Intussusception

intussusception

This 2-year old male child presented with classical signs and symptoms of bowel intussusception. The abdominal pain was mainly located in the epigastric region with several bouts of vomiting. The parents also reported bloody stools and associated screaming episodes.

Intussusception occurs in all ethnic groups with a M:F ratio of 3:1 and mostly in age groups from 6months-2years. In older children, there is higher association with leading points. A loop of bowel infolds (and inverts) more distally into the lumen of the bowel, and then is carried distally by peristalsis. Approximately 90% of intussusceptions are ileocolic, in which the terminal ileum is carried through the ileocaecal valve into the colon, and may reach the rectum.

Ultrasound
Transverse: Ultrasound (US) shows a mass with a swirled appearance of alternating sonolucent and hyperechoic bowel wall of the loop-within-a-loop.

Longitudinal: US of the mass shows a submarine sandwich-like appearance of the intussuscipiens and the intussusceptum. There appear to be multiple layers, which represent the walls of the intussuscepted bowel loops

Some centres use US to monitor reduction of the intussusception with fluid introduced via the rectum. Unless perforation, peritonitis, or Henoch-Schönlein purpura is present, attempt radiologic reduction. The success rate is 50-85% depending on factors such as the length of time of the intussusception and degree of oedema of the loop and ileocaecal valve. Reduction is still possible, although more difficult, in intussusceptions in place more than 48 hours. Assume that patients older than 2 years have a lead point aetiology and investigate further.

‘Rule of 3’ is helpful to remember cautions to be taken during reduction –

  • 1. No more than 3 attempts at reduction
  • 2. Maintain fluid level at no more than 3 feet above the patient
  • 3. Maintain the pressure no more than 3 minutes against a non-moving loop intussuception
  • Reference: Gloria del-Pozo et al. Intussusception in Children: Current Concepts in Diagnosis and Enema Reduction. RadioGraphics 1999; 19: 299.

    Credit: Dr Abhijit Datir