History

Fact Explanation
Paroxysmal, screaming attack with drawing up of legs due to abdominal pain which older children complain of. It typically lasts only a few minutes and the attack starts around 15 minutes later. Abdominal pain is the most common presentation. [1] Commonly occur up to 2 years of age. [2]
Passage of redcurrent jelly stool/ Per rectal bleeding [3] Initially the stool that is passed maybe normal. But later passage of blood and mucus [1] gives rise to the characteristic "redcurrant jelly stool".
Pallor and lethargy The exact mechanism is not known[4], but must be suspected in children with unexplained lethargy, this maybe the only initial symptom. [5]
Vomiting [1][5] May not be present initially, but may occur later.
References
  1. MANDEVILLE K, CHEIN M, WILLYERD FA, MANDELL G, HOSTETLER MA, BULLOCH B. Intussusception: clinical presentations and imaging characteristics. PubMed. Pediatric Emergency Care. 2012 Sep; Volume 28. Issue 9. Pages 842-4. Available from: doi: 10.1097/PEC.0b013e318267a75e. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/22929138
  2. NAKAGOMI T, TAKAHASHI Y, ARISAWA K, NAKAGOMI O. A high incidence of intussusception in Japan as studied in a sentinel hospital over a 25-year period (1978-2002). PubMed. Epidemiology of Infection 2006 Feb; Volume 134. Issue 1. Pages:57-61. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870358/figure/fig001/
  3. KLEIN EJ, KAPOOR D, SHUGERMAN RP. The diagnosis of intussusception. PubMed. Clin Pediatr (Phila). 2004 May; Volume 43. Issue 4. Pages:343-7. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/15118777
  4. American academy of pediatrics. American college of emergency physicians. Ed. GAUSCHE-HILL Marian, Susan FUCHS, Loren YAMAMOT, The pediatric emergency resource. Revised fourth edition. Jones and Bartlett publishers. Viewed on: 08/03/20014 http://books.google.lk/books?id=lLVfDC2dh54C&pg
  5. HICKEY RW, SODHI SK, JOHNSON WR. Two children with lethargy and intussusception. PubMed. Ann Emerg Med. 1990 Apr. Volume 19. Issue 4. Pages:390-2. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/2321825
  6. ADIOTOMRE Pauline, ASUMANG Edna , GODBOLE Prasad. Intussusception in a 7-week-old baby-case report. BMJ Case Reports 2013; doi:10.1136/bcr-2012-008518 Viewed on: 08/03/20014 http://casereports.bmj.com/content/2013/bcr-2012-008518.abstract

Examination

Fact Explanation
Features of dehydration and even shock. [1] Repeated vomiting and reduced fluid intake and depletion of fluid into the gut (due to the intestinal obstruction caused by intussusception) causes dehydration. Look for rapid thready pulse, low blood pressure.
Abdominal distension In delayed presentation. [1]
Palpable sausage-shaped abdominal mass [2] May harden on palpation. The triad of this in association with abdominal pain and vomiting has high positive predictive value. [3]
Positive sign of Dance [1] Emptiness of the right iliac fossa is felt on palpation.
Rectal examination may produce "redcurrant jelly stool". Due to presence of blood stained mucus.
Palpation of the apex of the intussusceptum on digital rectal examination. [1] Rarely the proximal part may extend through rectum.
References
  1. HESSE Afua A.J., Francis A. Abantanga, Kokila Lakhoo. Chapter 68. Intussusception. In: AMEH E, BICKLER S, LAKHOO K, NWOMEH B, POENARU D et al. Paediatric Surgery: A Comprehensive Text For Africa. Global help. Viewed on: 08/03/20014 http://www.global-help.org/publications/books/help_pedsurgeryafrica68.pdf
  2. KLEIN EJ, KAPOOR D, SHUGERMAN RP. The diagnosis of intussusception. PubMed. Clinical Pediatrics 2004 May;Volume 43. Issue 4. pages 343-7. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/15118777
  3. HARRINGTON L, CONOLLY B, HU X, WESSON DE, BABYN P, SCHUH S. Ultrasonographic and clinical predictors of intussusception. PubMed. Journal of Pediatrics 1998 May; Volume 132. Issue 5. Pages 836-9. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/9602196

