Intussusception in Children

Introduction to Intussusception in Children

Intussusception is a serious condition in which a part of the intestine telescopes into an adjacent section, causing bowel obstruction. It is the most common cause of acute intestinal obstruction in infants and young children between 3 months and 3 years of age.

The condition requires prompt diagnosis and treatment to prevent potentially life-threatening complications such as intestinal necrosis, perforation, and peritonitis. Understanding the pathophysiology, clinical presentation, and management options is crucial for pediatricians and emergency physicians to ensure optimal outcomes.

Epidemiology of Intussusception

Key epidemiological features of intussusception in children include:

  • Peak incidence occurs between 5 and 10 months of age
  • Approximately 80% of cases occur before 24 months of age
  • Male predominance with a male-to-female ratio of approximately 3:2
  • Incidence ranges from 0.5 to 2.3 cases per 1,000 live births in Western countries
  • Seasonal variation with peaks in spring and autumn in some regions
  • Higher incidence in certain populations (e.g., Native Americans)

Risk factors include:

  • Recent viral gastroenteritis
  • Upper respiratory tract infections
  • Anatomical abnormalities (e.g., Meckel's diverticulum, polyps)
  • Henoch-Schönlein purpura
  • Cystic fibrosis
  • History of abdominal surgery

Pathophysiology of Intussusception

The pathophysiology of intussusception involves:

  1. Mechanical Process: A segment of proximal bowel (intussusceptum) telescopes into the distal bowel (intussuscipiens).
  2. Types:
    • Ileocolic (most common): ileum prolapses into the colon
    • Ileoileocolic: ileoileal intussusception extends into the colon
    • Small bowel: involves only the small intestine
    • Colocolic: involves only the large intestine (rare in children)
  3. Lead Point: In most cases (90%) in infants, no specific lead point is identified (idiopathic). In older children, a pathological lead point is more common.
  4. Vascular Compromise: As the intussusception progresses, mesentery becomes compressed, leading to venous congestion, edema, and eventually arterial insufficiency.
  5. Bowel Obstruction: The telescoping causes mechanical obstruction of the intestinal lumen.
  6. Inflammatory Response: Mucosal injury triggers inflammation and can lead to bleeding ("currant jelly" stools).

Understanding this process is crucial for recognizing the urgency of diagnosis and treatment to prevent bowel ischemia and necrosis.

Clinical Presentation of Intussusception

The classic triad of symptoms (present in only about 20% of cases) includes:

  1. Colicky abdominal pain
  2. Vomiting
  3. "Currant jelly" stools (blood and mucus in stool)

Other important clinical features:

  • Pain: Intermittent, severe abdominal pain causing sudden crying episodes in infants
  • Lethargy: Periods of listlessness between pain episodes
  • Vomiting: Initially non-bilious, may become bilious as obstruction progresses
  • Abdominal Mass: Palpable "sausage-shaped" mass in the right upper quadrant or epigastrium
  • Rectal Bleeding: May occur without other symptoms, especially in infants
  • Dance's Sign: Empty right lower quadrant on palpation

As the condition progresses, signs of dehydration, sepsis, and peritonitis may develop. The presentation can be atypical, especially in very young infants or older children, making diagnosis challenging.

Diagnosis of Intussusception

Prompt and accurate diagnosis is crucial. The diagnostic approach includes:

  1. Clinical Evaluation:
    • Thorough history and physical examination
    • High index of suspicion in appropriate age group
  2. Imaging Studies:
    • Ultrasound: First-line imaging modality (sensitivity >97%, specificity >97%)
      • "Target sign" or "doughnut sign" on transverse view
      • "Pseudokidney" sign on longitudinal view
    • Plain Abdominal X-ray: May show signs of obstruction, but not specific for intussusception
    • Contrast Enema: Both diagnostic and potentially therapeutic
      • "Coiled spring" appearance
      • "Claw sign" or "meniscus sign"
    • CT Scan: Reserved for cases with diagnostic uncertainty or suspected complications
  3. Laboratory Tests:
    • Complete blood count
    • Electrolytes and renal function tests
    • Blood gas analysis in severe cases

Differential diagnosis includes appendicitis, gastroenteritis, malrotation with volvulus, and Henoch-Schönlein purpura. Careful evaluation is necessary to distinguish these conditions.

