Intussusception (medical disorder)

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Intussusception
VolvulusCT.PNG
An intussusception as seen on CT
Specialty Pediatrics, general surgery
Symptoms Abdominal pain, vomiting, bloody stool [1]
Complications Peritonitis, bowel perforation [1]
Usual onsetOver days to weeks in a 6- to 18-month-old [1]
CausesUnknown, lead point [1]
Diagnostic method Medical imaging [1]
Differential diagnosis Pyloric stenosis [1]
Treatment Enema, surgery [1]
Medication Dexamethasone [2]

Intussusception is a medical condition in which a part of the intestine folds into the section immediately ahead of it. [1] It typically involves the small bowel and less commonly the large bowel. [1] Symptoms include abdominal pain which may come and go, vomiting, abdominal bloating, and bloody stool. [1] It often results in a small bowel obstruction. [1] Other complications may include peritonitis or bowel perforation. [1]

Contents

The cause in children is typically unknown; in adults a lead point is sometimes present. [1] Risk factors in children include certain infections, diseases like cystic fibrosis, and intestinal polyps. [1] Risk factors in adults include endometriosis, bowel adhesions, and intestinal tumors. [1] Diagnosis is often supported by medical imaging. [1] In children, ultrasound is preferred while in adults a CT scan is preferred. [1]

Intussusception is an emergency requiring rapid treatment. [1] Treatment in children is typically by an enema with surgery used if this is not successful. [1] Dexamethasone may decrease the risk of another episode. [2] In adults, surgical removal of part of the bowel is more often required. [1] Intussusception occurs more commonly in children than adults. [1] In children, males are more often affected than females. [1] The usual age of occurrence is six to eighteen months old. [1]

Signs and symptoms

Early symptoms can include periodic abdominal pain, nausea, vomiting (sometimes green in color from bile), pulling legs to the chest area, and intermittent moderate to severe cramping abdominal pain. Pain is intermittent—not because the intussusception temporarily resolves, but because the intussuscepted bowel segment transiently stops contracting. Later signs include rectal bleeding, often with "red currant jelly" stool (stool mixed with blood and mucus), and lethargy. Physical examination may reveal a "sausage-shaped" mass, felt upon palpating the abdomen. [3] Children, or those unable to communicate symptoms verbally, may cry, draw their knees up to their chest, or experience dyspnea (difficult or painful breathing) with paroxysms of pain. In neonates it may present with bilious vomiting and blood stained stools [4]

Fever is not a symptom of intussusception. However, intussusception can cause a loop of bowel to become necrotic, secondary to ischemia due to compression to arterial blood supply. This leads to perforation and sepsis, which causes fever.

In rare cases, intussusception may be a complication of Henoch–Schönlein purpura, an immune-mediated vasculitis disease in children. Such patients who develop intussusception often present with severe abdominal pain in addition to the classic signs and symptoms of HSP.

Cause

Causes of intussusception are not clearly established or understood. About 90% of cases of intussusception in children arise from an unknown cause. [1] They can include infections, anatomical factors, and altered motility.[ citation needed ]

The rotavirus vaccine is linked to intussusception. [5]

Pathophysiology

Drawing of intussusception Intussusception EN.svg
Drawing of intussusception

In the most frequent type of intussusception, the ileum enters the cecum. However, other types occur, such as when a part of the ileum or jejunum prolapses into itself.

The part that prolapses into the other is called the intussusceptum, and the part that receives it is called the intussuscipiens. Almost all intussusceptions occur with the intussusceptum having been located proximally to the intussuscipiens. This is because peristaltic action of the intestine pulls the proximal segment into the distal segment. There are, however, rare reports of the opposite being true.

An anatomic lead point (that is, a piece of intestinal tissue that protrudes into the bowel lumen) is present in approximately 10% of intussusceptions. [6] The lead point (best exemplified by a polyp) serves as a focal area of traction, which the peristaltic action pulls into the distal bowel, thus invaginating the attached bowel segment. [7]

The trapped section of bowel may have its blood supply cut off, which causes ischemia (lack of oxygen in the tissues). The mucosa (gut lining) is very sensitive to ischemia, and responds by sloughing off into the gut. This creates the classically described "red currant jelly" stool, which is a mixture of sloughed mucosa, blood, and mucus. [8] A study reported that in actuality, only a minority of children with intussusception had stools that could be described as "red currant jelly", and hence intussusception should be considered in the differential diagnosis of children passing any type of bloody stool. [9]

Diagnosis

Small intestinal invagination on computed tomography Invagination 001 CT cor.png
Small intestinal invagination on computed tomography
An ultrasound showing intussusception [10]
An ultrasound shows a target sign--characteristic for intussusception Invagination Sonografie.jpg
An ultrasound shows a target sign—characteristic for intussusception

An intussusception is often suspected based on history and physical exam, including observation of Dance's sign. A digital rectal examination is particularly helpful in children, as part of the intussusceptum may be felt by the finger. A definite diagnosis often requires confirmation by diagnostic imaging modalities. Ultrasound is the imaging modality of choice for diagnosis and exclusion of intussusception, due to its high accuracy and lack of radiation. The appearance of target sign (also called "doughnut sign" on a sonograph, usually around 3 cm in diameter, confirms the diagnosis. The image seen on transverse sonography or computed tomography is that of a doughnut shape, created by the hyperechoic central core of bowel and mesentery surrounded by the hypoechoic outer edematous bowel. [11] In longitudinal imaging, intussusception resembles a sandwich. [11] It is also called "pseudokidney" sign because hyperechoic tubular centre is covered by a hypoechoic rim producing a kidney-like appearance. [12]

