NR 602 Soap Note Intussusception

Intussusception

Intussusception involves a section of intestine being pulled antegrade into the adjacent intestine with the proximal bowel trapped in the distal segment. The invagination of bowel begins proximal to the ileocecal valve and is usually ileocolic, but it can be ileoileal or colocolic. Intussusception is thought to be the most frequent reason for intestinal obstruction in children.

Intussusception most commonly occurs between 5 and 10 months of age and is also the most common cause of intestinal obstruction in children 3 months to 6 years old; 80% of the cases occur before 2 years of age.

In younger infants, intussusception is generally idiopathic and responds to nonoperative approaches. In some children, there is a known medical predisposing factor, such as polyps, Meckel diverticulum, Henoch-Schönlein purpura, constipation, lymphomas, lipomas, parasites, rotavirus, adenovirus, and foreign bodies. 

Intussusception may also be a complication of CF. Children older than 3 years are more likely to have a lead point caused by polyps, lymphoma, Meckel diverticulum, or Henoch-Schönlein purpura; therefore, a cause must be investigated. The currently approved rotavirus vaccines have not been associated with an increased risk of intussusception (Kennedy and Liacouras, 2011).

Clinical Findings

History

  • The classic triad for intussusception, intermittent colicky (crampy) abdominal pain, vomiting, and bloody mucous stools, are present in fewer than 15% of cases (Kennedy and Liacouras, 2011):
  • Paroxysmal, episodic abdominal pain with vomiting every 5 to 30 minutes.
  • Vomiting is nonbilious initially. Some children do not have any pain.
  • Screaming with drawing up of the legs with periods of calm, sleeping, or lethargy between episodes.
  • Stool, possibly diarrhea in nature, with blood (“currant jelly”).
  • A history of a URI is common.
  • Lethargy is a common presenting symptom.
  • Fever may or may not be present; can be a late sign of transmural gangrene and infarction.
  • Severe prostration is possible.

Physical Examination

  • Observe the baby’s appearance and behavior over a period of time; often the child appears glassy-eyed and groggy between episodes, almost as if sedated.
  • A sausage-like mass may be felt in the RUQ of the abdomen with emptiness in the RLQ (Dance sign); observe the infant when quiet between spasms.
  • The abdomen is often distended and tender to palpation.
  • Grossly bloody or guaiac-positive stools.

Diagnostic Studies

  • An abdominal flat-plate radiograph can appear normal, especially early in the course and reveal intussusceptions in only about 60% of cases (Fig. 33-5). A plain radiograph may show sparse or no intestinal gas or stool in the ascending colon with air-fluid levels and distension in the small bowel only.

FIGURE 33-5 Intussusception. A, Plain abdominal radiograph demonstrating a gas-filled stomach and relatively little gas in the distal end of the bowel. This baby had typical clinical features of intussusception and a palpable upper abdominal mass. 

Therefore, an enema with air was performed. B, The intussusception (arrows) is outlined by air. C, Reduction is proved by air refluxing into loops of small bowel. (From Burg FD, Ingelfinger JR, Wald ER, editors: Gellis and Kagan’s current pediatric therapy, ed 15, Philadelphia, 1999, Saunders.)

  • Abdominal ultrasound is very accurate in detecting intussusception and is the test of choice (Ross and LeLeiko, 2010). It shows “target sign” and the “pseudo kidney” sign and can also be used to evaluate resolution following air contrast enema.
  • An air contrast enema is both diagnostic and a treatment modality.

Differential Diagnosis

The differential diagnosis includes incarcerated hernia, testicular torsion, acute gastroenteritis, appendicitis, colic, and intestinal obstruction.

Management

  • Emergency management and consultation with a pediatric radiologist and a pediatric surgeon is recommended.
  • Rehydration and stabilization of fluid status; gastric decompression.
  • Radiologic reduction using a therapeutic air contrast enema under fluoroscopy is the gold standard.
  • Surgery is necessary if perforation, peritonitis, or hypovolemic shock is suspected or radiologic reduction fails.
  • IV antibiotics are often administered to cover potential intestinal perforation.
  • A period of observation following radiologic reduction is recommended (12 to 18 hours); clear discharge instructions to return with any recurrence of symptoms are required, and close phone follow-up for up to 72 hours is prudent.

Complications

Swelling, hemorrhage, incarceration, and necrosis of the bowel requiring bowel resection may occur. Perforation, sepsis, shock, and re-intussusception (reported to typically be less than 10%, usually within 72 hours of radiologic reduction but can occur up to 36 months later) can all occur. Recurrence is associated with the lead points described earlier.