Intussusception

Topic Overview

What is intussusception?

Intussusception is a condition that develops when one part of the intestine folds into itself, like a telescope. Although this can occur anywhere along the intestinal tract, it most commonly occurs between the lower part of the small intestine and the beginning of the large intestine. See an illustration of intussusception.

Intussusception is the most common cause of intestinal blockage in children age 2 years and younger.¹ It occurs mainly in young children; it is rare in adults. This topic focuses on intussusception in children.

What causes intussusception?

In children, the cause of intussusception is not known in 90% of cases.² However, it probably involves swelling of lymph nodes within the intestine wall. Intussusception sometimes develops after a child has a viral cold or inflammation in the stomach and intestines.

What are the symptoms?

A child with intussusception may have recurring episodes of severe abdominal pain and may scream and draw up his or her knees from severe cramping. During a bout of pain, the child may look pale. The cramping lasts from about 1 to 5 minutes. Afterward, the child may seem normal, only to have another episode of pain from 5 to 30 minutes later. Some children have an episode of pain before passing stool. As the condition gets worse, the child may become listless and weak between painful episodes.

How is intussusception diagnosed?

Based on your child's symptoms, your health professional will check the child's abdomen for a tender, sausage-shaped lump and will check the rectum for signs of bleeding or bulging of tissue into the rectum (prolapse).

An X-ray of the abdomen is usually done to look for a blockage in the intestine.

Your health professional may want to do other tests, such as an abdominal ultrasound or an air or barium enema. A computed tomography (CT) scan may be done to diagnose intussusception in adults, but it is rarely used in children.

How is it treated?

Most children with intussusception get better if treatment is started within 24 hours of the onset of symptoms. Treatment may involve an enema or surgery to return the intestine to its usual position. However, in children who have other diseases that involve their intestines, intussusception may develop into a more serious problem that requires surgical removal of the affected section of the intestine.

When intussusception occurs, the part of the intestine that folds inward may lose some or all of its blood supply. This section of the intestine becomes swollen and painful. If intussusception is not treated, the intestine may become blocked. In rare cases, the intestine may tear, and stool may leak from it into the child's abdomen, causing a serious, life-threatening condition, as well as gangrene.

Frequently Asked Questions

Symptoms

Symptoms of intussusception usually begin suddenly. Typically, symptoms in a child include:

• Irritability. A child may act fussy or uncomfortable and be difficult to soothe.
• Recurring episodes of sudden, severe abdominal pain. During a bout of pain, the child may look pale and may scream and draw up his or her knees. In the early stages, the child may seem normal between bouts of pain, which tend to recur every 5 to 30 minutes and gradually get worse. As the condition progresses, the child becomes weak and listless between episodes of pain.
• Frequent vomiting. As a child's condition gets worse, vomiting decreases. Green fluid in vomit is a sign that the intestine is blocked.
• Passing irregular stools. Early on, stools may appear normal. After a few hours, stools often are smaller but occur more frequently, and diarrhea may develop. About half of children begin to pass bloody stools, usually within about 12 hours to 1 or 2 days of the onset of other symptoms. As the condition progresses, stools may become deep red and also contain mucus, giving them a jelly-like appearance.
• A swollen, tender abdomen. You may be able to feel a mass shaped somewhat like a sausage, usually along the upper right side of the abdomen.

Very few intussusceptions heal on their own. If intussusception is not treated, serious and life-threatening complications can develop, such as infection of the lining of the abdominal wall (peritonitis) or a hole or opening (perforation) in the intestinal wall.

Signs that intussusception is progressing into a serious illness include:

• Shallow breathing and a rapid, weak heartbeat.
• Fever.
• Dehydration.

In adults, the symptoms of intussusception may be less obvious but include vague abdominal pain, nausea and vomiting, abdominal bloating, or a change in the usual stool output, color, or pattern.

Intussusception may sometimes be mistaken for other conditions with similar symptoms, such as a hernia or appendicitis.

Exams and Tests

A diagnosis of intussusception is usually based on the child's symptoms. If it is suspected, the health professional will do a physical exam. As part of the physical exam, the health professional examines the child's:

• Abdomen, for a tender, sausage-like lump, which suggests telescoping of the intestine. This lump may be difficult to detect, especially if the child is crying.
• Rectum, for the presence of blood or signs of bleeding or bulging of tissue into the rectum (prolapse).

An X-ray of the abdomen is usually done as well. An abdominal X-ray may show nothing unusual in the child's intestines, or it may show signs of a blockage in the intestine.

If the child has rectal bleeding, and an abdominal X-ray strongly suggests the condition, the diagnosis is likely to be intussusception.

Ultrasound of the abdomen and an air or barium enema are used to confirm a diagnosis of intussusception.

Ultrasound of the abdomen

An ultrasound of the abdomen can determine whether intussusception is present and show how much swelling there is in a child's intestinal wall.

Air or barium enema

During an enema, air or barium (a milky-white liquid) is flushed through a child's rectum into the intestines. If intussusception is present, X-rays taken during the enema will show a blockage or a small opening in the affected part of the intestine.

• Enemas using air rather than barium are generally preferred in babies and young children.
• Because of the risk of intestinal rupture during an enema, this procedure should only be done in a hospital where surgical access is immediately available.
• An air or barium enema is also used as a treatment to help clear the intestinal blockage.

