Consider the diagnosis of intussusception in a child with paroxysmal bouts of abdominalpain or emesis
Consider the diagnosis of intussusception in a child with paroxysmal bouts of abdominalpain or emesis: Excerpt from Avoiding Common Pediatric Errors
Michael Clemmens, MD
What to Do - Interpret the Data
Intussusception is the most common cause of bowel obstruction in children
afterthenewbornperiod.Theincidencepeaksinlateinfancybutmaybeseen
at any age. Intussusception occurs when a part of the bowel collapses into
the segment immediately distal to it, much in the way that a telescope collapses upon itself. The immediate consequence is restriction of venous flow,
resulting in engorgement of the involved section and subsequent bowel obstruction. Arterial flow may eventually be compromised, leading to necrotic
bowel and perforation. Untreated intussusception may lead to peritonitis,
sepsis, and death. However, an early diagnosis minimizes the occurrences of
these complications.
In children younger than 5 years, approximately 75% of classic ileocolic
intussusceptions are idiopathic. After that age, the presence of a lead point
is more common. The lead point may be a Meckel diverticulum, lymphoma,
duplication, hypertrophied lymphoid tissue, or associated with a bowel wall
lesion from Henoch-Schönlein purpura.
The initial history may be suggestive of gastroenteritis, with vomiting
and abdominal pain as the presenting symptoms. However, in cases of intussusception, the vomiting may be clear initially, but it often becomes bilious
with time. Bilious emesis in any child implies the presence of a bowel obstruction until proven otherwise. Also, in intussusception, the pain is more
severe and classically occurs in waves every 10 to 20 minutes. The stool
may be normal, have the appearance of currant jelly, or be grossly bloody.
A history of lethargy is common, especially between bouts of pain. A viral
syndrome frequently precedes intussusception.
The physical examination may be normal in children with intussusception. The child's general appearance may be lethargic and suggestive of
central nervous system disease. The abdomen may be flat, soft, and non-
tender. However, the classic finding is a right-sided, sausage-shaped mass,
which is the intussusception. A more nondescript mass may be present or
theremaybenomassatall.Peritonealsignsareonlypresentlateinthecourse
of the disease. A rectal exam may be helpful by confirming the presence of
blood in the stool.
The majority of children with intussusception have some of these findings.Theclinicaltriadofbiliousemesis,anabdominalmass,andcurrantjelly
stools is the exception rather than the rule. The clinician should consider
the diagnosis of intussusception in any child with altered sensorium, bilious
emesis, severe abdominal pain, abdominal mass, or blood in the stool.
Plainabdominalradiographsmaydemonstrateabowelobstructionwith
dilatedloopsandthepresenceofair-fluidlevels.However,earlyinthecourse,
the plain films may be normal. The diagnostic test of choice is the contrast
enema. This study may also be therapeutic, reducing the intussusception
in more than 80% of cases. Barium is most commonly used, although air
or saline may also suffice. When the contrast meets the obstruction, the
diagnosis is established. The contrast is then instilled with slightly more
pressure until the intussusception is reduced and there is free flow beyond
the blockage. Failure to obtain reduction increases the likelihood that a lead
point is present.
Prior to obtaining contrast studies, the patient should be stabilized.
Most patients require intravenous hydration, bowel decompression with a
nasogastric tube, and pain control. Antibiotics are administered when peritonitis is suspected. In addition, a contrast enema should not be attempted
without the immediate availability of a pediatric surgeon because of the risk
of perforation. When contrast enema does not reduce the intussusception,
the next step is surgery. Manual reduction at laparotomy can usually be accomplished. Resection is required if nonviable bowel or a pathological lead
point are found.
Suggested Readings
Davis CF, McCabe AJ, Raine PA. The ins and outs of intussusception: history and management
over the past 50 years. J Pediatr Surg. 2003;38(7 Suppl):60–64.
del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in
diagnosis and enema reduction. Radiographics. 1999;19:299–319.
West KW, Grosfeld JL. Intussusception. In: Wyllie R, Hyams JS. Pediatric Gastrointestinal
Disease: Pathophysiology, Diagnosis, Management. Philadelphia: WB Saunders; 1999:427.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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