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Key Features

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Essentials of Diagnosis
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  • Most common cause of bowel obstruction in the first 2 years of life

  • Most common location is ileocolic and 85% of cases are idiopathic

  • Ultrasound is the most sensitive and specific diagnostic modality

  • Air enema is the best therapeutic approach in the stable patient, with successful reduction in 75% of cases

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General Considerations
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  • Defined as the invagination of one segment of intestine into another segment

  • Most commonly starts just proximal to the ileocecal valve and extends for varying distances into the colon, but can occur anywhere along the small and large bowel

  • Swelling, hemorrhage, incarceration, vascular compromise, and necrosis of the intussuscepted ileum may occur, potentially resulting in intestinal perforation and peritonitis

  • Implicated primary causes

    • Small bowel polyp

    • Meckel diverticulum

    • Omphalomesenteric remnant

    • Duplication

    • Lymphoma

    • Lipoma

    • Parasites

    • Foreign bodies

    • Viral enteritis with hypertrophy of Peyer patches

  • Intussusception of the small bowel can also be seen in celiac disease, cystic fibrosis, and Henoch-Schönlein purpura

  • In 85% of cases, the cause is idiopathic but the likelihood of identifying a cause increases with the age of the patient

  • In children older than 6 years, lymphoma is the most common cause

  • It is three times more common in males than in females

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Clinical Findings

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  • Characteristically, recurring paroxysms of abdominal pain with screaming and drawing up of the knees develops in a previously healthy infant 3–12 months of age

  • Vomiting and diarrhea occur soon afterward (90% of cases)

  • Bloody bowel movements with mucus appear within the next 12 hours (50%)

  • Child is characteristically lethargic between paroxysms and may be febrile

  • Abdomen is tender and often distended

  • A sausage-shaped mass may be palpated, usually in the upper mid abdomen

  • The likelihood of bowel compromise increases with the duration of symptoms

  • In older children, sudden attacks of abdominal pain may be related to chronic recurrent intussusception with spontaneous reduction

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Diagnosis

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  • The constellation of abdominal pain, lethargy, vomiting, and a suspicious abdominal radiograph was found to have a sensitivity of 95% in identifying intussusceptions in children

  • Abdominal radiographs alone, however, are poorly sensitive for the diagnosis of intussusception

  • Abdominal ultrasound carries sensitivity for diagnosis of intussusception of 98–100%

  • Barium enema and air enema are both diagnostic and therapeutic

  • Reduction of the intussusception by barium enema should not be attempted if signs of strangulated bowel, perforation, or toxicity are present

  • Air insufflation of the colon under fluoroscopic guidance is a safe alternative to barium enema that has excellent diagnostic sensitivity and specificity without the risk of contaminating the abdominal cavity with barium

  • Rates of successful reduction by air enema approach 75%

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Treatment

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  • Surgery is required for extremely ill patients, in patients with evidence of bowel perforation, or in those in whom hydrostatic or pneumatic reduction has been unsuccessful (25%)

  • Surgery has the advantage of identifying a ...

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