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Intussusception

Intussusception - a pediatric emergency - occurs when a portion of the bowel telescopes or invaginates into an adjacent bowel portion. Because this disorder leads to bowel obstruction and other serious complications, it can be fatal, especially if treatment is delayed for more than 24 hours.

Intussusception is most common in infants and occurs three times more often in males than in females. About 87% of children with intussusception are under age 2; about 70% of these children are between 4 and 11 months old.

Causes

The causes of intussusception are not fully known. Viral infections of the intestine may possibly contribute to intussusception in infancy.

Intussusception is very rare in older children in whom the presence of a polyp or a tumor may trigger the intussusception. A polyp or tumor is a common cause of intussusception in adults.

Signs and Symptoms

If the patient is an infant or a child, the history may reveal intermittent attacks of colicky pain. Typically, this pain causes the child to scream, draw his legs up to his abdomen, turn pale and diaphoretic and, possibly, grunt. Parents may report that the child initially vomits stomach contents and, later, bile-stained or fecal material. Parents may describe the child's "currant jelly" stools, which contain a mixture of blood and mucus.

Inspection and palpation may reveal a distended, tender abdomen, with some guarding over the intussusception site. A sausage-shaped abdominal mass may be palpable in the right upper quadrant or in the midepigastric area if the transverse colon is involved. Rectal examination may show bloody mucus.

In an adult patient, the history may reveal nonspecific, chronic, and intermittent symptoms, such as colicky abdominal pain and tenderness, vomiting, diarrhea (occasionally constipation), bloody stools, and weight loss. The patient may describe abdominal pain that is localized in the right lower quadrant, radiates to the back, and increases with eating. The abdomen may be distended. Palpation may help pinpoint the tender area in the right lower quadrant.

In the adult patient, excruciating pain, abdominal distention, and tachycardia are signs that severe intussusception has led to strangulation.

Diagnostic tests

Various tests help to confirm the diagnosis: Barium enema confirms colonic intussusception when it shows the characteristic coiled-spring sign; it also delineates, the extent of intussusception. Upright abdominal X-rays may show a soft-tissue mass and signs of complete or partial obstruction, with dilated loops of bowel. White blood cell count up to 15,000/µl indicates obstruction; more than 15,000/µl, strangulation; and more than 20,000/µl, bowel infarction.

Treatment

In children, therapy may include hydrostatic reduction or surgery. Surgery is indicated for children with recurrent intussusception, for those who show signs of shock or peritonitis, and for those in whom symptoms have been present longer than 24 hours. In adults, surgery is always the treatment of choice.

During hydrostatic reduction, the radiologist drips a barium solution into the rectum through a catheter from a height of not more than 3' (0.9 m); fluoroscopy is used to trace the progress of the barium. If the procedure is successful, the barium backwashes into theileum and the mass disappears. If not, the procedure is stopped, and the patient is prepared for surgery.

During surgery, manual reduction is attempt first. After compressing the bowel above the intussusception, the doctor attempts to milk the intussusception, back through the bowel. However, if manual reduction fails, or if the bowel is gangrenous or strangulated, the doctor performs a resection of the affected bowel segment.

Prevention

There are no guidelines for preventing intussusception because the cause is unknown.



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