A computed tomography (CT) scan of the abdomen is helpful in diagnosing intussusception in adults. It is rarely done in children.

Treatment Overview

Ideally, treatment for intussusception begins within 24 hours after the onset of symptoms. Normally, a child is treated in the hospital with either an enema or surgery. The type of treatment varies depending on the age of the child and the extent of the problem in the intestine.

Enemas

• An enema usually consists of air, although barium (a milky-white liquid) may also be used. This procedure can also confirm a diagnosis. The enema increases the pressure in the child's intestine, which can often cause the affected area to return to its normal position. This process is called reduction.
• Enemas to treat intussusception are done in the X-ray department of a hospital. During the enema, an X-ray or ultrasound is used to check the condition of the intestine.
• An air enema is successful 75% to 94% of the time, and a barium enema is successful 50% to 78% of the time.³ However, the longer the symptoms have been present, the less likely it is that an enema reduction will be successful.
• Sometimes more than one enema is needed. However, an enema should not be used more than 2 or 3 times.
• An enema should not be used if there is evidence of an infection in the lining of the abdominal wall (peritonitis), a ruptured intestine, a severe reaction to an infection that has spread throughout the blood and tissues (sepsis), or the death and decay of tissue (gangrene) in the bowel.

Surgery

Sometimes surgery is needed for intussusception. Surgery may be needed if:

• Enemas have not corrected the problem after two or three attempts.
• Health professionals suspect that the intestine has been damaged and needs to be repaired.
• The child is very ill or the intestine has ruptured, leaking stool into the abdomen.

During surgery to correct intussusception:

• An incision is made through the skin into the abdomen.
• In children, the affected part of the intestine is stretched out and returned to its usual position. Any damaged part is removed. The appendix is usually removed as well.
• The incision through the skin into the abdomen is closed.

If a large portion of the intestine is removed during surgery or the intestine has developed a serious infection, the child may need an ileostomy. This is an opening in which waste leaves the small intestine and collects in an odor-proof plastic pouch fastened to the skin.

If intussusception is not treated, the affected part of the intestine will be blocked and may then rupture. This can cause serious infection and possibly death.

Sometimes intussusception recurs.

• Between 5% and 11% of the time, intussusception recurs in children after it has been treated with enemas.³ If intussusception recurs after it has been treated with enemas, additional enemas or surgery may be needed.
• Between 1% and 4% of the time, intussusception recurs in children after it has been treated with surgery.³ If intussusception recurs after surgery, another surgery of the abdomen is usually needed to correct it again, to look for other conditions that may be causing the condition, or to remove the portion of the intestine that is involved.

Most adults with intussusception need surgery.

Home Treatment

If your child has symptoms of intussusception, home treatment is not appropriate. Take the child to your health professional immediately for a physical exam. If your child has episodes of severe abdominal pain, you may need to take him or her for emergency evaluation.

If your child has had an enema to correct intussusception, watch for signs that the intussusception has recurred. The symptoms may be the same as those from the first episode, which generally include irritability, recurring abdominal pain, vomiting, diarrhea or irregular stools that may contain blood and mucus, and a swollen or tender abdomen.

If your child has had surgery for intussusception, talk with your health professional about your child's care. Usually after this surgery, parents need to:

• Check for signs of complications of surgery, such as nausea, vomiting, diarrhea, or a high fever that does not decrease with home treatment. For more information about fever in children, see the topic Fever, Age 3 and Younger, or Fever, Age 4 and Older.
• Take care of the child's abdominal incision. It may need to be cleaned regularly and checked for signs of infection (such as redness, warmth, pain, or swelling).

References

Citations

1. Sondheimer JM (2005). Intussusception section of Gastrointestinal tract. In WW Hay Jr et al., eds., Current Pediatric Diagnosis and Treatment, 17th ed., pp. 637-638. New York: McGraw-Hill.

2. Kombo LA, et al. (2001). Intussusception, infection, and immunization: Summary of a workshop on rotavirus. Pediatrics, 108(2): e37. Available online: http://www.pediatrics.org/cgi/content/full/108/2/e37.

3. Papadakis K, Feins NR (2002). Intussusception. In FD Burg et al., eds., Gellis and Kagan's Current Pediatric Therapy, vol. 17, pp. 591-594. Philadelphia: W.B. Saunders.

Other Works Consulted

• Hackam DJ, et al. (2005). Intussusception section of Pediatric surgery. In FC Brunicardi et al., eds., Schwartz's Principles of Surgery, 8th ed., pp. 1493-1494. New York: McGraw-Hill.

• Justice FA, et al. (2006). Intussusception: Trends in clinical presentation and management. Journal of Gastroenterology and Hepatology, 21(5): 842-846.

• Schafermeyer RW (2004). Pediatric abdominal emergencies. In JE Tintinalli et al., eds., Emergency Medicine: A Comprehensive Study Guide, 6th ed., pp. 813-821. New York: McGraw-Hill.

• Stevenson RJ (2003). Intussusception section of Gastroenterology and nutrition. In CD Rudolph et al., eds., Rudolph's Pediatrics, 21st ed., pp. 1407-1408. New York: McGraw-Hill.

• Wyllie R (2004). Intussusception section of Ileus, adhesions, intussusception, and closed-loop obstructions. In RE Behrman et al., eds., Nelson Textbook of Pediatrics, 17th ed., pp. 1242-1243. Philadelphia: Saunders.

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