An Introduction
Intussusception is a clinical condition where a part of the intestine folds into the adjacent segment of the intestine. Any alteration of normal peristaltic movement of the intestine creates the invagination in the segment of the small intestine (mainly ileum folds into cecum). The blood supply of the involved bowel segment is cut off and this may give rise to symptoms like abdominal pain, vomiting, and bloody stool (red currant jelly stool). It is seen commonly in children of age between 6 to 18 months of age. The condition requires urgent treatment and occasionally needs surgery.
What causes Intussusception?
The exact cause of Intussusception in children is not known in about 90% of the cases. [1] Works of the literature suggest various factors that could cause Intussusception in children and these are grouped as:
1. Intestinal infections.
2. Altered anatomy of the intestine.
3. Altered bowel movement.
4. Intestinal pathologies like Appendicitis, polyps, Meckel’s diverticulum, cystic fibrosis, hyperplasia of Peyer’s patches.
How common is Intussusception?
Intussusception is the disease of infants and young children and affects about 2000 children per year in the United States. It is the most common cause of abdominal emergency amongst young children and is the second most common cause of intestinal obstruction. [2]The condition peaks starting from 4months to 9 months of age and gradually decreases after 18months of age. Boys are more frequently affected than girls. [1]
Adults are also affected with Intussusception and the condition is more serious because it can be associated with neoplasm (cancer). Intussusception counts for 1% of bowel obstruction in adults. [1]
What are the risk factors?
Childrens when affected with disease conditions like bowel infections, polyps of the intestine, and cystic fibrosis have a higher risk of developing Intussusception. However, adults have separate known risk factors and they are endometriosis, intestinal tumors, and adhesions of the bowel wall.
What are the symptoms of Intussusception?
A child suffering from Intussusception initially develops intermittent abdominal pain. A child may also vomit and the vomitus may have a greenish stain of bile. Later on, as the disease advances, the child may develop rectal bleeding and the stool is typically “red currant jelly” in appearance. The pain may increase in intensity and the child cries excessively, and may even draw the knees up to their chest. The child may dehydrate and may become lethargic when the disease is severe.
The doctor (pediatrician) when examines the child feels a “sausage-shaped” mass in the abdomen. Digital rectal examination when performed by the doctor may feel for the fold (intussusceptum).
What tests should be performed to diagnose intussusception?
Ultrasound examination is the test of choice to diagnose the condition. “Target sign” or “Doughnut sign” is seen by the radiologist which confirms that the child is suffering from intussusception. However, when the Ultrasound cannot confirm the diagnosis CT scan of the abdomen has to be performed. Getting a CT scan in young children needs anesthesia and carries some risk. An “Air enema test” also can confirm the diagnosis and simultaneously can treat the condition as well.
How is this condition treated?
Intussusception requires rapid treatment as the small intestinal segment is cut off from its blood supply and further delay can put the segment of the intestine at the risk of necrosis. Necrosis can lead to the spreading of the infection and may even put the child at risk of sepsis and multiorgan failure. Early treatment carries a good prognosis and decreases the likelihood of the need for surgery.
Barium enema, water-soluble enema, or air-contrast enema can confirm as well as successfully treat the condition in almost 80% of the cases. [1] Enema, however, cannot reduce the folded intestinal wall in the rest 20% of the cases, and these subsets of patients need surgery. The surgeon manually reduces the part by squeezing the intestine either by open or laparoscopic method. If this is still not successful then the involved segment of the intestine is surgically cut off and removed.
Intussusception in adults has different treatment modalities. Adults usually have an organic lesion (neoplasm) which should be addressed. Treatment with air contrast enema is not preferred in adult intussusception.
What are other clinical diseases which mimic intussuception?
Numerous diseases can present with clinical features similar to intussusception. Appendicitis, abdominal hernia, colic, volvulus of intestine, testicular torsion, and blunt abdominal trauma have listed as important ones.
References:
1. Jain S, Haydel MJ. Child intussusception.
2. Marsicovetere P, Ivatury SJ, White B, Holubar SD. Approaches and Treatment of Intussusception, Volvulus, Rectal Prolapse, and Functional Disorders of the Colon, Rectum, and Anus: Intestinal Intussusception: Etiology, Diagnosis, and Treatment. Clinics in Colon and Rectal Surgery. 2017 Feb;30(1):30.
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