Intussusception

Certainly, we all are concerned about intussusception when we see a child with vomiting without diarrhea. But the management often seems to be different depending on the day of the week and the phase of the moon. Here’s my humble take on it, for what it is worth (per some request):

Basics

  • Age: 3months to 6 years, most common among 3-12 months (but in truth can occur at any age, even elderly patients)
  • The classic triad: colicky abdominal pain, vomiting, and red currant jelly stools
    • Occurs in only 21% of cases.
    • Currant jelly stools are observed in only 50% of cases.
    • 75% without obviously bloody stools will have positive occult blood.
      • This is one reason that checking for heme in the stool of a child with vomiting without diarrhea is reasonable.
  • A child vomiting without diarrhea should raise suspicion.
  • Consider it in infant/toddler with change in mental status/lethargy (TIPS AEIOU – one of the “I’s” is for Intussusception).

Imaging considerations:

  • Choice of Radiographic Evaluation is often based upon your specific institutional resources
    • U/S is the modality of choice for imaging, but cannot treat.
      • Pros: 1) Rapid and not invasive, 2) No radiation, 3) can make alternative diagnosis, 4) may be able to characterize the lead point
      • Con: 1) Does not fix the problem, 2) it is operator dependent
    • Air contrast enema is useful for diagnosis and treatment… but more invasive and still operator dependent.
    • Plain Abdominal Xrays alone are of limited value.
      • May demonstrate a mass in the RUQ.
      • Falsely negative in ~ 20% of cases.
      • Some have found that the combination of “suggestive abdominal radiograph, abdominal pain, lethargy, and vomiting” is highly specific for intussusception and comparable to ultrasound (~93%).

So, this is how I interpret it all:

  • Firstly, the vomiting kid alone should not receive the diagnosis of “acute gastroenteritis.” They all don’t necessarily need a huge work-up, because perhaps they look awesome and the vomiting has only been for a few minutes… so they haven’t had time to develop diarrhea yet; but, if you want to be most judicious, check the stool for occult blood.
  • Secondly, if I am concerned for intussusception then I check a plain film, but not to change my plan to investigate intussusception. Rather I check it to make sure there isn’t a lower-lobe pneumonia or obvious obstruction. What is imperative to know next is that when the radiologist resists doing another study because the plain film “looks normal” you merely state that it is known to be “normal” in a least 20% of cases.
  • Thirdly, I call my radiologist and discuss the case. My personal preference is going to favor the enema in those are not appearing well… let’s not waste any time. In those in whom the story is most suggestive and my pre-test probability is high, but they are currently well appearing (so we have some time) then I request the u/s followed by the enema. The u/s can better define the lead-point and may generate useful information for the surgeons, but with a high pre-test probability, a normal u/s isn’t good enough for me. If my pre-test probability is lower (I can’t define it as a number, but you have taken care of that kid that you had to consider the condition, but it just didn’t seem to make sense) then I request the u/s and perform serial examinations.
  • Fourthly, I call my surgeon. They should be involved early on.

Mendez D, Caviness AC, Ma L, Macias CC. The diagnostic accuracy of an abdominal radiograph with signs and symptoms of intussusception. Am J Emerg Med. 2011 Mar 28.

Broomfield D, Maconochie I. Role of plain abdominal radiograph in the diagnosis of intussusception. BestBETs; http://www.bestbets.org/bets/bet.php?id=00388; March 2009.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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4 Responses

  1. February 25, 2014
  2. July 7, 2014

    […] complaint that in the ED.  The differential is vast and includes some terrible conditions (ex, Intussusception, Necrotizing Enterocolitis, Malrotation) as well as rather common conditions (ex, Constipation).  […]

  3. January 15, 2016

    […] We have previously discussed some of the basic concepts of pediatric intussusception. […]

  4. November 29, 2016

    […] [Source] 2. Fox S. Intussusception. Pediatric EM Morsels. http://pedemmorsels.com/intussusception/ . Published May 20, 2011. Accessed October 10, 2016. 3. Intussusception in children. UpToDate. […]

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