Classification

In children, insussusception at the ileocecal junction accounts for 90 percent of all cases. [14]

Differential diagnosis

An intussusception has two main differential diagnoses: acute gastroenteritis and rectal prolapse. Abdominal pain, vomiting, and stool with mucus and blood are present in acute gastroenteritis, but diarrhea is the leading symptom. Rectal prolapse can be differentiated by projecting mucosa that can be felt in continuity with the perianal skin, whereas in intussusception the finger may pass indefinitely into the depth of the sulcus.

Treatment

The condition is not usually immediately life-threatening. The intussusception can be treated with either a barium or water-soluble contrast enema or an air-contrast enema, which both confirms the diagnosis of intussusception, and in most cases successfully reduces it. [15] The success rate is over 80%. However, approximately 5–10% of these recur within 24 hours.[ citation needed ]

Cases where it cannot be reduced by an enema or the intestine is damaged require surgical reduction. In a surgical reduction, the surgeon opens the abdomen and manually squeezes (rather than pulls) the part that has telescoped. If the surgeon cannot successfully reduce it, or the bowel is damaged, they resect the affected section. More often, the intussusception can be reduced by laparoscopy, pulling the segments of intestine apart with forceps.[ citation needed ]

Prognosis

Intussusception may become a medical emergency if not treated early, as it eventually causes death if not reduced. In developing countries where medical hospitals are not easily accessible, especially when other problems complicate the intussusception, death becomes almost inevitable. When intussusception or any other severe medical problem is suspected, the person must be taken to a hospital immediately.[ citation needed ]

The outlook for intussusception is excellent when treated quickly, but when untreated it can lead to death within two to five days. It requires fast treatment, because the longer the intestine segment is prolapsed the longer it goes without bloodflow, and the less effective a non-surgical reduction is. Prolonged intussusception also increases the likelihood of bowel ischemia and necrosis, requiring surgical resection.[ citation needed ]

Epidemiology

The condition is more common in children than in adults. [16] It strikes about 2,000 infants (one in every 1,900) in the United States in the first year of life. Its incidence begins to rise at about one to five months of life, peaks at four to nine months of age, and then gradually declines at around 18 months.[ citation needed ]

Intussusception occurs more frequently in boys than in girls, with a ratio of approximately 3:1. [17]

In adults, intussusception represents the cause of approximately 1% of bowel obstructions and is frequently associated with neoplasm, malignant or otherwise. [18]

Related Research Articles

<span class="mw-page-title-main">Constipation</span> Bowel dysfunction

Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Hirschsprung's disease</span> Medical condition

Hirschsprung's disease is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea and slow growth. Most children develop signs and symptoms shortly after birth. However, others may be diagnosed later in infancy or early childhood. About half of all children with Hirschsprung's disease are diagnosed in the first year of life. Complications may include enterocolitis, megacolon, bowel obstruction and intestinal perforation.

<span class="mw-page-title-main">Bowel obstruction</span> Medical condition

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Rectal prolapse</span> Medical condition

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

<span class="mw-page-title-main">Meckel's diverticulum</span> Medical condition

A Meckel's diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the vitelline duct. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

<span class="mw-page-title-main">Volvulus</span> Twisting of part of the intestine, causing a bowel obstruction

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

Intestinal malrotation is a congenital anomaly of rotation of the midgut. It occurs during the first trimester as the fetal gut undergoes a complex series of growth and development. Malrotation can lead to a dangerous complication called volvulus, in which cases emergency surgery is indicated. Malrotation can refer to a spectrum of abnormal intestinal positioning, often including:

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<span class="mw-page-title-main">Ischemic colitis</span> Medical condition

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.

<span class="mw-page-title-main">Distal intestinal obstruction syndrome</span> Medical condition

Distal intestinal obstruction syndrome (DIOS) involves obstruction of the distal part of the small intestines by thickened intestinal content and occurs in about 20% of mainly adult individuals with cystic fibrosis. DIOS was previously known as meconium ileus equivalent, a name which highlights its similarity to the intestinal obstruction seen in newborn infants with cystic fibrosis. DIOS tends to occur in older individuals with pancreatic insufficiency. Individuals with DIOS may be predisposed to bowel obstruction, though it is a separate entity than true constipation.

<span class="mw-page-title-main">Intestinal atresia</span> Medical condition

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<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

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<span class="mw-page-title-main">Intestinal ischemia</span> Restriction of blood flow to the small intestine resulting in injury

Intestinal ischemia is a medical condition in which injury to the large or small intestine occurs due to not enough blood supply. It can come on suddenly, known as acute intestinal ischemia, or gradually, known as chronic intestinal ischemia. The acute form of the disease often presents with sudden severe abdominal pain and is associated with a high risk of death. The chronic form typically presents more gradually with abdominal pain after eating, unintentional weight loss, vomiting, and fear of eating.

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<span class="mw-page-title-main">Colonic ulcer</span> Medical condition

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References

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Further reading