Intussusception: A Guide to Diagnosis

and Intervention in Children

Genevieve Daftary,
Harvard Medical School,
Year III
Gillian Lieberman, MD
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
2
The Anatomy of Intussusception

Intussusception occurs when
a segment of bowel, the
intussusceptum, telescopes
into a more distant segment
of bowel, the intussuscipiens

The most common type is
ileocolic (pictured here),
followed by ileoileocolic,
ileoileas, and colocolic
Radiologic Clinics of North America 1997
www.yoursurgery/Intussusception.jpg
Intussuscipiens
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Radiologic Clinics of North America 1997; Pediatrics 2000
3
Demographics

Most common acute abdominal disorder of early
childhood (56 children/ 100,000/ year in US)

Boys 4xs more frequently than girls

Majority of patients between 3 mon and 3 yr
Peak incidence between 5 and 9 months
75% under 2 years

Seasonal peaks in spring and autumn

95% no pathologic lead point

5-10% recognizable lead point

Some evidence of significant attributable risk with
rotavirus vaccine administration
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Radiologic Clinics of North America 1996,1997
4
Etiologies of Intussusception

Idiopathic: no defined lead point
Association with viral illness (adenovirus)
Hypertrophy of lymphoid tissue

Recognizable cause for lead point
Meckels diverticulum
Intestinal polyp
Enteric duplication
Lymphoma
Intramural hematoma
Ameboma
Henoch-Schnlein purpura
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Radiologic Clinics of North America 1996, 1997
5
Clinical Presentation: VARIABLE

Intermittent, colicky cramping, pain

Later development of lethargy and somnolence

Vomiting (may be bile-stained)

Current jelly stool (blood and mucus)

Sausage shaped mass

Distention and tenderness
Classic Triad: abdominal pain, currant jelly stool,
palpable abdominal mass (<50%)
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Radiologic Clinics of North America 1997
6
Complications
Typically do not occur within the first 24 hrs

Bowel obstruction

Intestinal ischemia

Perforation

Shock

Sepsis

Dehydration
thus we have a window of opportunity in which
to treat and avoid surgery.
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
AJ R 2005; Rad Clinics of N Amer 1996
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Overview of Screening Tools

Abdominal Radiograph
Screen for other Dxs and free air
Can be safely omitted in the presence of US
45% sensitivity

Abdominal Sonography
Diagnostic accuracy near 100%, eval of reducibility, +/- lead
point, post reduction, ischemia

Abdominal CT scan
Accuracy approaching 100%; especially good for lead points
High cost, risk of radiation, and risk of sedation in children
make it unpractical
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
8
Patient One: Presentation

6 year old female

3 weeks ago: URI w/ fever, vomiting, diarrhea
(greenish, non-bloody), abdominal pain;
seemed to resolve after 3 days

1 week ago: increasingly lethargic and irritable,
w/vomiting and fever
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
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Patient One: Supine KUB
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
10
Patient One: Supine KUB
Paucity of Gas
on Right Side of
Abdomen
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Radilogic Clinics of North America 1996; Amer J Rad 2005
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Abdominal Radiograph

Signs of Intussusception
Soft tissue mass
Target sign: created by mesenteric fat
Absence of cecal gas and stool
Meniscus sign: crescent of gas outlining intussusceptum
Loss of visualization of the tip of the liver
Paucity of bowel gas

Poor sensitivity for dx of intussusception: 45%

May be useful to exclude other Dx

Determine presence of free air (contraindication to non-
surgical reduction with contrast)

May be safely omitted if ultrasound is available
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
RadioGraphics 1999
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Target & Meniscus Signs
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
RadioGraphics 1999
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Target & Meniscus Signs
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
14
Patient One: Longitudinal Ultrasound
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
15
Patient One: Longitudinal Ultrasound
Telescoping
Bowel
Sandwich Sign/
Pseudokidney
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
16
Patient One: Axial Ultrasound
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
17
Patient One: Axial Ultrasound
Doughnut/
Target Sign
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
18
Patient One: Doppler Ultrasound
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
19
Patient One: Doppler Ultrasound
Blood flow
maintained
Rule out
ischemia of
involved bowel
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Rad Clinics of N Amer 1997
20
Abdominal Ultrasound

