Intussusception: Symptoms, Diagnosis, Treatment, Surgery
Intussusception definition, causes, signs, symptoms, diagnosis, treatment, and complications! Great review for nursing, medical, science students, USMLE, NCLEX, Board prep, and more!
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Intussusception: Online Learning
Intussusception is a type of bowel obstruction more common in pediatric patients than adults, primarily affecting babies and infants with an age range of 6-36 months.
Intussusception is often diagnosed using an ultrasound, and treatment may include observation, an air or contrast enema, or surgery.
This post will review the definition, causes, signs, symptoms, diagnosis, treatment, and complications of intussusception.
Make sure to check out the high-yield buzzwords and learning points at the end!
Let’s get right into it!
Intussusception: Review of its definition, features, symptoms, signs, diagnosis, and treatment. USMLE, NCLEX, exam buzzwords at the end!
What is Intussusception?
First we have to ask ourselves, what is intussusception?
Definition
Intussusception occurs when a portion of bowel or intestine folds in on itself, like a telescope, and this can lead to a bowel obstruction.
Intussusception Definition and Meaning: When a portion of the intestine folds in on itself, like a telescope, causing a bowel obstruction
Intussusception Explained
The intestines are shaped like a tube, and normally content travels through the tube without a problem.
During intussusception, a part of the intestine folds in on itself at a more distal segment downstream.
This phenomenon is called “telescoping” because it folds in on itself like a collapsing telescope.
The telescoping causes the intestine to become more narrow, and content will now have a harder time passing through the lumen.
This can lead to a bowel obstruction.
The telescoping of the intestine may also compress the blood vessels supplying it, causing decreased perfusion or ischemia to the affected bowel.
Ischemia can cause the intestine to become even more swollen or edematous, which can further worsen the obstruction and further compromise blood flow or perfusion.
This vicious cycle can lead to worsening bowel obstruction, bowel ischemia, and bowel necrosis.
Intussusception: The intestine folds in on itself like a collapsing telescope, causing a bowel obstruction.
Main Features of Intussusception
Intussusception is the most common cause of bowel obstruction in pediatric patients.
The majority of cases occur between 6-36 months of age.
More than half of cases occur at less than 12 months with a median age of about 9 months.
Intussusception can also affect younger or older patients, and even adults, however this is less common.
Intussusception is more common in males than females.
Most cases of intussusception occur at the ileocolic region near the junction of the ileum and cecum.
The information in red below is important for medical and board exams.
Often the question stem for intussusception will have a 6-36 month old male presenting with signs of a bowel obstruction and symptoms associated with the condition.
Let’s review those symptoms next.
Intussusception Features: Most common in males, 6-36 months of age, at the ileocolic region. Most common cause of pediatric bowel obstructions.
Symptoms of Intussusception
What are the symptoms to look out for?
Triad
There are 3 main symptoms to remember with intussusception.
The triad commonly seen on medical and board exams includes:
Vomiting - May be bilious
Abdominal Pain - Intermittent, colicky
Blood Stools - “Currant Jelly”
Let’s take a closer look at each of these below.
Intussusception Symptoms: High-yield triad for USMLE, NCLEX, medical exams includes vomiting, intermittent colicky abdominal pain, and bloody “currant jelly” stools.
1. Vomiting
The first symptom is vomiting, which makes sense.
If there is a bowel obstruction, then content cannot pass through the bowel and the patient may experience vomiting as a result.
Therefore, the vomiting may be bilious (yellow-green) in nature.
2. Abdominal Pain
The next symptom is abdominal pain.
The pain is often described as sudden onset, intermittent, and colicky that occurs in episodes.
Episodes are usually in 15-20 minute intervals.
During an episode, the infant may suddenly cry loudly and draw their knees up to their chest or curl up in a ball.
3. Bloody Stools
The third symptom is bloody stools.
The appearance of the stool is described as “currant jelly”.
A common buzzword used to describe intussusception on medical and board exams is “currant jelly stools”, so remember that.
Bloody stools may be a late finding and could be a sign that the affected bowel is not receiving enough blood supply, called ischemia, and subsequent tissue death or necrosis may be occurring.
“Sausage-Shaped” Abdominal Mass
Although this is more of a sign rather than a symptom, it commonly shows up on medical and board exams.
The patient may have a “sausage-shaped” abdominal mass on palpation of the abdomen during the physical exam.
“Sausage-shaped” abdominal mass is a common buzzword used to describe intussusception on exams.
Intussusception Signs and Symptoms: Vomiting (may be bilious); Abdominal Pain (intermittent, colicky); Bloody Stools (“currant jelly”); Sausage-Shaped Abdominal Mass
Intussusception Presentation by Age
What symptoms are most common by age?
< 12 Months
Typically what you will see in infants less than 12 months of age is emesis, irritability, and bloody stools.
Younger infants may also present with lethargy or altered levels of consciousness, so always keep intussusception in the back of your mind.
> 12 Months
Patients older than 12 months of age usually have abdominal pain as a more common symptom.
Intussusception Symptoms by Age: Emesis, irritability, and bloody stools are more common < 12 months old; Abdominal pain more common > 12 months old
What Causes Intussusception?
