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intussusception

Telescoping of one segment of the bowel into the lumen of an adjacent segment. Etiology: 1) idiopathic a) 90% of cases in children are idiopathic b) viral-induced hypertrophy of Peyer's patches may play a role 2) malignant tumors a) colon carcinoma, small intestinal carcinoma [3] b) leiomyosarcoma of the small intestine c) metastatic melanoma d) Kaposi's sarcoma 3) benign tumors a) lipoma b) adenomatous polyp c) hemangioma d) neurofibroma e) hamartoma - Peutz-Jeghers syndrome [3] f) villous adenoma 4) other predisposing factors a) AIDS b) sprue c) hemophilia d) nephrotic syndrome e) ascariasis f) cystic fibrosis g) Meckel's diverticulum h) Henoch-Schonlein purpura i) post-operative state Epidemiology: 1) in children, intussusception is the most common cause of intestinal obstruction & the 2nd most common cause acute abdominal pain after appendicitis 2) peak incidence in children 3-9 months of age, 3) 80% of patients are < 2 years of age 4) 5-10% of cases occur in adults 5) male/female ratio 2/1 6) 2-4 cases/1000 live births Pathology: 1) peristalsis subsequent to intussusception results in further telescoping of bowel 2) mesentery & vasculature accompany telescoped bowel 3) bowel infarction may result 4) most common at or proximal to the ileocecal valve Clinical manifestations: 1) paroxysms of abdominal pain a) duration 4-5 minutes b) interval 5-30 minutes c) localizes to the umbilicus 2) loud crying in infants 3) flexing at hips 4) progressive lethargy 5) nausea, vomiting 6) diarrhea 7) dehydration 8) hematochezia may occur with prolonged obstruction - a sign of vascular compromise 9) mucus in stool 10) abdominal tenderness 11) abdominal mass - palpable mass in right upper quadrant may occur with leocolic intussusception 12) hyperactive or hypoactive bowel sounds 13) physical examination is normal in 25% of cases Laboratory: 1) serum electrolytes 2) complete blood count (CBC) 3) urinalysis Radiology: 1) plain abdominal radiograph a) dilated loops of bowel b) soft tissue mass c) bowel obstruction d) abdominal films may be normal in 25% of cases 2) barium contrast enema a) may be both diagnostic & therapeutic b) cervix-like mass c) coiled-spring appearance of contrast between 2 segments of bowel d) contraindicated in patients with peritonitis, bowel perforation or hypovolemic shock 3) computed tomography imaging modality of choice - target sign [3] 4) abdominal ultrasound Differential diagnosis: 1) neonates - congenital intestinal atresia or stenosis - disorders of motility - necrotizing enterocolitis 2) infants & children - gastroenteritis - colic - gastroesophageal reflux disease (GERD) - sepsis - pyloric stenosis - appendicitis - bowel malrotation - volvulus - Meckel's diverticulum - adhesions - inflammatory bowel disease 3) adolescents & adults: as for infants & children plus: - testicular or ovarian disorders - pelvic inflammatory disease (PID) - ectopic pregnancy - ruptured GI tumor 4) misdiagnosis: 55-60% with gastroenteritis being most common incorrect diagnosis Management: 1) morbidity & mortality increase markedly if intussusception is not reduced in the 1st 24-48 hours 2) supportive therapy a) nasogastric decompression of bowel b) intravenous hydration & electrolyte balance c) broad spectrum antibiotics if bowel perforation or necrosis suspected d) nothing by mouth until intussusception reduced e) may begin refeeding after return of normal bowel sounds 3) hydrostatic reduction under fluoroscopy a) infants & young children b) contraindicated in adults c) relatively contraindicated in neonates & older children d) 85-90% success rate e) recurrence rate <10% f) risk of bowel perforation <0.5% 4) surgical reduction a) indicated in patients with contraindications to hydrostatic reduction or failed reduction b) manual reduction contraindicated if: - evidence of bowel ischemia - long loop of bowel to be resected c) resection of involved segment of bowel if manual reduction is unsuccessful or contraindicated d) 100% success rate e) recurrence 2-5%

General

intestinal obstruction

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 339-40
  2. Medical Knowledge Self Assessment Program (MKSAP) 16 American College of Physicians, Philadelphia 2012
  3. Burgers P, Dawson I Enteroenteric Intussusception. N Engl J Med 2014; 371:2217. December 4, 2014 PMID: 25470697 http://www.nejm.org/doi/full/10.1056/NEJMicm1313388