Differential Diagnoses

Fact Explanation
Gasteroenteritis This may also be associated with vomiting, blood and mucus diarrhoea and abdominal pain. A copious volume of stool which is persistent suggests gasteroenteritis.[1]
Other causes of intestinal obstruction These will also present with similar symptoms. Strangulated hernia can be diagnosed with examination of the groin. Other causes are volvulus, duplication cyst [1]
Acute appendicitis Both present with abdominal pain. Suspect appendicitis in older children(7-12 years of age[2] while intussusception is common in children less than 2 years[3]). Ultrasound scan will help in the diagnosis. [4]
Rectal prolapse (In cases where the intussusceptum protrudes through the rectum) Ability to insert a finger between the rectal mucosa and the mass (intussusceptum) indicates intussusception rather than rectal prolapse. [5]
References
  1. SOUTH Mike, ISAACS David. Practical Paediatrics 7th edition, Elsevier, Viewed on: 08/03/20014 https://www.inkling.com/read/practical-paediatrics-south-isaacs-7th/chapter-20-1/abdominal-pain-later-in-the
  2. RODNEY.S, Roshan. Clinical study of appendicitis in paediatric age Group. Rajiv Gandhi University of Health Sciences,Karnataka,Bangalore. General surgery. http://14.139.159.4:8080/jspui/handle/123456789/9245
  3. NAKAGOMI T, TAKAHASHI Y, ARISAWA K, NAKAGOMI O. A high incidence of intussusception in Japan as studied in a sentinel hospital over a 25-year period (1978-2002). PubMed. Epidemiology of Infection. 2006 Feb; Volume 134. Issue 1, Pages 57-61. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870358/figure/fig001/
  4. PEPPER VK, STANFILL AB, PEARL RH. Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum. PubMed. Surg Clin North Am. 2012 Jun, Volume 92, Issue 3, Pages 505-26. Available from: doi: 10.1016/j.suc.2012.03.011. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/22595706
  5. American academy of pediatrics. American college of emergency physicians. Edited by: GAUSCHE-HILL Marianne, Susan FUCHS, Loren YAMAMOT, The pediatric emergency resource. Revised fourth edition. Jones and Bartlett publishers. Viewed on: 08/03/20014 http://books.google.lk/books?id=lLVfDC2dh54C&pg

Investigations - for Diagnosis

Fact Explanation
X ray abdomen Distended bowel proximal to the intussusception can be seen while the caecal gas shadow will be absent since it will be collapsed. Positive meniscus sign(due to crescent of gas within the bowel due to intussusception) Target sign(due to hypoechogenic bowel with hyperechogenic center due to mesentry). [1] [2]
Ultrasound scan of the abdomen. The mass created by intussusception can be seen. Doughnut sign (hypoechogenic ring around the hyperechogenic bowel lumen formed mainly by returning limb of intussusceptum, this sign is seen mainly at the apex) Crescent in doughnut sign[3] (mainly seen in the base, due to the mesentery pulled along by the intussusceptum giving rise to increasing hyperechogenic crescentic pattern towards the base) Sandwich sign(on longitudinal view, the altering hypo and hyperechogenic shadows of bowel wall, lumen and mesentry give rise to sandwich like pattern) Pseudokidney sign(in longitudinal plane)[4] Enlarged lymphnodes maybe visible. Presence of fluid in between layers of bowel indicate ischemia. In older children the mass in the apex responsible for intussusception should be studied.
Barium enema For diagnosis as well as treatment. [2]
References
  1. ABRAHAMS Robert Bradford, FRANCOA Arie, LEWIS Kristopher Neal. Pediatric Colocolic Intussusception With Pathologic Lead Point: A Case Report. Journal of Medical Cases. Volume 3, Number 1, February 2012, pages 84-88 Viewed on: 08/03/20014 http://www.journalmc.org/index.php/JMC/article/view/402/288
  2. H.WILLIAMS. Imaging and intussusception. doi:10.1136/adc.2007.134304 . Arch. Dis. Child. Ed. Pract. 2008; Volume 93; Pages30-36 Viewed on: 08/03/20014 http://www.scp.com.co/ArchivosSCP/Boletines/www.scp.com.co/BancoMedios/Archivos/IntususcepcionArchDisChildEDPract-2008.pdf
  3. DEL-POZO G, ALBILLOS JC, TEJEDOR D. Intussusception: US findings with pathologic correlation--the crescent-in-doughnut sign. PubMed Radiology. 1996 Jun; Volume199. Issue 3. Pages:688-92. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/8637988
  4. SOTO Jorge A. , LUCEY Brian C. Emergency Radiology: The Requisites. Mosby. Elsevier. 2009 Viewed on: 08/03/20014 http://books.google.lk/books?id=DBmCmecq718C&pg=PA192&lpg=PA192&dq#v=onepage&q&f=false

