Intussusception: Clinical sciences

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Introduction0:00–0:52

Intussusception is a type of intestinal obstruction that occurs when one segment of the intestine telescopes inside of another segment of the intestine.
This telescoping often occurs around the ileocecal junction, which is where the ileum of the small intestine and cecum of the large intestine meet.
Typically, the distal ileum folds into the cecum. If left untreated, it can result in intestinal edema due to venous and lymphatic congestion, and can ultimately lead to ischemia, necrosis, and intestinal perforation.
Intussusception is a true emergency and must be treated promptly, either through reduction with an enema, or if unsuccessful, by surgical intervention.Alright, if a pediatric patient presents with a chief concern suggesting intussusception, your first step is to perform an ABCDE assessment to determine if your patient is unstable or stable.

Unstable Patient0:52–3:44

If they’re unstable, initiate acute management by stabilizing the airway, breathing, and circulation. Next, obtain IV access and initiate IV fluids for resuscitation.
Make sure to continuously monitor vital signs, including pulse oximetry, blood pressure, and heart rate. Finally, make your patient NPO and consider placing an NG tube for gastric decompression.
Okay, once you’ve acutely managed your patient, your next step is to obtain a focused history and physical exam. Symptoms typically occur in patients who are 4 to 36 months old, consisting of sudden, severe, paroxysmal abdominal pain and cramping; and the child will often draw their knees up toward the chest.
The pain is characterized by intermittent severe pain with pain-free periods in between. Additionally, caregivers typically note the child has had bloody stools that are often intermixed with mucus, called “currant jelly” stools; as well as vomiting, which can start out as nonbilious but may become bilious.
Additional symptoms may include lethargy and fever. You will also want to ask about potential risk factors in your patient’s history.
These include a recent viral illness or bacterial enteritis, as well as Meckel diverticulum, duplication cysts, vascular malformations, polyps, or lymphoma.
These conditions create a lead point, which serves as a spot that the intestinal wall snags on, creating the condition for it to telescope in on itself.Here’s a high yield fact!
The rotavirus vaccine has been associated with intussusception, although this side effect is very rare, and is not a reason to avoid giving this vaccine.
On a physical exam, you may find hypotension and tachycardia, along with an altered mental status. Patients may also have abdominal tenderness, distention, rebound, and guarding, which are concerning for perforation and peritonitis.
On palpation, look for a sausage-shaped mass in the right abdomen. Now, on laboratory analysis, CBC may show leukocytosis, while CMP may show electrolyte derangements.
With this presentation, suspect intussusception complicated by perforation or peritonitis, with or without sepsis. Okay, so the next step is to order an abdominal ultrasound and an abdominal X-ray.

Intussusception Complicated by Peritonitis or Perforation3:44–5:06

On ultrasound, look for evidence of the intestine within the intestine, also known as the "target sign," consisting of multiple concentric rings of bowel wall as one segment of the bowel telescopes into another; as well as a pathological lead point.
Meanwhile, on abdominal X-ray, if you find signs of perforation, such as pneumoperitoneum, you can diagnose intussusception that has been complicated by perforation or peritonitis, with or without associated sepsis.
Once you’ve made the diagnosis, your next step is to get your patient to the operating room as soon as possible for an emergent laparotomy to reduce the intussusception and resect the perforated and necrotic segments of bowel.
Be sure to administer preoperative IV fluids; electrolyte replacement; and broad spectrum IV antibiotics to cover anaerobes, coliforms, and enteric streptococci.
Here’s a clinical pearl! Reduction with an enema is contraindicated in this situation because it can worsen the bowel perforation!
Alright, now that we’ve discussed unstable patients, let's go back and talk about stable patients. Your first step is to obtain a focused history and physical exam.

Stable Patients5:06–6:10

Symptoms typically occur in patients who are 4 to 36 months old, and include sudden, severe, paroxysmal abdominal pain and cramping.
Caregivers typically report the presence of bloody or “currant jelly” stools, as well as vomiting. Again, common risk factors that predispose your patient to intussusception include a recent viral illness or bacterial enteritis; as well as Meckel diverticulum, duplication cysts, vascular malformations, polyps, or lymphoma.
Your physical exam findings may include a sausage-shaped mass in the right abdomen, along with focal tenderness in the right upper quadrant.
These findings should make you suspect intussusception.Your next step is to order an abdominal ultrasound. If the abdominal ultrasound does not show evidence of the “target sign” or telescoping bowel, you should consider an alternative diagnosis.

Intussusception6:10–7:01

On the other hand, if the ultrasound reveals the “target sign,” you can diagnose intussusception. Lastly, let's talk about the management of these patients.
Your first step is to try and get the bowel to reduce, which is most commonly done with either a pneumatic, or air, enema; or a hydrostatic enema, which uses contrast or saline.
An enema is often successful; however, if an enema does not successfully reduce the bowel, then an urgent laparotomy is necessary for surgical reduction.Alright, as a quick recap… Patients who present with intussusception typically have symptoms such as colicky abdominal pain, vomiting, and currant jelly stools.

Review7:01–7:41

Common physical exam findings include abdominal tenderness and a sausage-shaped mass in the right abdomen; while an abdominal ultrasound showing a “target sign” and telescoping bowel is diagnostic for intussusception.
Treatment for unstable patients includes an emergent laparotomy along with fluid resuscitation, electrolyte replacement, and broad spectrum IV antibiotics.
For stable patients, treatment includes enema for reduction, and if unsuccessful, an urgent laparotomy.