Management of Intussusception

Management of intussusception involves a stepwise approach:

  1. Initial Stabilization:
    • IV fluid resuscitation
    • Nasogastric tube decompression
    • Correction of electrolyte imbalances
    • Antibiotics if perforation is suspected
  2. Non-operative Reduction:
    • Pneumatic Reduction: Air enema under fluoroscopic guidance (success rate 70-90%)
      • Contraindicated in cases of perforation or peritonitis
      • Multiple attempts may be necessary
    • Hydrostatic Reduction: Using saline or contrast under ultrasound or fluoroscopic guidance
  3. Surgical Management: Indicated when:
    • Non-operative reduction fails
    • Perforation or peritonitis is present
    • Pathological lead point is suspected

    Surgical options include:

    • Manual reduction
    • Resection and anastomosis if bowel is nonviable
    • Laparoscopic approaches in select cases
  4. Post-reduction Care:
    • Close monitoring for recurrence (occurs in 5-10% of cases)
    • Gradual reintroduction of oral feeds
    • Patient and family education about potential recurrence

The choice of management strategy depends on the clinical presentation, duration of symptoms, and local expertise. Early intervention is key to preventing complications and improving outcomes.

Complications and Prognosis of Intussusception

Complications:

  • Bowel obstruction
  • Intestinal ischemia and necrosis
  • Perforation and peritonitis
  • Sepsis
  • Recurrence (5-10% risk, highest in the first 48 hours)
  • Short bowel syndrome (if extensive resection is required)

Prognosis:

  • Excellent when diagnosed and treated early (mortality <1% in developed countries)
  • Mortality increases significantly with delayed diagnosis (up to 20-25% in developing countries)
  • Long-term prognosis is generally good for uncomplicated cases
  • Regular follow-up is important, especially in the first year after the event

Factors affecting prognosis include:

  • Duration of symptoms before treatment
  • Presence of a pathological lead point
  • Success of non-operative reduction
  • Extent of bowel compromise if surgery is required

Early recognition and prompt treatment are crucial for optimal outcomes in children with intussusception.



