Emergency Physicians
Edited by Garry Wilkes, MD, Director, Emergency Medicine, Adjunct Associate Professor, Edith Cowan University, Department of Emergency Medicine, Bunbury Health Service; Robert Konop, PharmD, Director, Clinical Account Management, Ancillary Care Management, Inc; Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Division of Emergency Medicine, Children's Hospital of Boston
| Author's Email: | Lonnie King, MD |  |
|---|---|---|
| Editor's Email: | Garry Wilkes, MD |
eMedicine Journal, May 23 2006, VOLUME 7,
Number 5
| INTRODUCTION | Section 2 of 11  |
Background: Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment. Contrast enema can reduce the intussusception in approximately 75% of cases.
Pathophysiology: Intussusception most commonly occurs at the terminal ileum (ie, ileocolic). The telescoping proximal portion of bowel (ie, intussusceptum) invaginates into the adjacent distal bowel (ie, intussuscipiens).
The mesentery of the intussusceptum is compressed, and the ensuing swelling of the bowel wall quickly leads to obstruction. Venous engorgement and ischemia of the intestinal mucosa cause bleeding and an outpouring of mucous, which results in the classic description of red "currant jelly" stool.
Most cases (90%) are idiopathic, with no identifiable lesion acting as the lead point or pathological apex of the intussusceptum.
Frequency:
Mortality/Morbidity: Most patients recover if treated within 24 hours.
Sex:
Age: Intussusception is most common in infants aged 3-12 months, with an average age of 7-8 months.
| CLINICAL | Section 3 of 11 |
History:
Physical:
Causes: Most cases are idiopathic. In neonates and in patients older than 3 years, a mechanical lead point usually can be found.
| DIFFERENTIALS | Section 4 of 11 |
Abdominal Trauma, Blunt
Appendicitis, Acute
Hernias
Pediatrics, Gastroenteritis
Testicular Torsion
Other Problems to be Considered:
Adhesive band
Volvulus
Meckel diverticulum
Any process causing abdominal pain or GI bleeding
| WORKUP | Section 5 of 11 |
Lab Studies:
Imaging Studies:
| TREATMENT | Section 6 of 11 |
Emergency Department Care:
Consultations: Only perform a contrast enema in consultation with the surgeon caring for the child and the radiologist interpreting the study.
| FOLLOW-UP | Section 7 of 11 |
Further Inpatient Care:
Transfer:
Complications:
Prognosis:
| MISCELLANEOUS | Section 8 of 11 |
Medical/Legal Pitfalls:
| TEST QUESTIONS | Section 9 of 11 |
CME Question 1: An 8-month-old male presents to the ED with 8 hours of worsening intermittent crying, drawing his legs, vomiting, bloody stools, and apathy. His abdomen is distended. Abdominal x-ray findings show a right-sided soft tissue mass and free air. Which of the following is the next most appropriate action?
A: Call the radiologist to arrange for immediate air contrast enema.
B: Call the radiologist to arrange for immediate ultrasound of abdomen.
C: Prepare the patient for surgery and call a surgeon regarding the need for immediate surgery.
D: Call hematology to have blood immediately available for probable transfusion.
E: Call a radiologist to arrange for an immediate water-soluble contrast enema.
The correct answer is C: Intestinal perforation is a contraindication to contrast enema. Other contraindications include shock, prolonged obstruction, and signs of peritonitis.
CME Question 2: A pediatrician observed a 2-year-old boy earlier in the day for scrotal purpura and joint pain. Parents state he was diagnosed with Henoch-Schönlein purpura (HSP). Tonight, the child is vomiting and having severe colicky abdominal pain. The ED physician suspects intussusception. Contrast enema findings are negative. Which of the following is the most appropriate next step?
A: Discharge the patient with a follow-up scheduled for the next morning.
B: Admit the patient to pediatrics for IV fluids.
C: Repeat the contrast enema in 2 hours.
D: Consult with pediatric surgeon for immediate surgical evaluation.
E: Get an immediate ultrasound of the patient’s abdomen.
The correct answer is D: Half of the cases of intussusception in children with HSP involve only the small bowel; therefore, the contrast enema findings are negative. Intussusception is the most common surgical complication of HSP.
Pearl Question 1 (T/F): Intussusception is the most common cause of intestinal obstruction in children aged 3 months to 6 years.
The correct answer is True: Recurrence is observed in 3-11% of these cases. Most recurrences involve intussusceptions that were reduced with contrast enema.
Pearl Question 2 (T/F): Intussusception most commonly occurs in children aged 12-36 months.
The correct answer is False: Intussusception is most common in infants aged 3-12 months. This condition is less common in persons older than 36 months and is rare in persons younger than 3 months.
Pearl Question 3 (T/F): Colicky abdominal pain, vomiting, and red “currant jelly” stool is the classic triad of intussusception.
The correct answer is True: Colicky abdominal pain, vomiting, and red currant jelly stool is the classic triad of intussusception; however, currant jelly stools are observed in only 50% of cases.
Pearl Question 4 (T/F): The classic triad of symptoms (ie, colicky abdominal pain, vomiting, and red “currant jelly” stool) occurs in 52% of intussusception cases.
The correct answer is False: Only 21% of intussusception cases have the triad of symptoms.
| PICTURES | Section 10 of 11 |
| Caption: Picture 1. Note intussusception in the left upper quadrant on this plain film of an infant with pain vomiting. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite. | |
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| Picture Type: X-RAY | |
| Caption: Picture 2. Intussusception evident during air contrast enema prior to reduction. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite. | |
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 eMedicine Zoom View (Interactive!) | |
| Picture Type: X-RAY | |
| BIBLIOGRAPHY | Section 11 of 11 |
| NOTE: |
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| Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER |
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