Intussusception in a 6 year old

Images and text Genevieve Carbonatto

A 6 year old girl presents to the Emergency department with dysuria and abdominal pain. The symptoms have been  intermittent until the morning of the presentation when the symptoms were constant and also associated with a left sided limp. She is unwilling to weight bear on her left leg. She had not had a bowel motion since the night before. She has had no vomiting. On examination there is full painless passive movement of the left and right hips. She is tender in the left iliac fossa. No rebound tenderness or guarding. Urine microscopy shows no white, red cells or organisms. An abdominal  xray is performed

Xray shows faecal matter within the caecum, ascending colon, sigmoid colon and rectum with paucity of gas within the descending colon. No pneumoperitoneum

Examination on ultrasound of the gut revealed the following:

Small bowel dilated with to and fro movement of intestinal contents suggestive of bowel obstruction or ileus

Target sign in left anterior lower quadrant showing intussesception

Same structure but seen longitudinally, showing intussusceptum in intussuscepiens

 

Shortly after the ultrasound the patient vomited a large amount of green vomit followed by ongoing smaller clear vomits.

Her biochemistry and full blood count were unremarkable. She was transferred to a paediatric hospital where she seemed to improve. Because this intussusception was small bowel in nature ie ileo-ileal, and her symptoms improved she was observed. The intussusception self resolved without the need for surgical intervention.

Discussion

Definition: Intussusception is the invagination of a  part of the intestine into itself. It is the most common abdominal emergency  in children.

Age : 80 –  90 % of intussusception occurs in children under 2 years of age. 10 % occur in children over 5 and 3 -4 % in children over 10 years of age

Causes:

75% of childhood intussusception is idiopathic. Intussusception has been associated with

  • Viral illnesses. 30 % of children with intussusception have an associated or recent viral illness. There is a seasonal variation with peaks of intussusception during seasonal viral gastroenteritis such as adenovirus
  • Rotavirus vaccine which has since been removed from the market. The association with viral infections may be due to enteric lymphoid hyperplasia which may act as lead points.
  • Bacterial gastroenteritis

Pathological lead points are identified in 25 % of children only and are usually found in children over 5 or under 3 months. Lead points include : Meckel’s diverticulum (most common lead point) polyps, small bowel lymphoma, duplication cysts, vascular malformations,inverted appendiceal stumps, parasites, Henoch-Schonlein purpura, cystic fibrosis, haemolytic -uremic syndrome, chrone’s disease

Types : 90 % are ileo-colic.  Other types include ileo- ileal, ileo-ileo-colic, jejuno-jenunal,jejuno-ileal or colo-colic

Clinical presentation:

  • Less than 25% of children present with classic symptoms of intermittent abdominal pain, abdominal mass, vomiting  and red jelly stool and lethargy
  • Intussusception can also be asymptomatic and be found incidentally on imaging for other reasons
  • Due to the nonspecific nature of the presentations, there should be a high index of suspicion of intussusception in children

Physical examination : Minimal abdominal tenderness or just focal tenderness usually in the RUQ (as most of intussusceptions are ileo-colic). Palpable sausage shaped mass (present in less than 25% of patients )

Diagnostic testing:

  • Ultrasonography has a 100% sensitivity and specificity in experienced sonographers and is the imaging of choice. The classic sign is the “Target “sign when the bowel is seen in the short axis.  Ultrasound can also help identify other differential diagnoses of abdominal pain in children such as appendicitis, ovarian torsion or incarcerated hernia.
  • Abdominal Xray is not sensitive in diagnosing intussusception but may be useful to exclude other pathology such as perforation.
  • CT scan can identify intusscusception but has the disadvantage of radiation exposure and requires sedation

Management:

Hydrostatic or pneumatic pressure reduction

  • Ileocolic intussusception is best managed non operatively by using pneumatic (air or carbon dioxide) or hydrostatic pressure by enema with fluoroscopic or ultrasound guidance. Ultrasound guidance is only possible with hydrostatic pressure reduction (barium or saline). Carbon dioxide has the advantage of being easily absorbed when compared to air and is therefore more comfortable for the patient.
  • Perforation occurs in 1% of patients undergoing pneumatic or hydrostatic reduction usually on the distal side of the intussusception
  • Success rate of 70 -85% using this technique

Surgery

  • If acutely ill or have evidence of perforation
  • If there is no ability to perform hydrostatic reduction and pneumatic pressure reduction safely

Small bowel intussusception

  • Less likely to respond to nonoperative treatment but more likely to resolve spontaneously

Teaching point: It is worth considering intussusception in patients over 2 years of age. The clinical presentation as in this case is not always straight forward. A high index of suspicion is necessary. The ability to carefully look at the bowel using point of care ultrasound is invaluable in these patients

References

  1. Emerg Med Australas. 2007 Feb;19(1):45-50. Paediatric intussusception: epidemiology and outcome. Blanch AJ1, Perel SB, Acworth JP
  2. N Z Med J. 2010 Oct 15;123(1324):32-40. Ten-year review of intussusception at Starship Hospital: 1998-2007. Kodikara H1, Lynch A, Morreau P, Vogel S
  3. Acta Chir Belg. 2015 Sep-Oct;115(5):327-33. Intussusception in Children: A Clinical Review. Charles T1, Penninga L, Reurings JC, Berry MC.
  4. https://www.uptodate.com/contents/intussusception-in-children
  5. Journal of Pediatric Surgery Case Reports Volume 2, Issue 5, May 2014, Pages 228-23 open access Reports Left sided colo-colic intussusception in a child with acute lymphoblastic leukemia: A case report and systematic review of the literature

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