Replaced abdominal radiograph as primary
screening modality

Sensitivity 98 -100%; specificity 88 -100%

Appearance: outer hypoechoic region
surrounding an echogenic center or multiple
concentric rings

Use Doppler to determine bowel ischemia;
guides reduction decisions

Guide hydrostatic and pneumatic reduction
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
RadioGraphics 1999
21
Ultrasound Cross-Sections
A =intussuscipiens
B =everted intussusceptum
C =central intussusceptum
M =mesentery
L = lymph nodes
MS =contacting mucosal
surfaces
S =contacting serosal
surfaces
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
22
Patient One: Air Enema
Normal bowel gas pattern: Spontaneous Reduction
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
RadioGraphics 1999
23
Enemas

Air, Liquid (saline, soluble contrast), Barium

At one time used for Dx
Coiled spring: edematous mucosal folds of returning
intussusceptum outlined by contrast in colon
Meniscus sign

Now used mainly for Treatment/Reduction
Avoid patient discomfort and risk of perforation
US better diagnostic tool & rule out tool
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
RadioGraphics 1999
24
Meniscus & Coiled Spring Signs
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Radiology 2001; AJ R 2004 & 2005; Rad Clinics of N Amer 1996
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Reduction Procedures

Barium enema: previous standard for Dx and
reduction
Risk of barium peritonitis, infection, adhesions,
radiation exposure with fluoroscopy, only see lumen
55-95% accuracy
Iodinated contrast safer but causes fluid shifts

US-guided Hydrostatic reduction
No radiation, good visualization of intussusception &
lead points
Need sonographer
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Radiology 2001; AJ R 2004 & 2005; RadioGraphics 1999
26
Reduction Procedures cont.

Pneumatic reduction with fluoroscopic guidance
Quick, safe, clean (less fecal spillage), cheap
Radiation exposure, cannot depict lead points well, only see
intraluminal content

US-guided Pneumatic reduction
No radiation, confirm dx, highest successful reduction rate
(92%), quick and clean, can see lead points well (but not all)
Air blocks US beam; difficult to see ileocecal valve and
residual intussusceptions

Surgical
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Rad Clinics of N Amer 1996
27
Contraindications to Enema

Dehydration

Peritonitis

Shock

Sepsis

Free air on radiograph
Stabilize then treat surgically
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
AJ R 2005
28
Complications of Reduction

Perforation
Overall rate of 0.8%
Similar rates for liquid and air enemas
Perforations with air usually smaller

Recurrence
Approximately 10%
Similar rates for liquid and air enemas
50% will occur within 48 hrs
Repeat enemas are safe and effective
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
AJ R 2005
29
Reduction Guidelines

Liquid Enema Rule of Threes for Barium
3 attempts
3 min duration
Liquid enema bag 3 feet above fluoroscopy table (5
feet if using water-soluble contrast)

Air Enema
Ensure maximal pressures <120 mm Hg at rest
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
AJ R 2002 & 2005
30
Success of Reduction Depend On

Short duration of symptoms (<24-48 hrs)

Adequate hydration

Age (older than 3 months)

Absence of small-bowel obstruction

Absence of trapped intraperitoneal fluid

Absence of enlarged lymph nodes in the
intussusceptum

Adequate blood flow

Location other than the rectum (rectum only 25%
success)
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
31
Patient Two: Presentation

2 year old male

Worsening vomiting and abdominal pain since the
morning of admission

Vomited 8xs since morning, no bile, blood or stool

No fevers; no current or recent illness

No new foods, travel or trauma

Prior incident of vomiting which he recovered from one
month prior

Abdomen soft, non-distended with active BS, diffusely
tender
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
32
Patient Two: Supine KUB
Patient does not have
classic triad of
intussusception
Use KUB to
consider other
diagnoses
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
33
Patient Two: Supine KUB
Paucity of
Gas on Right
Dilated
loops of
small bowel
Looks like
obstruction
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Felson, Gamuts in Radiology
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DDx of Intestinal Obstruction in a Child

