An 11-month-old previously healthy male infant is brought to the Emergency Department (ED) for a 1-day history of fussiness and vomiting. His parents report that throughout the day he has had periods of crying and has been inconsolable, drawing his knees in towards his chest. Crying episodes last for about 20 minutes. Between episodes, he had been content. He then developed vomiting immediately after an episode of crying. He passed a bowel movement that appeared to have blood and mucus in the stool. He became more lethargic between crying episodes and his parents have become quite concerned. In the ED, he appeared moderately dehydrated, appeared sleepy, and was noted to have tenderness on palpation of the abdomen. After stabilization with intravenous fluids the physician ordered an abdominal ultrasound, which was concerning for intussusception (Figure 58-1A–C). The pediatric radiologist was able to reduce the intussusception with an air enema under fluoroscopic guidance. The patient tolerated the procedure well and recovered completely.
FIGURE 58-1
A. Intussusception in an 11-month-old infant. Transverse plane ultrasound images demonstrates a typical “target sign” with alternating concentric hypoechoic and hyperechoic bands of intussuscepted bowel walls. B. Sagittal plane ultrasound image of intussusception in the same patient demonstrating alternating layers of hypoechoic bowel wall and hyperechoic mesentery. C. Oblique sagittal plane ultrasound image of intussusception in the same patient demonstrates a typical “pseudokidney sign” with hypoechoic bowel wall mimicking the appearance of renal cortex and hyperechoic mesentery the renal sinus fat. (Used with permission from Ellen Park, MD.)
Most commonly diagnosed in children between the ages of 3 months and 36 months.
It is the most common form of intestinal obstruction in children less than 2 years of age.1–3
Male predominance.
Between 1998 and 1999, there was an increased incidence of intussusception in infants who had received the tetravalent rhesus—based rotavirus vaccination (RotaShield, Wyeth Laboratories, Inc., Marietta, PA).4 This vaccine was then taken off the market.
Post marketing surveillance of RotaTeq TM, a currently available pentavalent rotavirus vaccine, did not show an increased incidence of intussusception, and rotavirus immunization continues to be a recommended immunization in the primary immunization series.5,6
Most cases of intussusception are idiopathic.
It is thought that lymphoid hyperplasia of the Peyer’s Patches can act as a lead point in idiopathic cases.
Seasonal variation of the incidence of intussusception suggests a correlation with common gastrointestinal viruses, such as adenovirus.
The most common type of intussusception is ileocolic when the ileum enters the cecum. Ileoileocolic, colocolic, or small bowel-small bowel intussusceptions have also been described, but are less frequent.
When the intussusceptum invaginates into the intussuscipiens, the surrounding mesentery is pulled with it. This leads to intestinal edema.
Complications of intussusception include intestinal ischemia, perforation, peritonitis, and death.
Lead points for the intussusception are more common in children older than 2 years of age. Lead points may include: Meckel’s diverticulum, polyp, cyst, hematoma, or lymphoma.
Henoch-Schonlein purpura can cause a small bowel hematoma, which acts as a lead point for intussusception.
Cystic fibrosis: thick inspissated stool is the lead point.
Post-operative intussusception: within several days of intra-abdominal surgery (Figure 58-2).
Prior intussusception: Intussusception can recur in 5 to 10 percent of idiopathic cases.
FIGURE 58-2
Small bowel-small bowel post-operative intussusception (intussusception within the small bowel after previous abdominal surgery). This was successfully reduced in the operating room without bowel resection. (Used with permission from John DiFiore, MD.)
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