In the majority of uncomplicated cases, the cause is unknown.
It is thought intussusception may occur secondary to a viral infection.
During a viral GI infection, the intestinal lymphatic tissue becomes inflamed.
This can act as lead point for the intestine to fold in on itself and subsequently develop an intussusception.
While in many cases the cause is unknown, intussusception can also be a result of underlying pathology including:
Meckel’s Diverticulum
Intestinal polyps
Hemangioma
Neurofibroma
Lymphoma
The above are examples of pathologic lead points, and can potentially cause the intestine to telescope.
Intussusception Etiology: Causes include possible viral infections, Meckel’s diverticulum, intestinal polyps, hemangioma, neurofibroma, and lymphoma.
Diagnosis: Ultrasound & Imaging
Let’s discuss how intussusception is diagnosed.
Ultrasound
Ultrasound has a high sensitivity and specificity for diagnosing intussusception.
There is no radiation, making it safe in pediatric patients.
Furthermore, it can be performed at bedside if the clinician has experience.
Ultrasound may show a “target sign” or “bull’s eye” in the short axis.
This is due to the intestine folding in on itself, which creates a target or bull’s eye appearance.
“Target sign” and “bull’s eye” are common buzzwords used on medical and board exams, so make sure you remember them.
Ultrasound may also show a “hayfork” or “pseudo-kidney” appearance in the long axis.
Again this is caused by the telescoping of the intestine.
Abdominal X-Ray
Abdominal x-rays can potentially diagnose intussusception as well.
There may be signs of intestinal obstruction or other radiological signs to suggest intussusception, however this has a lower sensitivity and specificity than ultrasound.
Of note, CT scans can also show intussusception. However, ultrasound is becoming more of the gold standard especially in pediatric patients where there is no radiation.
Treatments
While ultrasound is commonly used for diagnosis, some of the treatments for intussusception can potentially be diagnostic and therapeutic as well.
This brings us to the management which we will discuss next.
Intussusception Diagnosis: Ultrasound may show a “target sign” or “bull’s eye”; Abdominal x-ray may show intestinal obstruction pattern; Treatments can be diagnostic and therapeutic
Intussusception Treatment & Surgery
How do you treat intussusception?
Small Bowel-to-Small Bowel Cases
Many small bowel-to-small bowel cases are transient and resolve on their own.
They may not require intervention, especially if they are uncomplicated.
If the uncomplicated small bowel-to-small bowel intussusception is caused by a viral infection, then it can self resolve as the infection and lymphatic inflammation improve.
Having said that, there are features, risk factors, and underlying causes that may still require intervention in these cases, so it is always good to discuss the case with appropriate teams (i.e. surgery, radiology, etc.)
Ileocolic Cases
The majority of intussusception cases are ileocolic.
Ileocolic intussusceptions typically require intervention, see treatment below.
Treatment
If it is determined the intussusception requires treatment, then there are a couple different options.
Air or Contrast Enema
Surgery
1. Air or Contrast Enema
If the intussusception is uncomplicated, then an air or contrast enema can be performed to try to reduce it.
If the first attempt is unsuccessful, then a repeat attempt could potentially be performed in about 30 minutes to 4 hours under certain circumstances.
The patient would need to be stable without signs of peritonitis or any other complications.
Again this should be a joint decision between surgical, radiological, and any other appropriate teams.
A successful second attempt could potentially avoid the need for surgery.
That brings us to the second form of treatment which is surgical intervention.
2. Surgery
Surgery may be necessary if non-operative approaches fail, or if there are complications such as an unstable patient, bowel perforation, peritonitis, or any other contraindications to a non-operative approach.
Surgery may involve reduction of the intussusception, resection of necrotic bowel, and/or intervention on any underlying pathologic lead points.
Intussusception Treatment: Options include observation for self-limiting transient cases, air or contrast enema, and surgery
Complications of Intussusception
If intussusceptions are not treated or do not resolve on their own, then complications can arise.
Complications may include:
Ischemic Bowel
Sepsis
Bowel Perforation
Peritonitis
Intussusception Complications: Ischemic bowel, sepsis, bowel perforation, peritonitis, etc.
Intussusception Buzzwords
Let’s wrap it up with the main learning points and buzzwords you might see on exams.
Buzzwords
“Telescoping”
“Currant Jelly Stools”
“Sausage-Shaped Abdominal Mass”
“Target Sign” or “Bull’s Eye”
Learning Points
Definition: Intussusception is “telescoping” of the intestine
Features: Most common in males between 6-36 months of age
Symptoms: Triad
Vomiting - May be bilious
Abdominal Pain - Intermittent, colicky
Bloody Stools - “Currant Jelly” appearance
Physical Exam: There may be a “sausage-shaped” abdominal mass
Diagnosis: Ultrasound may show a “target sign” or a “bull’s eye”
Treatment: May involve observation, air or contrast enema, or surgery
Intussusception Buzzwords: “Telescoping”; “Currant Jelly Stools”; “Sausage-Shaped Abdominal Mass”; “Target Sign”; “Bull’s Eye”
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