Intussusception in Children
  1. QUESTION: What is intussusception in children?
    ANSWER: Intussusception is a condition where one part of the intestine telescopes into an adjacent section, causing a bowel obstruction.
  2. QUESTION: At what age is intussusception most common in children?
    ANSWER: Intussusception is most common in children between 3 months and 3 years of age, with a peak incidence around 5-9 months.
  3. QUESTION: What are the classic symptoms of intussusception in children?
    ANSWER: The classic symptoms include sudden onset of severe abdominal pain (often cyclical), vomiting, and "currant jelly" stools (bloody, mucoid stools).
  4. QUESTION: How is intussusception diagnosed in children?
    ANSWER: Diagnosis is typically made through a combination of clinical presentation, physical examination, and imaging studies such as ultrasound or air/contrast enema.
  5. QUESTION: What is the most common type of intussusception in children?
    ANSWER: The most common type is ileocolic intussusception, where the ileum (last part of the small intestine) telescopes into the colon.
  6. QUESTION: What is the "target sign" in the context of intussusception?
    ANSWER: The "target sign" is a characteristic ultrasound finding in intussusception, showing concentric rings of the telescoped bowel in cross-section.
  7. QUESTION: How does intussusception affect blood supply to the intestine?
    ANSWER: Intussusception can compromise blood supply to the affected bowel segment, potentially leading to ischemia and necrosis if left untreated.
  8. QUESTION: What is the first-line treatment for uncomplicated intussusception in children?
    ANSWER: The first-line treatment is typically non-surgical reduction using air or contrast enema under fluoroscopic or ultrasound guidance.
  9. QUESTION: When is surgical intervention necessary for intussusception in children?
    ANSWER: Surgery is necessary when non-surgical reduction fails, if there are signs of peritonitis or perforation, or if there's a pathological lead point causing recurrent intussusception.
  10. QUESTION: What is a pathological lead point in intussusception?
    ANSWER: A pathological lead point is an abnormality in the intestine (such as a polyp, lymphoid hyperplasia, or Meckel's diverticulum) that can initiate and perpetuate intussusception.
  11. QUESTION: How does the presentation of intussusception differ in older children compared to infants?
    ANSWER: Older children may be able to more accurately describe their pain and symptoms, and are more likely to have a pathological lead point causing the intussusception.
  12. QUESTION: What is the role of intravenous fluids in managing intussusception?
    ANSWER: Intravenous fluids are crucial for correcting dehydration and electrolyte imbalances that may result from vomiting and reduced oral intake.
  13. QUESTION: How does intussusception affect the lymphatic drainage of the intestine?
    ANSWER: Intussusception can obstruct lymphatic drainage, leading to edema of the bowel wall and potentially contributing to the characteristic "currant jelly" stools.
  14. QUESTION: What is the recurrence rate of intussusception in children after successful non-surgical reduction?
    ANSWER: The recurrence rate is approximately 10-15% after successful non-surgical reduction, with most recurrences happening within 72 hours.
  15. QUESTION: How does rotavirus vaccination affect the incidence of intussusception?
    ANSWER: While the first rotavirus vaccine was associated with an increased risk of intussusception, current vaccines have a much lower risk, with benefits outweighing the small increased risk.
  16. QUESTION: What is the "dance sign" in the context of intussusception?
    ANSWER: The "dance sign" refers to the to-and-fro movement of the intussusception mass that can sometimes be observed during abdominal palpation.
  17. QUESTION: How does intussusception affect nutrient absorption in the affected bowel segment?
    ANSWER: Intussusception impairs nutrient absorption in the affected segment due to compromised blood flow and mucosal damage.
  18. QUESTION: What is the significance of free intraperitoneal air in a child with suspected intussusception?
    ANSWER: Free intraperitoneal air suggests bowel perforation, which is a surgical emergency and contraindicates attempts at non-surgical reduction.
  19. QUESTION: How does chronic or recurrent intussusception differ from acute intussusception in children?
    ANSWER: Chronic or recurrent intussusception often presents with intermittent abdominal pain and vomiting over weeks or months, and is more likely to have a pathological lead point.
  20. QUESTION: What is the role of CT scanning in diagnosing intussusception in children?
    ANSWER: While ultrasound is the preferred initial imaging modality, CT can be useful in complex cases, older children, or when a pathological lead point is suspected.
  21. QUESTION: How does intussusception affect gut motility in the affected bowel segment?
    ANSWER: Intussusception disrupts normal peristalsis in the affected segment, leading to bowel obstruction and altered motility patterns.
  22. QUESTION: What is the importance of timely diagnosis and treatment of intussusception?
    ANSWER: Timely diagnosis and treatment are crucial to prevent bowel ischemia, necrosis, and perforation, which can lead to severe complications and the need for bowel resection.
  23. QUESTION: How does intussusception affect the mesenteric blood vessels?
    ANSWER: As the bowel telescopes, it pulls the mesentery with it, potentially compressing or twisting mesenteric blood vessels and compromising blood supply to the affected segment.
  24. QUESTION: What is the role of plain abdominal radiographs in diagnosing intussusception?
    ANSWER: While not diagnostic, plain radiographs can show signs of bowel obstruction or perforation, and may sometimes reveal the characteristic "target sign" or "crescent sign" of intussusception.
  25. QUESTION: How does the success rate of non-surgical reduction change with the duration of symptoms?
    ANSWER: The success rate of non-surgical reduction decreases as the duration of symptoms increases, due to increasing edema and ischemia of the bowel wall.
  26. QUESTION: What is the significance of pneumatosis intestinalis in a child with intussusception?
    ANSWER: Pneumatosis intestinalis (gas in the bowel wall) suggests bowel wall ischemia or necrosis, indicating a need for urgent surgical intervention rather than attempted non-surgical reduction.
  27. QUESTION: How does intussusception affect the gut microbiome in children?
    ANSWER: Intussusception can disrupt the normal gut microbiome due to changes in intestinal motility, mucosal damage, and potential use of antibiotics during treatment.
  28. QUESTION: What is the role of antibiotics in the management of intussusception?
    ANSWER: Antibiotics are typically given prophylactically when perforation is suspected or if surgical intervention is required, but are not routinely used in uncomplicated cases.
  29. QUESTION: How does intussusception in premature infants differ from that in full-term infants?
    ANSWER: Intussusception in premature infants is rarer, often has atypical presentation, and may be associated with necrotizing enterocolitis or other complications of prematurity.
  30. QUESTION: What is the role of laparoscopy in the management of intussusception?
    ANSWER: Laparoscopy can be used for diagnostic purposes and for reduction of intussusception, offering a minimally invasive alternative to open surgery in selected cases.


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