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Chapter 58: Intussusception

Allison W. Brindle, MD; Ellen Park, MD; John DiFiore, MD

Patient Story

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.)

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Introduction

Intussusception refers to the “telescoping” or invagination of one portion of the intestine (the intussusceptum) into a more distal portion, the intussuscipiens. It leads to an intestinal obstruction.

Epidemiology

  • 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

Etiology and Pathophysiology

  • 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. ...

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