In this lecture, we’re going
to discuss intussusception.
Intussusception is a prolapse of
proximal portion of intestine
into a distal portion
Perhaps, the easiest way to see it
is on the right side of this slide
where you can see the proximal intestine
invaginating into the distal intestine.
It’s sometimes hard to describe
this to families and patients,
and the way I will sometimes describe
it is if we have a balloon animal --
balloon, you know those long balloons
that we make balloon animals out of --
and I push my finger into the balloon
animal and I can see my finger,
that’s often how it happens.
It starts really on this side of
the intestine and pushes it in,
and it’s from a lead point, something
abnormal in the side of the intestine
that’s causing that piece
of intestine to invaginate.
Intussusception is mostly
a pediatric problem.
It’s most common abdominal emergency in
children in the two years of age range.
It usually happens between three
months and six years of age.
And the peak incidence is around
six months to twelve months.
The majority of cases
We can’t figure out what was the
problem that cause this to happen.
There was no obvious lead point.
Although we suspect that the lead point
is almost invariably a Peyer's patch.
Remember, the Peyer's patch is that
area of lymphoidal tissue in the ileum
in children where they have a
larger amount of lymphoidal tissue.
These Peyer’s patches can be
slightly inflamed or enlarged
and could be the lead point
for an intussusception.
And because these Peyer’s patches
are mostly in the ileum,
In other words, it comes from the
ileum and goes in through the cecum
and into the large intestine.
Patients who have intussusception will
have a classic triad of symptoms.
So, the classic triad is
intermittent colicky abdominal pain,
and bloody stools.
Now, this is what you’ll
see written on your test,
and you should definitely
The reality as though is
that most intussusception,
we do not actually
find bloody stools.
It’s a rare finding when the diagnosis has
been missed for a long period of time.
The other thing that’s key to discuss
with any patient who’s presenting
with intussusception is a
remarkable altered mental status.
Children with intussusception, for
reasons we do not understand,
can have such altered mental status.
They can literally be unarousable.
And this mental status will wax and wane
between severe somnolence and severe
irritation and abdominal pain.
These children may have
a sort of cyclical
severe irritability followed
by excessive somnolence.
In the differential diagnosis, for an
unresponsive child, it’s intussusception.
intussusception generally happen
if a patient has a
delay in diagnosis.
In this picture of this little
boy here with intussusception,
this is a remarkable photo
because you can actually see
the right upper quadrant mass
that is his intussusception.
This child is severely ill, likely
because of a delay in diagnosis.
Delay in diagnosis isn’t that uncommon.
It could be a tricky thing to figure out
because children this age can’t
tell you why things hurt.
And sometimes, you just confuse this
for something like gastroenteritis.
However, if a delay in
diagnosis is happening,
children may develop complications.
They may develop obstruction
at their intestinal wall.
The passage of material can’t
continue to pass that intussusception
and they have small
They may develop intestinal edema.
The edema may lead to intestinal
ischemia or death of the bowel wall,
which is a surgical emergency.
It can lead in turn
And once that intestinal
they may develop peritonitis,
which is a bacterial infection
of the entire peritoneal cavity.
Peritonitis eventually leads to
shock, and potentially, even death
if the diagnosis isn’t made
or the child isn’t treated.
So, let’s go through typical physical exam
findings for a child with intussusception.
On your abdominal exam, you may be able to
palpate a sausage-shaped abdominal mass.
This is important to remember
and this is often on a test.
Realistically, however, it’s very
rare to find an actual palpable mass.
The reason being is
that these children are
usually noncompliant with
your abdominal exam.
And when they’re resisting
your abdominal exam,
it’s hard to get through that abdominal
musculature to actually feel the mass.
Takes some patience.
What you may notice
is this mass,
if it’s the classic
is in the right upper quadrant,
and that’s important to remember.
Patients may get a currant jelly stool.
I don’t know if you’ve ever seen currant
jelly, but it’s that red thick consistency.
And when you see that, that is usually
associated with intussusception.
However, remember, the majority of children,
we actually don’t see bloody stools in.
Nonetheless, high yield on a
test is currant jelly stools.
This is usually a later finding.
It’s a result of a delay in diagnosis,
and that child is bleeding because the
intestinal wall has become edematous
and has started becoming
That child is at risk for peritonitis.
So how do we diagnose it?
If we suspect intussusception, the
test of choice is the ultrasound.
What we’ll do is we’ll
hold the abdominal probe
up to the abdominal wall
and we’ll look inside
and we’ll see this
very classic picture,
which is often common to
go on the [00:06:41] test,
and we’ll call it a
bull’s eye sign.
What you can see here is an inner
That’s the piece of intestine that
is entering the distal segment.
And an outer, intussuscipiens.
The intussuscipiens is the
part of the intestine
that is receiving the proximal material.
So, what you see then is
this bull’s eye picture
where you have the outer
wall of the intestine
followed by the inner
wall of the intestine,
and that’s a classic finding on ultrasound.
The inner piece and the outer piece.
How do we treat intussusception?
Well, in most children, this is ileocecal,
which means that if we could
re-expand that colon,
we can actually effectively push out the
intussuscipiens, the proximal portion,
pop it out, and actually fix the
problem without doing surgery.
And this is in fact what we do.
Usually, we use air.
We used to do things like contrast enemas.
That’s less commonly performed now.
This is a nonsurgical approach
that’s done by your radiologist
where they insert air forcefully
into the rectal vault
and try to re-inflate
This image here is a
contrast, not an air enema.
This has about a 75% success rate.
If that doesn’t work, we typically
will then move on to surgery.
We often do surgery also if
there’s peritonitis present.
In other words, the bowel
has already perforated
because we want those surgeons to run the
bowel and look for areas of necrosis
that might need to be cut out.
If there’s a concern for perforation,
of course, we’re going to go for
surgery for that very reason.
And if the child is acutely
ill or toxic-appearing,
chances are that’s
We’re going to be calling the surgeons.
So, let’s review the important things
to remember with intussusception
that are likely to
show up on your exam.
What is the most common location?
We’re talking about the
right upper quadrant.
Remember, the lower cecum has material
that’s going up into the ascending colon,
and you’ll notice that mostly
in the right upper quadrant.
The classic triad of symptoms is
right upper quadrant pain, a
mass and bleeding in the stools.
The characteristic ultrasound
finding is that bull’s eye.
And if you do a rectal exam
in a child who has a delay,
you’ll notice currant jelly stools.
And lastly, the typical age
group for intussusception
is in children between the ages
of three months to six years
with the most of them happening
around a year of age.
If you see intussusception in a
child who’s over six years of age,
this is non-Hodgkin’s
lymphoma until ruled out.
Basically, over six years of age,
or really over five years of age,
we’re worried about a pathologic lead point
as opposed to something
benign like a Peyer’s patch.
The last caveat I’ll leave you
with before we end this lecture
is that remember, there is one condition
which is associated with intussusception
that is different, and that’s
We’ll do a separate lecture on HSP,
but remember, HSP causes more
often, ileo-ileal intussusception
rather than ileocecal
because the lead point there is in fact
one of the purpura from