Adhesions/Congenital peritoneal bands (Ladds
bands

Appendicitis

Hernia, incarcerated (internal or external)

Hirschsprung disease

Intussusception
Uncommonly: Crohns, fecal impaction, bezoar,
Kawasaki , neoplasm, congenital stenosis, TB,
volvulus, CF, Chronic granulomatous disease
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
35
Patient Two: Longitudinal Ultrasound
Use US to explore
possible causes of
obstruction including
intussusception
Patient is not exposed
to any further radiation
or the discomfort of
enema until further Dx
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
36
Patient Two: Sagittal Ultrasound
Dilated loops of bowel
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
37
Patient Two: Axial Ultrasound
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
38
Patient Two: Axial Ultrasound
Doughnut/Target
Sign
Patients obstruction
is due to
intussusception
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
39
Patient Two: Doppler Ultrasound
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
Children's Hospital Boston
40
Patient Two: Doppler Ultrasound
Blood flow
maintained
Rule out bowel
ischemia
Patient is safe to
receive an US
guided air enema
with likelihood of
resolution
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
41
Review

Intussusception is COMMON in young children

Clinical presentation is variable underscoring the need
for a safe, quick, inexpensive screening tool such as
ultrasound

Ultrasound is extremely accurate in diagnosing
obstruction; CT is more accurate in defining a lead
point; abdominal radiographs can be helpful in
considering other diagnoses

Ultrasound guided air enema combines the safety of
ultrasound (lack of radiation) with the effectiveness,
ease, cleanliness, and safety of air enema in reducing
intussusception
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
42
What does intussusception look like on CT?

Since lead points are more likely in the adult
population, CT is done more frequently in this
population with suspected intussusception

Scroll through the following images to get a
sense of what intussusception looks like on CT

Notice the familiar target sign, also useful in
diagnosis using plain film and ultrasound!
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
BIDMC PACS
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Intussusception on CT
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
BIDMC PACS
44
Intussusception on CT
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
BIDMC PACS
45
Intussusception on CT
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
BIDMC PACS
46
Intussusception on CT
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
BIDMC PACS
47
Intussusception on CT
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
BIDMC PACS
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Intussusception on CT
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
49
References

Applegate KE. Clinically Suspected Intussusception in Children: Evidence-Based
Review and Self-Assessment Module. AJR 2005; 185: S175-S183.

Daneman A and Alton J . Intussusception: Issues and Controversies Related to
Diagnosis and Reduction. Radiologic Clinics of North America 1996; 34: 743-756.

Del-Pozo G et al. Intussusception in Children: Current Concepts in Diagnosis and
Enema Reduction. RadioGraphics 1999; 19: 299-319.

Felson. Gamuts in Radiology.

Koumanicou C et al. Sonographic Detection of Lymph Nodes in the
Intussusception of Infants and Young Children. AJR 2002; 178: 445-450.

Navarro O, Daneman A, Chae A. Intussusception: The Use of Delayed Repeated
Reduction Attempts and the Management of Intussusceptions Due to Pathologic
Lead Points in Pediatric Patients. AJR 2004; 182: 1169-1176.

Parashar UD et al. Trends in Intussusception-Associated Hospitalizations and
deaths Among US Infants. Pediatrics 2000; 106: 1413-1421.

Sivit CJ . Gastrointestinal Emergencies in Older Infants and Children. Radiologic
Clinics of North America 1997; 35: 865-877.

Yoon CH, Kim HJ , Goo HW. Intussusception in Children: US-guided Pneumatic
ReductionInitial Experience. Radiology 2001; 218: 85-88.
Genevieve Daftary, MS3
Gillian Lieberman, MD
November 2005
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Acknowledgements

Special Thanks To
Melissa Gerlach, MD
Anne-Catherine Kim, MD
Larry Barbaras, Webmaster
Pamela Lepkowski
Gillian Lieberman, MD