The Tale of the Telescoping Bowel: Intussusception

• Intussusception
• Appendicitis
• Incarcerated hernia , specifically inguinal hernias given his age.
• Testicular torsion
• Gastroenteritis

• A word that might get you first place on a medical spelling bee or is difficult to say many times very fast.
• Also, it’s when a portion of the proximal bowel slides into a more distal portion, almost like a telescope, that causes a momentary obstruction. It usually resolves, and then occurs again, explaining the colicky pain that can occur. It usually occurs in the ileocolic region.⁽¹⁾
• That obstruction can cause bowel wall edema and inflammation, which can lead to perforation and peritonitis. Thus, intussusception is a medical emergency.
• Most cases are idiopathic, but other etiologies may contribute by causing “lead” points in the bowel, often through inflammation. Some contributing factors are thought to be viral illness, intestinal infections, and other medical conditions such as Henoch-Schonlein purpura (HSP), inflammatory bowel disease, hemolytic uremic syndrome, or Meckel’s diverticulum. HSP, in particular, is associated with ileo-ileal intussusceptions.⁽¹⁾

• It occurs most often between the ages of 3 months and 3 years.

The classic triad is colicky abdominal pain, “red-currant jelly stools”, and a palpable sausage shaped mass, usually in the right upper quadrant.

• This triad is not often seen, so it shouldn’t be relied upon.
• Children often present with colicky or crampy abdominal pain, often occurring every 15-20 minutes, as the bowel obstructs and returns to its normal position. The mass may at times be palpated during this time as well. The child may have a normal exam, especially in between painful episodes.
• Intestinal inflammation and necrosis can lead to “red-currant jelly” stools.
• There may be episodes of bilious vomiting, especially when the obstruction does not reduce on it’s own.
• Edema and ischemia can lead to acidosis, sepsis, lethargy, and ultimately death if not corrected.

• Early diagnosis is key, and pediatric surgery should be contacted as soon as possible for reduction if intussusception is suspected.
• Most importantly, as always, you should stabilize your patient making sure their ABC’s are intact. Make sure you adequately resuscitate a lethargic child and work up your differential diagnoses with bloodwork and imaging as needed.
• Both X-Rays and ultrasound can be used to aid diagnosis, but if intussusception is strongly suspected, neither test is definitive if negative.
• Abdominal X-Rays might show dilated small bowel and a lack of gas in the cecum or a mass-like impression within the colonic gas. A prospective experimental study by Morrison et. al evaluating the use of abdominal X-Ray’s for diagnosis of intussusception, showed a sensitivity of 48% and specificity of 21%, when interpreted by pediatric emergency medicine physicians.⁽²⁾ Although radiographs may have a low sensitivity and specificity for diagnosis, they can still aid in the work-up of suspected intussusception. They may be helpful in looking for free peritoneal air, or ruling out other considerations in the differential.

• Ultrasound is an excellent tool for diagnosis and should be ordered if the diagnosis is in question.

• Ultrasound often shows a mass with a swirled appearance, with alternating hyper and hypoechoic areas representing the loop of bowel within another. This is called a “target” sign.
• Ultrasound has been shown to reach diagnostic accuracy approaching 100% in experienced hands in some studies, and other studies have shown a sensitivity of 98-100%, reducing the amount of false negatives, and a specificity ranging from 88-100%.⁽³⁾

• All children should have an IV placed, adequate fluid resuscitation, and an NG tube placed for decompression. Ultimately, the intussusception needs to be reduced, either surgically or non-surgically.
• The previous gold standard was a barium enema, which can be diagnostic and therapeutic. However, risks include peritonitis, infections, adhesions, and radiation exposure. Contraindications to non-operative treatment with a therapeutic enema include perforation and peritonitis.⁽⁴⁾
• Ultrasound-guided pneumatic reduction—AKA an “air enema”—and pneumatic reduction with fluoroscopic guidance has also been shown to have successful reduction rates. Currently, reduction with an air enema is the preferred treatment for a stable child, when trained personnel are available.⁽⁴⁾
• Ultimately, if none of these techniques are successful, surgical management is needed.

• After appropriate resuscitation, pain control, and diagnostics, your patient should be admitted, with pediatric surgery on board, to watch for recurrence or need for further definitive management.