Intussception: YouTube Videos and Emedicine Excerpts

Outstanding YouTube video by Dr. Larry Mellick, Life Threatening Intussception Emergency, showing a child with intussception and showing the reduction with an air contrast enema.

Entered ultrasound for intussception into YouTube search and the following came up and found:

[Ultrasound for Dx of] Intussusception,11:18, Aug 27, 2012, from the ACMC EM Residency Channel (the video cites the following 2004 article as the only article addressing operator experience, Intussusception in children: can we rely on screening sonography performed by junior residents?. Unfortunately, the abstract does not contain enough information to evaluate the article and the full article is behind the publisher’s firewall.

INTUSSCEPTION – RLQ 7:54, Aug 8, 2012. This is an excellent ultrasound exam of intussception in an adult. Because of the noise of the ultrasound scanner, the sound is suboptimal–but don’t be deterred by that. This is an excellent teaching video. The author of this video, Dr. Tahir Ahmed, has numerous ultrasound videos on his YouTube channel.

All that follows below is from

Background and Patient Education from emedicine accessed 4-19-2014:

Intussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction. A common cause of abdominal pain in children, intussusception is suggested readily in pediatric practice based on a classic triad of signs and symptoms: vomiting, abdominal pain, and passage of blood per rectum. (See History and Physical Examination.)

Intussusception presents in 2 variants: idiopathic intussusception, which usually starts at the ileocolic junction and affects infants and toddlers, and enteroenteral intussusception (jejunojejunal, jejunoileal, ileoileal), which occurs in older children. The latter is associated with special medical situations (eg, Henoch-Schönlein purpura [HSP], cystic fibrosis, hematologic dyscrasias) or may be secondary to a lead point and occasionally occur in the postoperative period. Intussusception is demonstrated in the images below. (See Etiology and Pathophysiology.)

[The above link also includes imaging examples of intussception of x-ray, air contrast enema, barium enema, CT scan, and ultrasound scan.]

Educate parents and caregivers of a patient treated with nonoperative reduction with regard to the risks and signs and symptoms of recurrence so that the initiation of care is not delayed.

Physical Examination and Nonoperative Reduction from emedicine accessed 4-19-2014:

The hallmark physical findings in intussusception are a right hypochondrium sausage-shaped mass and emptiness in the right lower quadrant (Dance sign). This mass is hard to detect and is best palpated between spasms of colic, when the infant is quiet. Abdominal distention frequently is found if the obstruction is complete.

Therapeutic enemas include the following:

Hydrostatic: With barium or water-soluble contrast
Pneumatic: With air insufflation; this is the treatment of choice in many institutions, and the risk of major complications with this technique is small.

Lead points from emedicine accessed 4-19-2014

In approximately 2-12% of children with intussusception, a surgical lead point is found. Occurrence of surgical lead points increases with age and indicates that the probability of nonoperative reduction is highly unlikely. Examples of lead points are as follows:

  • Meckel diverticulum[4]
  • Enlarged mesenteric lymph node
  • Benign or malignant tumors of the mesentery or of the intestine, including lymphoma, polyps, ganglioneuroma,[5] and hamartomas associated with Peutz-Jeghers syndrome
  • and others (see Lead points link above)

Henoch-Schönlein purpura and other causes of intussception from emedicine accessed 4-19-2014:

Children with HSP often present with abdominal pain secondary to vasculitis in the mesenteric, pancreatic, and intestinal circulation. If pain precedes cutaneous manifestations, differentiating HSP from appendicitis, gastroenteritis, intussusception, or other causes of abdominal pain is difficult.

Occasionally, children with HSP develop submucosal hematomas, which can act as lead points and cause small bowel intussusception. Elucidating the cause of the pain is essential in any child in whom HSP is suspected.

Since the intussusception associated with HSP is usually enteroenteral (small bowel to small bowel), these patients require surgery rather than an enema.

During the initial investigation, obtain supine and upright plain radiographs of the abdomen to identify the small bowel obstruction associated with intussusception. If radiographic findings are normal, assume the patient with HSP has mesenteric vasculitis and treat with steroids.

[Other causes of intussception that are discussed in the above link include hemophilia and other coagulation disorders, ostoperative intussusceptions,  indwelling jejunal catheters, cystic fibrosis, and other causes.]

Epidemiology from emedicine accessed 4-19-2014

A wide geographic variation in incidence of intussusception among countries and cities within countries makes determining a true prevalence of the disease difficult. Studies on the absolute prevalence of intussusception in the United States are not available. Its estimated incidence is approximately 1 case per 2000 live births. In Great Britain, incidence varies from 1.6-4 cases per 1000 live births.

Overall, the male-to-female ratio is approximately 3:1. With advancing age, gender difference becomes marked; in patients older than 4 years, the male-to-female ratio is 8:1.

Two thirds of children with intussusception are younger than 1 year; most commonly, intussusception occurs in infants aged 5-10 months. Intussusception is the most common cause of intestinal obstruction in patients aged 5 months to 3 years.

Intussusception can account for as many as 25% of abdominal surgical emergencies in children younger than 5 years, exceeding the incidence of appendicitis. Although extremely rare, intussusception has been reported in the neonatal period.

History from emedicine accessed 4-19-2014:

The constellation of signs and symptoms of intussusception represents one of the most classic presentations of any pediatric illness; however, the classic triad of vomiting, abdominal pain, and passage of blood per rectum occurs in only one third of patients.

Initially, vomiting is nonbilious and reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious. Any child with bilious vomiting is assumed to have a condition that must be treated surgically until proven otherwise.

Parents also report the passage of stools that look like currant jelly. This is a mixture of mucus, sloughed mucosa, and shed blood. Diarrhea can also be an early sign of intussusception.

Lethargy is a relatively common presenting symptom with intussusception. The reason lethargy occurs is unknown, because lethargy has not been described with other forms of intestinal obstruction. Lethargy can be the sole presenting symptom, which makes the diagnosis challenging. Patients are found to have an intestinal process late, after initiation of a septic workup.

Imaging in Child Intussusception from emedicine/medscape accessed 4-19-2014:

Preferred examination

In some countries, history and physical findings are sufficient criteria for undertaking reduction procedures for intussusception. However, abdominal radiography and ultrasonography may be useful studies, and in some institutions, reduction of the intussusception takes place under ultrasonographic guidance with fluid or air.

Abdominal radiography may used to search for dilated small bowel and an absence of gas in the region of the cecum (see the image below). In some cases, a mass impression within the colonic gas indicates an intraluminal mass created by the intussuscepting loop.

Limitation of techniques

Intussusception may not be apparent on plain-film abdominal radiography. Radiographs may appear indeterminate or normal; therefore, the presence of an unremarkable abdominal radiograph should not be the basis for excluding a diagnosis of intussusception.

Ultrasonographic examination is almost always positive, although overlying loops of air-containing bowel may obscure intussusception (see the following image).

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