Pediatric emergency medicine trisk 939
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Triad of bilious emesis, abdominal mass, and blood per rectum is seen
in less than 10% of cases
Intussusception should be considered in infants and toddlers with
emesis and altered mental status
Children with intussusception may arrest during a pneumatic reduction
and therefore the clinical team must be prepared
After successful enema reduction, intussusception recurs in
approximately 5% of cases within the first 48 hours
Current Evidence
Intussusception occurs when one segment of bowel invaginates into a more distal
segment. This is the leading cause of acute intestinal obstruction in infants, and it
occurs most commonly between 3 and 12 months of age. The most common
intussusception is ileocolic but the small bowel may intussuscept into itself.
Typically, this small bowel intussusception then prolapses through the ileocecal
valve ( Figs. 116.6 and 116.7 ). The intussusception continues through the colon a
variable distance, occasionally as far as the rectum, where it can be palpated on
rectal examination. Colocolic intussusceptions are rare. In infants, the lead point
for ileocolic intussusception may be hypertrophied Peyer patches. In children
older than 2 years of age, a specific lead point such as a polyp, a Meckel
diverticulum, an intestinal duplication, or a tumor should be considered. A
diarrheal illness or viral syndrome may occur several days to a week before the
onset of abdominal pain and obstruction. Henoch–Schönlein purpura has been
associated with intussusception (generally small bowel–small bowel). Small
bowel–small bowel intussusceptions may cause symptoms but generally selfresolve.
Clinical Considerations
Clinical Recognition. The primary manifestation of intussusception is colicky
abdominal pain in an infant or toddler. Children with intermittent abdominal pain
and vomiting, especially if bilious, should be evaluated for intussusception. The
condition of the patient is highly variable between being happy and playful
between episodes to critically ill children with evidence of peritonitis and shock.
Occasionally, the primary complaint may be blood per rectum or vomiting and
altered mental status.
FIGURE 116.6 Ileocolic intussusception. A: Beginning of an intussusception in which terminal
ileum prolapses through the ileocecal valve. B: Ileocolic intussusceptum continuing through the
colon. This can often be palpated as a mass in the right upper quadrant.
FIGURE 116.7 Ileocolic intussusception. Barium enema shows the intussusception as the filing
defect within the hepatic flexure surrounded by spiral mucosal folds. Significant distended
small bowel represents distal small bowel obstruction.
Triage Consideration. Blood per rectum or bilious emesis in a child with
possible intussusception should be triaged to an acute treatment area with
immediate assessment by the emergency department team. Children with
evidence of shock or bowel obstruction may need immediate operative care.
Initial Assessment. Most children present with significant intermittent abdominal
pain. This symptom may have been preceded by the symptoms and signs of a
viral gastroenteritis or even an upper respiratory infection. Gradually, the child
becomes more irritable and anorectic, and may vomit. The pattern of pain in a
child with an intussusception is often consistent and characteristic, and the
diagnosis should be considered strongly if a history of episodic pain is obtained.
The child may appear comfortable and well between episodes. Occasionally, the
child may appear lethargic and listless. At times, patients with intussusception
have been misdiagnosed as being in a postictal state or encephalopathic.
The localized portion of the intussusception leads to partial or complete
obstruction and generalized abdominal distension. In some cases, the
intussuscepted mass can be palpated as an ill-defined, sausage-shaped structure if
the abdomen is not too distended. This mass is most often palpable in the right
upper quadrant.
When children arrive in the ED early in the course of intussusception, there is
often no history of having passed a currant jelly stool, although blood may be
found on rectal examination (50% to 75% of cases have occult blood). However,
the absence of bloody stools should not preclude making the diagnosis of a
possible intussusception. Infants and young children with colicky abdominal pain
and emesis should be evaluated for intussusception. Less than 10% of infants
with intussusception have the triad of colicky abdominal pain, abdominal mass,
and bloody stools.
As the bowel becomes more tightly intussuscepted, the mesenteric veins
become compressed, whereas the mesenteric arterial supply remains intact. This
leads to the production of the characteristic currant jelly stool, which may be
passed spontaneously or found on the rectal examination. As the intussusception
becomes swollen, the pressure of entrapment occludes the arteries. At this point,
the bleeding lessens, but the bowel can become gangrenous and even perforate,
leading to peritonitis.
Management. A well-appearing patient may proceed directly to diagnostic
imaging. Dehydrated patients should receive IV fluids. A pediatric surgeon
should be consulted immediately if the patient is critically ill or has signs of
peritonitis. Nasogastric suction minimizes the risk of vomiting and aspiration if
the child is critically ill. Once perfusion has improved and blood has been sent for
CBC, electrolytes, and a blood bank sample, the patient should have diagnostic
imaging.
Plain radiograph findings of intussusception are variable and depend primarily
on the duration of the symptoms and the presence or absence of complications. In
early cases, a normal gas pattern is seen. Distal colonic air cannot be interpreted
as an absence of intussusception. Unless the radiograph exhibits air in the cecum,
ileocolic intussusception cannot be excluded by the radiograph. To improve yield,
