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Paediatric clinic - Intussusception

Surgeon Ms Joanne Minford and colleagues discuss this serious case of an infant with abdominal pain

A nine-month-old boy presents to his GP with a two-day history of non-bilious vomiting and crying.  His mother describes a dark red jelly-like substance in the nappy and explains that the child has periods of inconsolable distress, drawing his knees up to his abdomen. Initially he was well between these episodes but now seems pale and lethargic. His abdomen is generally tender and an upper abdominal mass is palpated. Intussusception is suspected and the child is transferred to a paediatric surgical centre, where an abdominal ultrasound confirms the diagnosis.  Air enema reduction is thought unwise because of the length of history, abdominal tenderness and ultrasound appearances.  Laparotomy and manual reduction is performed. No other gastrointestinal abnormality is identified.  The child recovers promptly after surgery and is discharged home three days later.

The problem

· Intussusception is a process in which a proximal segment of intestine (intussusceptum) invaginates into the adjoining distal intestinal lumen (intussucipian) causing bowel obstruction.

· Intussusception is the most common cause of bowel obstruction in infants1 and up to the age of three years2.  This condition still carries a mortality of up to 1%3.

· The incidence of intussusception is between 1.5 and four cases per 1000 live births, and is slightly more common in boys than girls3.  The peak age of incidence is between five and 10 months.

· Intussusception may be associated with a pathological lead point, but 95% of cases in children are idiopathic.

· Examples of pathological causes of intussusception include Meckel’s diverticulum, intestinal polyps and lymphoma.  Associations with systemic conditions such as Henoch-Schönlein purpura and cystic fibrosis are also described.

· Idiopathic intussusception is often associated with a recent viral infection causing enlargement of Peyer’s patches (lymphoid aggregates) within the wall of the intestine which act as a lead point.

· An association with vaccination against rotavirus infection has been described, but a Cochrane review found no significant difference in incidence when compared with placebo4.

 

Features

·  A history consistent with a preceding viral illness is common.

· A typical pattern of episodes of crying and drawing up of the knees, with intervals of relative normality or lethargy is often described by the carer.

· The child may appear seriously unwell without specific indication of an abdominal cause.

· Vomiting may occur and becomes bile-stained as obstruction progresses. 

· Mucosal ischaemia and infarction results in the passage of blood per rectum. 

· Features of systemic sepsis result from bowel infarction in advanced cases.

· The classical triad of abdominal pain, abdominal mass and blood per rectum is only seen in 30% of cases1. A high index of suspicion must be maintained, particularly where there is intermittent severe, colicky abdominal pain or systemic upset without adequate explanation.

 

Examination

· Early signs may be quite non-specific. 

· Pallor, lethargy, prolonged capillary refill, reduced urine output may reflect hypovolaemia.

· A mass in the right hypochondrium is sometimes palpable (possibly with Dance’s sign - an ‘empty feeling’ right lower quadrant). Abdominal distension and tenderness may be present.  Peritonitis suggests progression to infarction or perforation.

· Blood, or the typical ‘redcurrant jelly stool’, may be seen on examination of the nappy contents.

· Abdominal X-ray may reflect Dance’s sign or show bowel obstruction but has poor sensitivity for the detection of intussusception.  The definitive diagnostic test is abdominal ultrasound which shows a target-sign appearance of the intussuscepted bowel5.

 

Treatment

· Initial management is usually with pneumatic reduction under radiological screening. This is successful in over 80% of children. 

· Air enema carries a small risk of perforation (up to 1%) 5 and should be performed in a paediatric surgical centre.  Perforation is more likely if the history is long, or if ultrasound appearances show free peritoneal fluid or compromised blood supply in the intussuscepted bowel. 

· Pneumatic reduction is less likely to be successful in older children or if the history is longer than 24 hours.  Recurrences, which occur in up to 10% of children, can also be managed with air enema reduction 5.

· Surgery is required if there is evidence of perforation or peritonitis, or when air enema is unsuccessful or deemed unsafe, or in older cases, where a pathological lead point is likely.

 

References

1. Samad L, Marven S, El Bashir H, Sutcliffe AG, Cameron JC, Lynn R, Taylor BProspective surveillance study of the management of intussusception in UK and Irish infants. Br J Surg. 2012 Mar;99(3):411-5

2. Blanco F, Cuffari C, Chahine A et al. Medscape: Intussusception Treatment and Management. Available from http://emedicine.medscape.com/article/930708-overview. Accessed 07/01/13

3. American Paediatric Family Association: Intussusception. Available from http://www.pediatricsurgerymd.org/AM/Template.cfm?Section=List_Of_Conditions&TEMPLATE=/CM/ContentDisplay.cfm&ContentID=1549. Accessed 07/01/13

4. Soares-Weiser K, MacLehose H, Bergman H, et al. Vaccines for preventing rotavirus diarrhoea: vaccines in use. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD008521

5. Appletgate KE. Intussusception in Children: Diagnostic Imaging and Treatment in Evidence Based Imaging in Paediatrics, (2010) Santiago ML and Applegate KE (eds) pages 459-473

 

Ms Joanne Minford is a consultant paediatric surgeon, Mr Mohamed Mohamed is a paediatric surgeon and Mr Osama Abusanad is a paediatric surgeon at Alder Hey Children’s Hospital, Liverpool.

Alder Hey is one of Europe’s biggest and busiest children’s hospitals providing care for over 275,000 children and young people each year.  Alder Hey has a broad range of hospital and community services for direct referral from primary care.  The Trust also offers more complex tertiary services – it is the designated national centre for head and face surgery and a Centre of Excellence for children with cancer, spinal and brain disease. Alder Hey has been chosen to be a national centre for heart surgery, a respiratory ECMO surgery centre and one of just four specialist centres to provide surgery for drug-resistant epilepsy. For more information go to: www.alderhey.nhs.uk.

 

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