Intussusception
Intussusception
Definition
Intussusception is a medical emergency in which one portion of the intestine (bowel) slides or “telescopes” into another section of bowel, cutting off the blood supply and blocking the flow of materials through the digestive system.
Description
In the process of intussusception, one part of the intestine infolds into another section the intestine. The most common place for this to occur is at the junction where the end of the small intestine (the ileum) meets the large intestine (the colon). Here, the small intestine slides into the large intestine. Occasionally one part of the small intestine will slide into another part of the small intestine, but this is much less common.
Once the infolding begins, the blood supply is to intestines and the tissue (mesentery) that surrounds it and holds it in place is cut off. The intestines are a long tube. The infolding tissue creates an obstruction that blocks the passage of material through the intestine. The walls of the intestine and the surrounding tissue begin to swell, increasing the blockage. The intestine may bleed or rupture, and eventually gangrene develops as the tissue dies.
Demographics
Intussusception occurs most often in infants and toddlers. It is the leading cause of intestinal obstruction in children ages 3 months to 5 years. The highest rate of intussusception occurs in children age 3 to 12 months. Two-thirds of cases occur before the child’s
KEY TERMS
Gangrene —death of body tissue due to a cutting off of the blood supply.
Idiopathic —occurring from unknown causes.
Perforation —a whole in the wall of an organ in the body.
Polyp —a tissue growth that extends out into the hollow space of an organ such as the intestine or uterus.
Rectum —the last few inches of the large intestine.
first birthday. Intussusception is the leading cause of abdominal surgery in children age 5 and younger.
In infants, 3 boys develop intussusception for every 2 girls that do, but as children age, the rate changes sharply and the disorder becomes much more common in boys. By age 4, the boy:girl ration is 8:1. There is no difference in the rate of intussusception among races or ethnic groups. Internationally, although few statistics are available, the rate seems to be about the same as in the United States.
Adults can develop an intussusception, but the condition is rare.
Causes and symptoms
The cause of most cases of intussusception cannot be identified (idiopathic intussusception). In general, researchers believe that uneven forces on the wall of the intestine start the process. In some cases, a spot called a lead point develops. This seems to be a heavy spot or pocket on the wall of the intestine that then “leads” the slide of one section of intestine into another. Some lead points develop around surgical scar tissue, tumors, polyps, collections of blood or fluid in the intestinal wall, or, in the case of cystic fibrosis, the accumulation of sticky mucus on the wall of the intestine. However, a lead point is identified in less than 12% of cases in children.
Another theory on why intussusception develops suggests that the process is set off by uncordinated bowel contractions (peristalsis). Viral infection may also play a role. There is an association between recent viral infection and intussusception, but no clear cause and effect relationship has been determined. At one time, it appeared that vaccination for rotavirus, a virus that causes severe diarrhea in young children, increased the rate of intussusception. The vaccine in question was withdrawn from the U. S. market. As of 2007, a new vaccine used in the United States against rotavirus, RotaTeq, has shown no association with increased intussusception.
Intussusception is a medical emergency. Symptoms of intussusception usually appear suddenly in an otherwise healthy child. The classic symptoms of intussusception are abdominal pain, vomiting, and passing reddish, jelly-like stools called “current jelly” stools. The jelly-like material comes from shedding of mucus from the intestinal wall, and the red is from fresh blood. However, this constellation of three symptoms is present in only about 20% of children. About 50% of children have abdominal pain and current jelly stools without vomiting.
Normally an infant who appears healthy suddenly draw up his or her legs and scream or cry frantically in pain. The child may vomit. This is followed by a period when the pain disappears and the child appears normal. Painful episodes return, however, at roughly 10–20 minute intervals. The child may have loose watery stools at first. Over time, the stools become reddish and jelly-like. Eventually the child becomes lethargic between bouts of pain and may develop a swollen abdomen and fever. If left untreated, intussusception is fatal.
Adults can also experience intussusception, although the disorder is uncommon to rare. In adults, the cause is often an unsuspected tumor or polyp growing in the intestine. Symptoms often appear much more gradually in adults and may come and go over a long period. Adult symptoms of intussusception include changes in bowel frequency, urgent desire to have abowel movement, abdominal cramps, pain in a single area of the abdomen, rectal bleeding, nausea and vomiting. These symptoms resemble the symptoms of other gastrointestinal disorders complicating diagnosis.
