Small Bowel Intussusception

Small Bowel IntussusceptionIntussusception is a common concern that we manage when faced with a child with abdominal pain and/or vomiting. We have discussed multiple aspects of the evaluation and management of intussusception (ex, Intussusception, Intussusception and HSP, Change in Mental Status, and Disposition). Obviously, the use of ultrasound has dramatically improved our ability to expeditiously evaluate these children, but what do you do when the ultrasound finds something unexpected? What do you do with Small Bowel Intussusception?

 

Small Bowel Intussusception: Basics

  • Any segment of bowel can develop intussusception.
    • Most often (~80%) it is located at the ileocecal junction or in the ileocolic region.
    • Small Bowel Intussusception is more rare.
  • Can occur in any age, but more rare in children compared to adults. [Koh, 2006]
  • Small Bowel Intussusception presents in non-specific fashion:
    • Irritability
    • Vomiting
    • Abdominal Pain
    • Fever (~50% in one case series) [Ko, 2002]

 

Small Bowel Intussusception: The Benign and The Bad

The Benign

  • Small Bowel Intussusception can be transient and of no clinical consequence. [Mateen, 2006]
  • Can be seen incidentally on other studies performed for other reasons (ex, Pelvic U/S, Abd CT). [Strouse, 2003]
  • Thought to be due to “momentary dysrhythmic contractions.” [Mateen, 2006]
  • Often will reduce spontaneously… many times during the ultrasound study.

 

The Bad

  • Small Bowel Intussusception can also lead to intestinal necrosis.
    • More likely to be associated with underlying pathologic process like:
      • Post-surgical adhesions or Jejunal Tubes
      • Malabsorption syndromes
      • Inflammatory processes (ex, Crohn’s Disease, HSP)
    • Even with underlying pathology, observation has been shown to be appropriate in some cases. [Sonmez, 2002]
  • Require surgical correction, as air-contrast enema is less effective in treating small bowel. [Koh, 2006]
  • More difficult to diagnose than large bowel associated intussusception. [Ko, 2002]
    • Delays in diagnosis and surgical correction are common.
    • These delays are associated with higher complication rates. [Ko, 2002]

 

Small Bowel Intussusception: Will it be Transient?

  • So, if the condition can be either “no big deal” or a “real big deal,” what can be done to differentiate between these two extremes?
    • Obviously it would be best to avoid unnecessary surgery for those that will have spontaneous reduction of their benign small bowel intussusception.
    • Equally important, it is necessary to limit ischemic time and not delay surgical intervention for those with pathologic small bowel intussusception.
  • Several studies have determined that U/S characteristics can help with this determination:
    • Likely to spontaneously reduce:
      • Length < 1.8 cm, Mean diameter < 1.5 cm, No Wall Swelling, Preserved Wall Motion, No Lead Point [Kim, 2004]
      • Length < 3.5 cm, No Lead Point, Normal Wall Thickness, No Proximal Dilation, Normal Blood Flow [Mateen, 2006]
    • Likely to need a surgeon to reduce:
      • Length > 3.5 cm [Munden, 2007]
      • Length ≥ 4.2 cm, Diameter ≥ 2.1 cm, Outer Rim Thickness ≥ 0.04 cm [Zhang, 2011]

 

Moral of the Morsel

  • Small Bowel Intussusception can be Benign… but it can also lead to Badness!
  • U/S Characteristics can help distinguish which ones will likely reduce on their own… and which ones will not.
    • Smaller is better.
    • Motion is marvelous.
    • Lead Points are bad.
  • Pay attention to the patient!  Persistent symptoms may warrant repeat U/S and/or surgical consultation.
  • If the intussusception does not spontaneously reduce during the U/S study, even if it has low risk findings, have low threshold for repeating the U/S. [Kornecki, 2000]

 

References

Rajagopal R, Mishra N1, Yadav N, Jhanwar V, Thakur A, Mannan N. Transient versus surgically managed small bowel intussusception in children: Role of ultrasound. Afr J Paediatr Surg. 2015 Apr-Jun;12(2):140-2. PMID: 26168754. [PubMed] [Read by QxMD]

Lioubashevsky N1, Hiller N, Rozovsky K, Segev L, Simanovsky N. Ileocolic versus small-bowel intussusception in children: can US enable reliable differentiation? Radiology. 2013 Oct;269(1):266-71. PMID: 23801771. [PubMed] [Read by QxMD]

Zhang Y1, Bai YZ, Li SX, Liu SJ, Ren WD, Zheng LQ. Sonographic findings predictive of the need for surgical management in pediatric patients with small bowel intussusceptions. Langenbecks Arch Surg. 2011 Oct;396(7):1035-40. PMID: 21274558. [PubMed] [Read by QxMD]

Munden MM1, Bruzzi JF, Coley BD, Munden RF. Sonography of pediatric small-bowel intussusception: differentiating surgical from nonsurgical cases. AJR Am J Roentgenol. 2007 Jan;188(1):275-9. PMID: 17179377. [PubMed] [Read by QxMD]

Mateen MA1, Saleem S, Rao PC, Gangadhar V, Reddy DN. Transient small bowel intussusceptions: ultrasound findings and clinical significance. Abdom Imaging. 2006 Jul-Aug;31(4):410-6. PMID: 16944032. [PubMed] [Read by QxMD]

Koh EP1, Chua JH, Chui CH, Jacobsen AS. A report of 6 children with small bowel intussusception that required surgical intervention. J Pediatr Surg. 2006 Apr;41(4):817-20. PMID: 16567200. [PubMed] [Read by QxMD]

Kim JH1. US features of transient small bowel intussusception in pediatric patients. Korean J Radiol. 2004 Jul-Sep;5(3):178-84. PMID: 15467415. [PubMed] [Read by QxMD]

Strouse PJ1, DiPietro MA, Saez F. Transient small-bowel intussusception in children on CT. Pediatr Radiol. 2003 May;33(5):316-20. PMID: 12695864. [PubMed] [Read by QxMD]

Ko SF1, Lee TY, Ng SH, Wan YL, Chen MC, Tiao MM, Liang CD, Shieh CS, Chuang JH. Small bowel intussusception in symptomatic pediatric patients: experiences with 19 surgically proven cases. World J Surg. 2002 Apr;26(4):438-43. PMID: 11910476. [PubMed] [Read by QxMD]

Sönmez K1, Turkyilmaz Z, Demirogullari B, Karabulut R, Aral YZ, Konuş O, Başaklar AC, Kale N. Conservative treatment for small intestinal intussusception associated with Henoch-Schönlein’s purpura. Surg Today. 2002;32(12):1031-4. PMID: 12541018. [PubMed] [Read by QxMD]

Kornecki A1, Daneman A, Navarro O, Connolly B, Manson D, Alton DJ. Spontaneous reduction of intussusception: clinical spectrum, management and outcome. Pediatr Radiol. 2000 Jan;30(1):58-63. PMID: 10663512. [PubMed] [Read by QxMD]

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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