Intussusception

Abstract

Intussusception is a telescoping of the intestine into itself. It is one of the most common causes of abdominal pain in children under 5 years of age. The disease occurs most commonly in children between 6 and 18 months of age, but has been described in all age groups including babies in utero and in adults. Approximately half of all cases occur in the second 6 months of life, and 90% of all cases occur before 3 years of age.

Appendices

Summary Points

Ninety percent of cases occur in children under 3 years of age.

Ileocecal intussusception is the most common form, most commonly caused by a viral illness.

In older children, idiopathic/viral is still the most common cause, but the presence of a pathologic lead point needs to be considered.

History and physical examination suggest the diagnosis: intermittent severe abdominal pain (every 15–20 min) with intervening periods of being asymptomatic.

Bowel obstruction and currant jelly stool are late findings.

Either barium or air contrast studies confirm the diagnosis and are often therapeutic. Antibiotics are given prior to or just after the radiographic study depending on the regional concern for E. coli 0157:H7 infection. Ultrasound is gaining increased use as a screening tool and may be better at discerning the enteroenteral intussusception.

If the intussusception is successfully reduced by radiology, the child is admitted overnight for antibiotics and has feedings advanced the next morning.

If the intussusception is not reduced hydrostatically or pneumatically, the child must be operatively reduced.

Intussusception recurs in 5–7% of children radiographically reduced and 1% of those surgically reduced.

Editor’s Comment

Intussusception is impossible to exclude with certainty by history, physical examination, laboratory studies or plain radiographic images either alone or in combination. In fact, if intussusception has been mentioned as a possibility and no other diagnosis can been confirmed, some feel very strongly that it absolutely must be ruled out using either ultrasound or contrast enema. If intussusception is confirmed, the next step is contrast enema, the type of which (air or liquid) should be determined by the radiologist, not the surgeon. Some radiologists insist that a surgeon be present “just in case” of a perforation, even though this is never an indication to perform surgery in the radiology suite or to take a child directly to the OR without first being resuscitated and properly prepared. Perhaps the most important role of the surgeon in these situations is to maintain a calm and commanding presence while patient and parents are being prepared for a trip first back to the ED or ward and then soon thereafter to the OR. Even after a perforation, ileostomy should almost never be necessary, as a primary anastomosis, except in the most extraordinary of circumstances, is almost always able to be done quickly and safely.

I routinely perform surgical reduction laparoscopically and feel that it is enormously preferable to laparotomy. Besides the usual benefits of smaller incisions, quicker recovery, and less conspicuous scarring, perhaps the thing I like most about the approach is that it nicely disproves yet another formerly sacrosanct surgical dictum (“never ever pull the bowel apart”). I still perform an appendectomy, possibly out of habit, but I believe there is little harm done and that it might prevent recurrence or appendiceal colic (due to scarring in the appendix) in the future. Performing a biopsy (or, worse, a resection) when one encounters an edematous or hemorrhagic “mass” in the wall of the cecum or ileum is a common “rookie mistake,” though it should not discourage one to look carefully for a potential lead point.

Children over the age of five with classic ileo-colic intussusception pose a challenge, as do children of any age who develop more than one recurrence. A diligent search for a lead point (US, CT, endoscopy) is reasonable, but I do not believe either is an absolute indication for laparotomy or bowel resection. Obviously, a great deal of clinical experience and good judgment is needed in such cases. On the other hand, small bowel intussusception is always pathologic and should prompt at least a diagnostic laparoscopy to rule out lymphoma, Meckel’s diverticulum, polyp, tumor, or vascular malformation (blue rubber bleb syndrome is an example). A short period of observation (12–24 h, if there are no signs of sepsis or peritonitis) is reasonable when a small bowel intussusception occurs in patients who have recently undergone a retroperitoneal dissection (Wilms tumor) or those with HSP, as it can occasionally resolve spontaneously in these patients.

Differential Diagnosis

• Appendicitis

• Viral illness and gastroenteritis

• Hemolytic uremic syndrome

• Rectal prolapse

Preoperative Preparation

• Intravenous antibiotics (second generation cephalosporin):

  • If <6 months old, give before contrast enema.

  • If >6 months old in geographic areas where E. coli 0157:H7 is endemic, give only after intussusception has been confirmed; in other areas, give before.

• If radiographic reduction is unsuccessful, consider another attempt in 4–6 h, or proceed with operative reduction.

• Intravenous hydration.

• If there is vomiting or evidence of obstruction, place a nasogastric tube.

• Informed consent.

Technical Points

Laparotomy

• Right-sided transverse incision above or below level of umbilicus

• Deliver the mass from the abdomen

• Reduce intussusception by pushing on the intussusceptum

• Warm moist packs for 10–20 min to assess ­perfusion and viability

• Check for pathologic lead point. (Don’t be fooled by hypertrophied Peyer’s patch!)

Laparoscopy

• Standard techniques

• Gently pull the bowel apart to reduce the intussusception

• If unable to reduce, bowel resection and primary anastomosis.

• Ileostomy should rarely, if ever, be necessary.

Parental Preparation

• Possible bowel resection due to necrosis or perforation

• Probable primary anastomosis

• Possibility that the intussusception reduced simply by placing child under anesthesia

• Small chance of recurrence

• The appendix will likely be removed empirically.