Investigations - Fitness for Management

Fact Explanation
Color doppler Presence of blood flow indicates viability of the bowel thus barium enema would be the primary treatment modality, while absence of it suggests the need for surgical intervention. [1]
Ultrasound scan Presence of fluid between layers of bowel indicate ischemia, thus surgical reduction is needed.[2]
References
  1. LIM HK, SH BAE, KH LEE, GS SEO, GS YOON. Assessment of reducibility of ileocolic intussusception in children: usefulness of color Doppler sonography. Radiology. June 1994. Volume 191, Issue 3 Viewed on: 08/03/20014 http://pubs.rsna.org/doi/abs/10.1148/radiology.191.3.8184064
  2. H.WILLIAMS. Imaging and intussusception. Arch. Dis. Child. Ed. Pract. 2008; Volume 93; Pages 30-36 Available from: doi:10.1136/adc.2007.134304 Viewed on: 08/03/20014 http://www.scp.com.co/ArchivosSCP/Boletines/www.scp.com.co/BancoMedios/Archivos/IntususcepcionArchDisChildEDPract-2008.pdf

Investigations - Followup

Fact Explanation
Ultrasound scan of the abdomen. To confirm that the intussusception has been reduced after treatment
References

Management - General Measures

Fact Explanation
Pediatric surgical care maybe necessary. It is a surgical emergency. If pediatric surgical facility is not available, initial resuscitation and diagnosis with ultrasound should be done before transferring. [1]
Intravenous fluids. Anticipate and manage possible hypovolemic shock. Inadequate fluid therapy may result in high mortality. [2]
Antibiotics Routine antibiotics seem to be of small value. [3]
References
  1. CALDER Francis R., Susan TAN, Lara KITTERINGHAM, Evelyn H. DYKES. Patterns of Management of Intussusception Outside Tertiary Centre, London, England. Viewed on: 08/03/20014 http://www.sassit.co.za/Journals/Paeds/Intussusception/Managing%20intussusception%20outside%20tertiary%20referral%20centers.pdf
  2. STRINGER MD, PLEDGER G ,DRAKE DP. Childhood deaths from intussusception in England and Wales, 1984-9. BMJ. Mar 21, 1992; Volume 304, Issue 6829, Pages 737–739. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881600/
  3. AL-TOKHAIS T, HSIEH H, PEMBERTON J, ELNAHAS A, PuULINGANDLA P, FLAGEOLE H. Antibiotics administration before enema reduction of intussusception: is it necessary?. Journal of Pediatric Surgery 2012 May; Volume47, Issue 5, Pages 928-30. Available from: doi: 10.1016/j.jpedsurg.2012.01.050. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/22595575

