HWN Suggests

Intussusception Part 3: Air it out

OK, so you made the diagnosis of ileocolic intussusception – so let’s fix this problem. The current standard is nonoperative reduction using pneumatic pressure – the Air Contrast Enema. Some facilities use hydrostatic pressure with barium, normal saline or water soluble contrast material as well. The technique is performed under fluoroscopy to watch the intussusception reduce in real time and is 80-95% successful. Reduction under ultrasound with normal saline as the contrast material is also an option. Early studies indicate similar success rates as fluoroscopy without the downsides of radiation exposure.

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  Intussusception Part 1: The basics

Well, it is the #1 cause of intestinal obstruction in children 6 months to 36 months. So, its got that going for it, which is nice. Think about intussusception like a collapsible telescope. One piece of bowel – the proximal intussusceptum, usually the ileum, slides into another piece – the distal intussuscipiens – usually the colon and gets momentarily stuck.

  Intussusception Part 2: Ultrasound-ing good

How good is an ultrasound at diagnosing intussusception? The sensitivity and specificity approaches 100% in the hands of a good sonographer.

 A Bowel Inside a Bowel: Intussusception

Intussusception is the most common abdominal emergency in early childhood, with the majority of cases occurring in patients <2 years of age.

 A New Twist on Intussusception

With increased use of ultrasound, small bowel intussusception is becoming more frequently recognized. The most important predictor of whether it will need to go the OR is length greater than 3.5 cm.

 Intussusception: we dare you to spell it correctly

The classically taught presentation is sudden onset of intermittent, severe abdominal pain. These episodes are marked by crying, distress, and occur at 20-minute intervals. In between these episodes the child is said to behave “normally”. Emesis can occur as well. Rarely, a sausage-shaped mass is felt in the right side of the abdomen... To summarize: in any child aged 6 to 36 months of age with isolated and unexplained lethargy or altered consciousness, intussusception should be suspected. We hate to break it to you, but these symptoms are extremely unreliable. In fact, the triad of pain, palpable sausage-shaped mass, and currant-jelly stool is <15% of patients. Wow that’s poor.

 When an Intussusception Isn't

Small bowel-small bowel intussusceptions may present a diagnostic dilemma within the emergency department. They are often idiopathic, but can be seen after upper respiratory infection including otitis media and rhinitis, rotavirus vaccination, enteric and nonenteric adenovirus infection, bacterial enteritis, in the setting of Henoch-Schönlein purpura, or due to pathological mechanical lead point such as a Meckel's diverticulum, duplication cyst, or a small bowel lymphoma.

Articles of Interest

EM@3AM: Intussusception

In pediatric patients, the classic triad includes sudden colicky pain, a sausage shaped abdominal mass on the right that is palpable, and currant jelly stool. This triad is present in 21% of patients, with currant jelly stool present in 50% of patients. Patients commonly present with intermittent episodes of pain and vomiting. They may present in the knee to chest position during episodes of pain.

A podcast on intussusception

Any list of “Top 10 Emergency Department diagnoses in children you can’t miss” should include intussusception. This episode reviews the diagnosis and management in practical manner that should help you on your next shift.

Adult Intussusception: Not like Trix, Not Just for Kids

The key point is to remember that in contrast to children, the management is usually surgical and all adult patients with intussusception should have a surgical consultation.

Imaging in Intussusception

In children with a low suspicion for intussusception 3-view abdominal x-rays may help rule out the diagnosis. Ultrasound for intussusception is sensitive and specific

It's vital to catch intussusception ASAP

Although the clinical triad is not a perfect predictor of intussusception, the level and nature of training and work experience of the referring physician does greatly influence his or her medical decision making and its repercussions for the patients and their families. It is both appalling and heartening to see the financial resources, time, and energy that parents often spend going from smaller EDs to a larger center to determine "what is wrong with their child."

Keep Your Eye on the Target: POCUS for Intussusception

Abdominal ultrasound is the modality of choice, with sensitivity and specificity approaching 100% when performed by experienced ultrasonographers. The classic imaging findings include a “target sign” or “bull’s eye” that occurs due to the layers of intestines within one another. This target is usually ≥3 cm in diameter.

PEM POCUS Series: Intussusception

Although few studies have looked at point of care ultrasonography (POCUS) for intussusception, the existing studies have shown excellent test characteristics and a decreased length of stay with using POCUS.

Ultrasound Diagnosis of Intussusception

PEM POCUS identifies intussusception with high sensitivity and specificity. These results emphasize the importance of specifying anatomic location of intussusception for predicting success or failure of air enema.

Resources

Pediatric EM Morsels

A child vomiting without diarrhea should raise suspicion.

CanadiEM

Henloch-Schonlein Purpura (HSP) is a IgA mediated small-vessel systemic vasculitis. Intussusception is the most common GI complication of HSP. Submucosal hematoma or edema of the small bowel can act as a pathologic lead point, contributing to intussusception. In HSP, intussusception has a predilection to small bowel as opposed to idiopathic intussusception which typically is ileocolic.

Core EM

“Currant jelly” stools occur in less than 50% of cases.

EM Res

Ultrasound is a great initial diagnostic modality to use that does not involve radiation, and does not require specialty services (so you can do this at your shop even if you do not have immediate availability of pediatric surgery). Sensitivity and specificity have been reported up to 98-100%. However, remember that it is most useful when the patient is in pain, and this can make it difficult. The colicky pain followed by lethargy may result from telescoping and un-telescoping of bowel, so if performed during lethargic or painless periods or by an inexperienced sonographer it may not yield useful information.

SAEM

Intussusception is a common cause of bowel obstruction in infants and young children. 80-90% of children are less than 2 years of age with a slight male predominance.