Peds

Intussusception

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Intussusception, Intussusception Ultrasound, Currant Jelly Stool

  • Definitions
  1. Intussusception
    1. Bowel 'telescopes' onto itself in early childhood
  • Epidemiology
  1. Most common cause Intestinal Obstruction age <6 years
  2. Incidence: 1 to 4 in 1000 newborns
  3. Ages affected
    1. Rare before age 3 months
    2. Most common ages 3 to 12 months (66%)
    3. Peak Incidence at 10 months of age
    4. Less common after age 36 months
  4. Gender predominence: Males > Females by 3:1 ratio
  • Pathophysiology
  1. Bowel telescopes on itself, causing venous and lymphatic congestion, then ischemia, perforation and peritonitis
  2. Occurs most commonly at ileocecal junction (but may occur anywhere along ileum, jejunum or colon)
  • Etiology
  1. Idiopathic (75-90%)
  2. Pathologic lesion at lead point of Intussusception
    1. Enlarged Peyer's Patch (follows recent gastrointestinal illness)
      1. Common cause
    2. Intestinal polyp
      1. Peutz-Jeghers Syndrome
      2. Juvenile Polyposis
      3. Familial Polyposis Coli
    3. Henoch-Schonlein Purpura
    4. Hemolytic Uremic Syndrome
    5. Hemangioma
    6. Meckel's Diverticulum
    7. Lymphosarcoma
    8. Abdominal Trauma, prior surgical scar or foreign body
  • Risk Factors
  1. Cystic Fibrosis
  2. Indwelling gastrointestinal tubes
  3. Recent infection
    1. Upper Respiratory Infection
    2. Acute Gastroenteritis
  • Symptoms
  1. Child often appears well between episodes of pain
    1. Appear agitated, inconsolable during painful episodes
    2. May be listless and pale between episodes
  2. Vomiting (delayed onset by 6-12 hours)
    1. Initially yellow Emesis progressing to Bilious Emesis
  3. Abdominal Pain
    1. Sudden onset
    2. Cramping, colicky with paroxysms of pain in 20 minute intervals (may flex knees to Abdomen in pain)
  4. Stool change
    1. Watery stools in first 12 to 24 hours
    2. Red Currant Jelly Stools (bloody mucus) are a late finding (occurs in 50% of cases, only 15% at presentation)
      1. Indicates infarcted or necrotic bowel
  • Signs
  1. Children may be pain free in up to 20% of cases
  2. Lethargy may be only presenting finding (10% of cases)
  3. Evolution of abdominal examination
    1. Initial: Benign Abdomen
    2. Later: Abdominal Distention with peritoneal signs
  4. Right upper quadrant or epigastric, sausage-shaped abdominal mass
  • Evaluation
  1. Four clinical signs and symptoms are most associated with Intussusception
    1. Crying
    2. Abdominal mass
    3. Pallor
    4. Vomiting
  2. Interpretation
    1. All four clinical signs and symptoms: 95% Intussusception probability
    2. Intussusception is unlikely if all 4 criteria absent
  3. References
    1. (2014) Pediatr Emer Care 30:718-22 [PubMed]
  • Precautions
  1. Consider in any child with irritability and Vomiting without Diarrhea (esp. with lethargy between episodes)
  2. Have a low threshold for evaluation (Ultrasound)
    1. Ultrasound is definitive (in experienced hands), non-invasive and inexpensive
    2. Missed Intussusception is lethal
  3. Listen to parents with concern regarding Abdominal Pain out of proportion to exam
  4. References
    1. Cantor (2016) Literature Review, ACEP PEM Conference, Orlando, attended 3/8/2016
  • Imaging
  1. Ultrasound
    1. Preferred first screening for Intussusception
    2. Technique: General
      1. Linear Probe follows course of Large Bowel
      2. Normal colon with haustra and minimal peristalsis compared with Small Bowel
    3. Technique: Option 1
      1. Follow ascending colon from RLQ, then transverse colon from RUQ, then descending colon from LUQ
      2. Stomach may be used as acoustic window if there is Bowel Obstruction with fluid in Stomach
    4. Technique: Option 2 (Adam Sivitz, MD)
      1. Follow ascending colon from RUQ to RLQ (identifies most cases of Intussusception)
    5. Findings: Abnormal
      1. Transverse axis
        1. Target sign (concentric rings)
      2. Longitudinal axis
        1. Sandwich or pseudokidney (multiple bowel layers)
    6. Efficacy
      1. Emergency Bedside Ultrasound is accurate (but operator dependent)
        1. Test Sensitivity 85%, Test Specificity: 97%
        2. Riera (2012) Ann Emerg Med 60(3): 264-8 [PubMed]
    7. References
      1. Claudius and Seif in Herbert (2013) EM:Rap 13(11): 1-3
  2. Contrast Enema
    1. Sensitivity: 95% of Intussusception
    2. Curative in most early cases of Intussusception
    3. Contraindications
      1. Patient unstable
      2. Surgical Abdomen
  3. Abdominal XRay signs of Intussusception (variably present)
    1. Right lower quadrant abdominal mass
    2. Absent bowel gas in right upper quadrant
    3. Target sign or Cresent sign
      1. Air trapped between the bowel lumens
  • Management
  • Reduction
  1. Immediate air or contrast enema if no contraindication
    1. Fluoroscopy guidance of air or contrast enema has typically been used
    2. Ultrasound guidance of saline enema has also been used
      1. Flaum (2016) J Pediatr Surg 51(1): 179-82 [PubMed]
  2. Surgical Consultation
  3. Consider prophylactic antibiotics prior to attempted reduction
  • Management
  • Disposition
  1. Most patients are admitted and observed for recurrence for at least 24 hours
    1. Due to risk of recurrence in 5-10% of cases
  2. Indications for discharge after 6-8 hours of observation (studies support 3 hour observation)
    1. Asymptomatic for at least 3 hours after reduction AND
    2. Tolerating oral liquids AND
    3. Reliable family and able to return to Emergency Department if needed AND
    4. Reduction successful within 3 attempts AND
    5. No serious findings before reduction (e.g. bloody stool, fever, long prodrome)
    6. Ravel (2015) Pediatrics 136(5):e1345-52 +PMID: 26459654 [PubMed]
  • Course (and Prognosis)
  1. Mortality
    1. Mortality 1 to 3% with early treatment
    2. Fatal if not treated within 2-5 days
  2. Recurrence in 3 to 11% of cases (most in first day)