Management - Specific Treatments

Fact Explanation
Ultrasound (US) guided hydrostatic reduction. [1] Exclude peritonitis (by abdominal examination) and bowel perforation (by presence of pneumoperitoneum in imaging)[2]. Hydrostatic reduction has a lesser chance of perforation than air reduction because hydrostatic pressure exerts a relatively more constant pressure than in air reduction.[3]
Barium enema reduction. Exclude peritonitis and bowel perforation.[4] Barium enema has high risk of radiation exposure while US guided reduction has none.[3]
Rectal air insufflation. Exclude peritonitis and bowel perforation.[5] Caution should be taken to avoid perforation and subsequent pneumoperitoneum which could be life threatening. Great caution should be adopted if performed where emergency paediatric surgery is not readily available. [6]
Operative reduction. Laparoscopic and open surgery. Laparoscopic surgery is preferred over open surgery where an early diagnosis has been established and there are no signs of peritonitis. [7] [8] Should be considered when rectal air insufflation or barium enema has failed [9] or in the presence of a pathological lead point at the apex[10] (mucocele of appendix, Meckel's diverticulum, Benign polyp, Ileal duplication, Lymphosarcoma). The resected bowel should be sent for histopathological study.
References
  1. BAI YZ, QU RB, WANG GD, ZHANG KR, LI Y, HUANG Y, ZHANG ZB, ZHANG SC, ZHANG HL, ZHOU X, WANG WL. Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: a review of 5218 cases in 17 years. PubMed. American Journal of Surgery. 2006 Sep; Volume 192, Issue3, Pages 273-5. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/16920416
  2. SARIN YK, JS RAO, E Stephen. Ultrasound guided water enema for hydrostatic reduction of childhood intussusception-a preliminary experience, GASTROINTESTINAL RADIOLOGY, 1999, Volume 9, Issue 2, Pg 59-63 Viewed on: 08/03/20014 http://www.ijri.org/article.asp?issn=0971-3026;year%3D1999;volume%3D9;issue%3D2;spage%3D59;epage%3D63;aulast%3DSarin
  3. DEL-POZO G, ALBILLOS JC, TEJEDOR D, CALERO R, RASERO M, de-la-CALLE U, LOPEZ-Pacheco U. Intussusception in children: current concepts in diagnosis and enema reduction. Radiographics. 1999 Mar-Apr;Volume 19, Issue 2, Pages 299-319. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/10194781
  4. LYNETTE L. YOUNG, MD. Case Based Pediatrics For Medical Students and Residents, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, Chapter X.4. Intussusception, December 2002 Viewed on: 08/03/20014 http://www.hawaii.edu/medicine/pediatrics/pedtext/s10c04.html
  5. DONNELLY Lane F, Pediatric imaging the fundamentals, Elsevier, 2009 Viewed on: 08/03/20014 http://books.google.lk/books?id=QHf1r-eXNKEC&pg=PA105&lpg=PA105&dq#v=onepage&q&f=false
  6. FALLON SC, KIM ES, NAIK-MATHURIA BJ, NUCHTERN JG, CASSADY CI, RODRIGEUZ JR. Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception. PubMed. Pediatr Radiol. 2013 Jun; Volume 43. Issue 6, Pages 662-7. Available from: doi: 10.1007/s00247-012-2604-y. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/23283408
  7. APELT N, FEATHERSTONE N, GIULINI S. Laparoscopic treatment of intussusception in children: a systematic review. PubMed. J Pediatr Surg. 2013 Aug;48(8):1789-93. doi: 10.1016/j.jpedsurg.2013.05.024. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/23932624
  8. BONNARD A, DEMARCHE M, DIMITRIU C, PEDEVIN G, VARLET F, FRANCOIS M, VALIOULIS I, ALLAL H; GECI (Groupe d'Etude de Coelioscopie Pédiatrique). Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI). Journal of Pediatric Surgery. 2008 Jul; Volume 43, Issue 7, Pages 1249-53. Available from: doi: 10.1016/j.jpedsurg.2007.11.022. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/18639677
  9. NIRAMIS R, WATANATITTAN S, KRUATRACHUE A, ANUNTKOSAL M, BURANAKITJAROEN V, RATTANASUWAN T, WONGTAPRADIT L, TONGSIN A. Management of recurrent intussusception: nonoperative or operative reduction? Journal of Pediatric Surgery. 2010 Nov; Volume 45, Issue 11, Pages 2175-80. Available from : doi: 10.1016/j.jpedsurg.2010.07.029. Viewed on: 08/03/20014 http://www.ncbi.nlm.nih.gov/pubmed/21034940
  10. KOH Elisa Poh Kim, CHUA Joyce Horng Yiing, CHUI Chan Hon. A report of 6 children with small bowel intussusception that required surgical intervention. Journal of Pediatric Surgery. Volume 41, Issue 4, April 2006, Pages 817–820 Viewed on: 08/03/20014 http://www.jpedsurg.org/article/S0022-3468(05)00967-X/abstract