Intussusception - Quick Consult
Last Updated / Reviewed: October 2024

Definition
Key History
Key Physical Exam
Risk Factors for Intussusception
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications

Definition

Intussusception is the invagination of part of the intestine into itself. It is the most common abdominal emergency in early childhood and the most common cause of intestinal obstruction in children between 4 months and 36 months of age. 60% are younger than one year old, and 80% are younger than two years old.

There is now an increasing body of evidence that suggests that viral triggers may play a role in some cases. The incidence of intussusception has a seasonal variation; approximately 30% of patients experience viral illness before the onset; and there appears to be a strong association with adenovirus infection.

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Key History

  • Sudden onset, intermittent, severe, progressively worsening abdominal pain.
  • Relief from pain between episodes.
  • Inconsolable crying.
  • Drawing legs up toward the abdomen.
  • Episodes typically occur at 15-to-20-minute intervals, increasing in severity and frequency over time.
  • Vomiting follows the onset of abdominal pain.
  • Lethargy as symptoms progress.
  • Stool with gross blood – in up to 70% of cases.
  • Stool mixed with mucus and blood – currant-jelly appearance in about 20% of cases.
  • Classic triad – currant-jelly stool, sausage-shaped abdominal mass in RUQ, and pain - seen in less than 15% of patients.
  • Up to 20% of infants have no obvious pain.
  • Approximately 33% of patients do not pass blood or mucus or develop an abdominal mass.
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Key Physical Exam

  • Sausage-shaped abdominal mass in RUQ
  • If event witnessed, infant drawing leg up to abdomen and in obvious severe pain.
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Risk Factors for Intussusception

  • Recent rotavirus vaccination
  • Antecedent viral illness
  • Adenovirus may be a trigger
  • Postoperative small bowel intussusception
  • Henoch-Schönlein purpura
  • Cystic fibrosis
  • Meckel’s diverticulum
  • Small bowel lymphoma
  • Intestinal parasites – ascaris lumbricoides
  • Celiac disease
  • Crohn’s disease
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Differential Diagnosis

  • Adhesive band small bowel obstruction
  • Appendicitis
  • Gastroenteritis
  • Incarcerated hernia
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Diagnostic Testing

Text / literature information and recommendations include:
  1. Imaging:
    • If intussusception is suspected, the initial evaluation should include two-view plain abdominal radiographs, mainly to exclude perforation.
    • Ultrasound – Should be the first study when the diagnosis is not clear at presentation; accuracy of ultrasound for intussusception approaches 100%.
    • CT – Can identify intussusception, but it is time consuming and best used for patients for whom the other imaging modalities are unrevealing.
    • Air contrast enema study – Is the standard procedure for diagnosis and treatment for children with high suspicion of intussusception.
  2. Labs:
    • CBC
    • Urinalysis
    • Electrolytes
    • Stool guaiac
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Clinical Risk and Safety Pearls

  • Maintain a high index of suspicion for intussusception in this age group.
  • The initial presenting sign may be lethargy or altered consciousness alone. Thus, intussusception is often confused with sepsis.
  • Intussusception should be considered in the evaluation of lethargy or altered consciousness, especially in infants.
  • Prior to the air contrast enema study, the patient should be stabilized and prepped for surgery in the event surgery becomes necessary. The surgical team should be notified before the enema is performed.
  • The lead point is the leading edge of the intussusception and is usually seen in older children; it may be due to an anatomic anomaly such as Meckel’s diverticulum, polyp or lymphoma.
  • Classic triad – Currant-jelly stool, sausage-shaped abdominal mass in RUQ, and pain - seen in less than 15% of patients.
  • Approximately 33% of patients do not pass blood or mucus or develop an abdominal mass.
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Treatment

Common text / literature recommendations include:
  1. ABCs
  2. Reduction is most commonly performed under fluoroscopic guidance, using either hydrostatic (saline or contrast) or pneumatic (air) enemas.
  3. Surgery is indicated when nonsurgical attempts at reduction are incomplete or unsuccessful.
  4. Enema reduction is contraindicated if there is free air, air fluid levels, peritonitis, perforation, hypovolemic shock, or currant-jelly stools for more than 24 hours.
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Complications

  • Perforation of bowel – Risk is higher the longer the intussusception has been present.
  • Recurrence after successful nonoperative reduction is about 10%. Recurrence is not necessarily an indication for surgery. Each recurrence should be handled as if it were the first episode.
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Arbizu RA, Aljomah G, Kozielski R, et al. Intussusception associated with adenovirus. J Pediatr Gastroenterol Nutr. 2014; 59:e41.

Carroll AG, Kavanagh RG, Ni Leidhin C, et al. Comparative Effectiveness of Imaging Modalities for the Diagnosis and Treatment of Intussusception: A Critically Appraised Topic. Acad Radiol. 2017; 24:521.

Charles T, Penninga L, Reurings JC, Berry MC. Intussusception in children: A clinical review. Acta Chir Belg. 2015;115(5):327-333.

Edwards EA, Pigg N, Courtier J, Zapala MA, MacKenzie JD, Phelps AS. Intussusception: Past, present and future. Pediatr Radiol. 2017;47(9):1101-1108.

Fleischman R. Chapter 133: Acute Abdominal Pain in Infants and Children. In: Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2020.

Gluckman S, Karpelowsky J, Webster AC, McGee RG. Management for intussusception in children. Cochrane Database Syst Rev. 2017;6.

Mandeville K, Chien M, Willyerd FA, et al. Intussusception: clinical presentations and imaging characteristics. Pediatr Emerg Care. 2012; 28:842.

Marsicovetere P, Ivatury SJ, White B, Holubar SD. Intestinal Intussusception: Etiology, Diagnosis, and Treatment. Clin Colon Rectal Surg. 2017 Feb;30(1):30-39. doi: 10.1055/s-0036-1593429. PMID: 28144210; PMCID: PMC5179276.

Ntoulia A, Tharakan SJ, Reid JR, Mahboubi S. Failed Intussusception Reduction in Children: Correlation Between Radiologic, Surgical, and Pathologic Findings. AJR Am J Roentgenol. 2016; 207:424.

Thanh Xuan N, Huu Son N, Huu Thien H. Treatment Outcome of Acute Intussusception in Children Under Two Years of Age: A Prospective Cohort Study. Cureus. 2020 Apr 18;12(4):e7729. doi: 10.7759/cureus.7729. PMID: 32432007; PMCID: PMC7234032.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.
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