Abdominal Pain Intussusception

Author: Philip Wolfson, M.D. Jefferson Medical College

Revision Editor: Linda Barney, M.D. Joseph Iocono, M.D.

Emme Hall
Your patient in the ER is a 14-month-old female with a 12 hour history of irritability and abdominal discomfort.

History
What other points of the history do you want to know?

History, Emme Hall

Consider the Following

Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors:

Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms

History, Emme Hall

Characterization of pain: Unable to verbalize but discomfort seems intermittent, in spasms
Temporal sequence: Has become more pronounced in past 4 hrs Activity level: Much less active than usual, irritability with the pain alternating with periods of lethargy

Associated Signs & Symptoms Vomited 3 X, initially clear but now yellowish; had a watery bowel movement with a mixture of blood and mucus

PMH Born at 37 weeks gestation. Otitis media at age 8 months. Upper respiratory infection 2 weeks ago

Physical Examination
What would you look for on physical examination?

Physical Examination, Emme Hall

Vital Signs: T= 101.2 P= 144 R= 22 BP= 80/55 General: Well nourished, pale, irritable Abdomen Inspection mild distention, symmetric, shallow breathing Auscultation bowel sounds present but diminished Percussion tympanitic; elicits tenderness in RLQ and RUQ Palpation - generally soft, but + RUQ and RLQ tenderness Rectal: Normal patency, no mass palpable, gross blood on glove Remainder of examination is within normal limits

What is your Differential Diagnosis?

Diagnostic Studies
What studies would you obtain?

Studies ordered, Emme Hall

CBC
Hgb Hematocrit WBC

Electrolytes Abdominal x-rays

Laboratory Studies, Emme Hall

CBC
Hb Hematocrit WBC 14.2 41 15.6 137/103/3.9/22

Electrolytes

X-ray results, Emme Hall

Obstructive Series chest x-ray normal; abdominal films show mildly dilated loops of small intestine. There is a paucity of gas in the right colon.

Clinical Studies, Emme Hall

The hemoglobin is normal. The white cell count is moderately elevated, suggesting an infection or inflammation. The serum electrolytes are normal. The abdominal x-rays suggest the possibility of an intestinal abnormality, but the findings are nonspecific.

What is your revised Differential Diagnosis?

Differential Diagnosis
Viral gastroenteritis Intussusception Appendicitis

Management
What would you do now?

Further management, Emme Hall An attempt should be made to reduce this intussusception radiographically, using pressure from barium or air and visualized fluoroscopically. Some physicians prefer to have intravenous fluids running and administer broad spectrum antibiotics before this procedure.

Air enema

Sequential images with arrows demonstrating reducing lead point of intussusception

Air enema

The air passes up through the large intestine until it reaches the right side of the transverse colon where it encounters a filling defect. The radiologist is able to reduce the mass up to the proximal right colon but no further.

Further Management

What does this mean? What should be done next?

Management, Emme Hall

The intussusception can only be partially reduced, and there remains a filling defect in the cecum.

Management, Emme Hall

Since the intussusception cannot be reduced, surgery is necessary and should be performed immediately. Broad spectrum antibiotics effective for lower intestinal organisms should be administered preoperatively.

Management, Emme Hall

A right lower quadrant incision is made, and the ascending colon is delivered. There is an intussusception of the ileum half-way up the right colon.

Management, Emme Hall

Using manual pressure on the colon above the intussusception, the ileum is reduced. The bowel is pink and viable; no pathological lead point is seen. An appendectomy is also performed.

Hospital Course
Emme Hall recovers uneventfully and is discharged the following day, tolerating a regular diet

Discussion
Intussusception is a telescoping of one portion of the intestine into another, and typically affects children between the ages of 6 to 18 months. The ileum usually invaginates and advances a variable distance into the colon. It often follows a nonspecific viral illness and may be due to hypertrophy of Peyers patches; rarely is there a pathological lead point in the intestinal wall. The patient presents with intermittent bouts of pain where they may draw their knees up to the chest; in between episodes they may be irritable or lethargic. Vomiting is common and as the condition progresses there may be blood and mucus (classically the current jelly) in the stools as the mucosa becomes ischemic. Physical examination may be fairly normal initially but there may be irritability, somnolence, fever, and right sided abdominal tenderness; occasionally a right upper abdominal mass can be palpated. Abdominal x-rays may appear normal or show a paucity of air in the right lower quadrant and some dilatation of the small intestine.

Discussion
Intussusception is considered to be an emergency, as the intestine can become necrotic. If the diagnosis is suspected, a contrast enema will be diagnostic and often therapeutic. Radiologists are increasingly utilizing air rather than barium because of the greater success with contrast reduction and lower morbidity if there should be a perforation. Some advocate administration of intravenous fluids and broad spectrum antibiotics at the time of the x-ray studies, especially if the child is ill. Successful radiographic reduction is confirmed if there is reflux of contrast into the ileum, in which case the child is admitted to the hospital for 24 hours of observation. If contrast reduction is unsuccessful, surgery is mandatory to reduce the intussusception manually. The appendix is usually removed. If the intestine is necrotic, a resection is necessary. Recurrence of intussusception occurs in approximately 5% of children. The diagnosis of intussusception must be considered in any patient between 6 months and 2 years with unexplained abdominal pain, and a contrast x-ray usually is obtained. There may also be a role for ultrasound as a screening test.

Adult Intussusception
Older children and adults with Intussusception usually have a pathological lead point, which is a malignant tumor in approximately half of all instances. Patients present with small intestinal obstruction and have a "target" sign on CT scan. Surgical intervention is usually required

CT Scan Ileo-colonic Intussusception

CT Scan Ileo-colonic Intussusception

QUESTIONS ??????

Summary

Acknowledgment
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