Diagnosis
Diagnosis is made on the basis of patient history and imaging studies. X ray images of the abdominal region will show a mass or obstruction in the bowels. Computed tomography (CT) scans or ultrasound may be done in addition to x rays. If there is no sign that the bowel has torn (perforated) or ruptured, a contrast x ray is done on the large intestine. In a contrast colon x ray, a liquid containing barium is inserted through the rectum and into the colon. The barium contrasts with the surrounding tissue to provide clearer x ray images of the affected area.
Treatment
With intussusception, diagnosis sometimes results in treatment. Forcing barium into the colon may reduce the intussusception as pressure from the barium pushes the infolded piece of bowel back out of the large intestine. This occurs in as many as 75% of cases. Sometimes the procedure needs to be repeated to get complete reversal of the infolding. When a barium enema provides effective treatment, the pain stops immediately and the child becomes dramatically better. The child is usually hospitalized for observation for about 18–24 hours. This precaution is taken because most recurrences of the intussusception occur within that time.
If the initial x rays show that the bowel has ruptured, has a perforation, or if massive infection is present (peritonitis), a barium enema cannot be used and emergency surgery is required. Surgery is also required if the barium enema is ineffective in reversing the blockage. About 25% of children require surgery. Recovery after surgery is usually complete and no complications are expected.
Nutrition/Dietetic concerns
Individuals whose intussusception is successfully treated without surgery can return to a normal diet immediately. Individuals who require surgery will initially be fed intravenously (IV), followed by a clear liquid diet, then progressing to soft foods until normal bowel function is established. At this time they can return to their regular diet.
Prognosis
Untreated intussusception is fatal, usually within 2–5 days. Death is caused by complications from gangrene and massive infection. Individuals who are successfully treated for intussusception recover, usually without complications. Repeat intussusception can be as high as 10% in individuals whose intussusception is cleared by barium enema. Most of the time, if recurrence is going to occur, it happens within the first 24 hours, although a longer time frame is always possible.
Prevention
There is no way to prevent intussusception. However, prompt medical care can prevent death.
Resources
BOOKS
Lalani, Amina and Suzan Schneeweiss, eds. The Hospital for Sick Children Handbook of Pediatric Emergency Medicine. Sudbury, MA: Jones & Bartlett Publishers, 2007.
ORGANIZATIONS
American Academy of Family Physicians. P. O. Box 11210, Shawnee Mission, KS 66207. Telephone: (913)906-6000. Website: <http://www.aafp.org>.
American Academy of Pediatrics. 14 Northwest Point Blvd. Elk Grove, IL 60007. Telephone: (874)434-4000. Website: <http://www.aap.org>.
OTHER
Chahine, A. Alfred. “Intussusception.” eMedicine.com, April 11, 2006. <http://www.emedicine.com/ped/ topic1208.htm> King, Lonnie. “Pediatrics, Intussusception.” eMedicine.com, May 23, 2006. <http://www.emedicine.com/ped/ topic385.htm> .
Mayo Clinic Staff. “Intussusception.” MayoClinic.com, September 6, 2006. <http://www.mayoclinic.com/ health/ntussusception/DS00798>.
Tish Davidson, A.M.
Intussusception
Intussusception
Definition
Intussusception is the enfolding of one segment of the intestine within another. It is characterized and initially presents with recurring attacks of cramping abdominal pain that gradually become more painful.
Description
Intussusception occurs when part of the bowel or intestine is wrapped around itself producing a masslike object on the right side of the abdomen during palpation (a procedure used during a physical examination, when the examiner touches the abdomen with his/her hand, usually feeling for mass, pain, or discomfort). The number of new cases of intussuscetion is approximately 1.5 to four cases per 1,000 live births. The onset of abdominal pain is usually abrupt and severe. Just as fast as the onset of pain appears, it disappears and the child resumes activity normally. This process of sudden severe abdominal pain appearing out of the blue then disappearing is repeated with duration of painful attacks. The pain usually increases after approximately five hours of recurrent cycles of severe abdominal pain followed by relaxation. Vomiting and diarrhea occur in about 90% of cases with six to 12 hours after initial onset of symptoms.
