Intussusception

58 y/o male with no significant past medical 58 y/o male with no significant past medical history has a 3 day history of intermittent history has a 3 day history of intermittent cramping abdominal pain, vomiting, and cramping abdominal pain, vomiting, and

diarrhea. diarrhea.

Abdominal RadiographAbdominal Radiograph

Erect Abdominal RadiographErect Abdominal Radiograph

Barium StudyBarium Study

Intussusception Intussusception

The Invagination or telescoping of a The Invagination or telescoping of a proximal segment of bowel proximal segment of bowel (intussusceptum) into the lumen of a distal (intussusceptum) into the lumen of a distal segment (intussuscipiens) segment (intussuscipiens)

PathophysiologyPathophysiology

The invaginated segment is carried distally The invaginated segment is carried distally by peristalsis. by peristalsis. Mesnetery and vessels become involved Mesnetery and vessels become involved with the intraluminal loop and are with the intraluminal loop and are squeezed within the engulfing segment squeezed within the engulfing segment causing venous congestion. causing venous congestion. Types: enteroenteric, enterocolic, and Types: enteroenteric, enterocolic, and colocolic. colocolic.

Epidemiology (Children)Epidemiology (Children)

Most common in infants and children Most common in infants and children Accounts for 95% of all cases of Accounts for 95% of all cases of intussusception intussusception Ranks 2Ranks 2ndnd to appendicitis as a cause of to appendicitis as a cause of acute abdomenacute abdomen90% of the cases in children are idiopathic90% of the cases in children are idiopathicMost common in children of 6 months to 2 Most common in children of 6 months to 2 years in ageyears in age

Epidemiology (Adults)Epidemiology (Adults)

Rare in adults: accounts for 0.003% to Rare in adults: accounts for 0.003% to 0.02% of all hospital admissions 0.02% of all hospital admissions Accounts for 1% of all bowel obstructions Accounts for 1% of all bowel obstructions in adultsin adults80-90% of cases have and underlying 80-90% of cases have and underlying cause cause 65% are due to neoplasm65% are due to neoplasm

EpidemiologyEpidemiology

LocationLocation– Adults: ileoileal > ileocolic > colocolicAdults: ileoileal > ileocolic > colocolic– Children: ileocolic > ileoileal > colocolic Children: ileocolic > ileoileal > colocolic

EtiologyEtiologyIdiopathic (most common in children)Idiopathic (most common in children)NeoplasmNeoplasm– Benign Benign (more common in small bowel) (more common in small bowel)

Polyp, Leiomyoma, Lipoma, Lymphoma, Adenoma of appendix, Polyp, Leiomyoma, Lipoma, Lymphoma, Adenoma of appendix, Appendiceal stump granulomaAppendiceal stump granuloma

– MalignantMalignantPrimary (more common in colon)Primary (more common in colon)Metastatic (more common in small bowel) Metastatic (more common in small bowel)

EtiologyEtiology

Postoperative (more common in small Postoperative (more common in small bowel)bowel)Meckel’s diverticulum Meckel’s diverticulum Colitis Colitis Many cases thought to be related to viral Many cases thought to be related to viral gastroenteritis in childrengastroenteritis in children

History and Physical History and Physical

Children:Children:– Well nourished infantWell nourished infant– Cramping abdominal painCramping abdominal pain– Poor feeding / VomitingPoor feeding / Vomiting– Diarrhea (often currant-jelly stools)Diarrhea (often currant-jelly stools)– A palpable, tender, sausage shaped mass in A palpable, tender, sausage shaped mass in

the abdomenthe abdomen– Hx of abdominal surgeryHx of abdominal surgery

History and PhysicalHistory and Physical

AdultsAdults– Intermittent painIntermittent pain– Nausea and vomiting Nausea and vomiting – Often red blood per rectum Often red blood per rectum – Often nonspecific complaints Often nonspecific complaints

Abdominal Studies Abdominal Studies

Abdominal films often Abdominal films often show signs of small show signs of small bowel obstructionbowel obstruction

Abdominal StudiesAbdominal Studies

Erect films often show Erect films often show fluid levels in the fluid levels in the small bowelsmall bowel

Barium StudiesBarium Studies

Show a classic “coiled Show a classic “coiled spring” appearance spring” appearance due to trapping of due to trapping of contrast between contrast between layers of bowel. layers of bowel.

UltrasoundUltrasound

Ultrasound: Ultrasound: transverse scan transverse scan shows a target sign shows a target sign

CT (see-tee)CT (see-tee)

Target sign is also Target sign is also seen in CT.seen in CT.Can also see a Can also see a sausage shaped sausage shaped mass mass

ImagingImaging

CT is the most accurate detecting 78% of CT is the most accurate detecting 78% of the cases.the cases.Ultrasound is often used in childrenUltrasound is often used in childrenBarium studies are also very usefulBarium studies are also very useful

Treatment (children)Treatment (children)

Air reduction is the treatment of choice for Air reduction is the treatment of choice for children and is successful 75-90% of the children and is successful 75-90% of the time time Contrast reduction was more frequently Contrast reduction was more frequently used a decade agoused a decade ago

Treatment (Adults)Treatment (Adults)

Adults require surgical exploration and Adults require surgical exploration and resection of the intussuscepted bowel resection of the intussuscepted bowel loops loops Reduction is not recommended in adults Reduction is not recommended in adults due to the risk of spreading/seeding due to the risk of spreading/seeding malignant cells, potential perforation of the malignant cells, potential perforation of the intussuscepted bowel, and venous intussuscepted bowel, and venous embolization at the ulcerated mucosa area embolization at the ulcerated mucosa area

ReferencesReferences

Alfred Chahine, MDAlfred Chahine, MD IntussusceptionIntussusceptionEmedicine:Emedicine:

http://www.emedicine.com/ped/topic1208.htmhttp://www.emedicine.com/ped/topic1208.htm

Edwin C. Ouyang, Edwin C. Ouyang, Ileocolonic IntussusceptionIleocolonic Intussusception Medscape:Medscape:

http://www.medscape.com/viewarticle/510397_1http://www.medscape.com/viewarticle/510397_1