Physical examination and palpation usually reveal a sausage shaped mass of enfolded bowel in the right upper mid portion of the abdomen. Within a few hours approximately 50% of cases have bloody, mucus filled bowel movements. At about this time the child is visibly very ill with fever, tenderness, and distended abdomen. Intussusception is the most frequent cause of intestinal obstruction during the first two years of life and commonly affects children between three to 12 months of age. The disease is three times more common in males than in females. In about 85% of cases the cause is idiopathic (meaning unknown). The remaining 15% of cases can be caused by a variety of other diseases such as tumors of the lymph nodes (lymphoma), fat tumors (lipomas), foreign bodies/objects, or from infections that mobilize immune cells to the area causing and an inflammatory reaction and intestinal blockage. Most cases of intussusception do not strangulate the affected bowel within the first 24 hours. If the disease is not treated after this time, the possibility of intestinal gangrene, shock, and death increases.
Causes and symptoms
The major symptom of intussusception is when a healthy child suddenly and without warning experiences severe abdominal pain that subsides and usually results in continuation of normal activities such as playing. The duration of the painful attacks increases as the hours go by. Usually, the child develops nausea, vomiting, and diarrhea soon afterwards in about 90% of all cases. The child becomes weak, exhausted, and develops a fever. The affected child may also expel bloody, mucus-like bowel movements. These blood filled bowel movements are usually due to impaired blood flow to the obstructed area. During palpation there may be a sausage-shaped mass located on the upper right mid portion of the abdomen. If the disease progresses and is undetected, the child may develop necrosis death of cells within the affected area. Additionally, there may be perforation or hole in the intussusception bowel that can cause a life threatening infection in the peritoneum (a layer of tissue that protects the organs and intestines within the abdominal cavity). This infection of the peritoneum is called peritonitis. Some patients may exhibit altered states of consciousness or seizures.
Diagnosis
A presumed diagnosis can be made by history alone. If the clinician suspect's intussusception x-ray films should be performed, which may reveal a mass in the right upper mid abdominal region. Two classical clinical signs are mucus-blood filled stools and a "coiled string" appearance in the affected bowel as visualized during an x ray with a barium enema. Blood chemistry analysis is not specific for intussusception. Depending on vomiting and blood loss through the stools, blood chemistry may reflect signs of dehydration and anemia.
KEY TERMS
Barium— A chemical used in certain radiological studies to enhance visualization of anatomical structures.
Obstruction— A blockage that prevents movement.
Treatment
Treating intussusception by reduction (alleviating the source of blockage) is an emergency procedure. The barium examination is not only the diagnostic tool of choice, but also frequently curative. Infusion by gravity from a catheter placed in the rectum will tend to relieve pressure buildup. If this does not relieve the area, then air can be pumped into the colon to clear blockage. If these procedures are unsuccessful then surgery is required. Approximately 25% of affected children require surgical intervention. Surgery in the affected bowel is advantageous since the actual cause can be removed, and the procedure decreases the possibility of recurrences. In general without surgical correction of the affected bowel, there is a 5-10% chance of recurrence. Recurrence usually appears within the first 24 to 48 hours after barium procedure.
Prognosis
The outcome of intussusception depends on the duration of symptoms before treatment initiation. Most infants will recover if treatment is initiated within the first 24 hours. Untreated intussusception is almost always fatal. Overall even with treatment, approximately 1-2% of affected children will die.
Prevention
Prevention of death can be accomplished with immediate medical care, within the first 24 hours. Once intussusception is suspected, emergency measures should be initiated. Untreated intussusception is almost always fatal. There is an increased chance for death if the disorder is not treated within 48 hours.
Resources
BOOKS
Behrman, Richard E., et al, editors. Nelson Textbook of Pediatrics. 16th ed. W. B. Saunders Company, 2000.
Townsend, Courtney M., et al. Sabiston Textbook of Surgery. 16th ed. W. B. Saunders Company, 2001.
OTHER
University of Maryland. 2001. 〈http://www.umm.edu〉.