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Emergency And Acute Medicine – Intussusception
Basics
Description Intussusception occurs when a proximal segment of bowel telescopes into a distal segment, leading to bowel obstruction, ischemia, infarction, and possible gangrene. More than 80% of cases involve the ileocecal region. It is the most common cause of intestinal obstruction in the first 2 years of life. Mortality is less than 1% with prompt treatment, but morbidity increases significantly with delayed diagnosis.
Epidemiology Most cases occur between 5 and 9 months of age, with an incidence of approximately 2.4 per 1,000 live births. There is a male predominance of about 2:1. Children older than 2 years are more likely to have a pathologic lead point, and in children older than 6 years, lymphoma is the most common lead point. Adults almost always have an identifiable pathologic lead point.
Alert Any infant or child presenting with episodic abdominal pain, vomiting, lethargy or altered mental status, or heme-positive stool should be evaluated for intussusception.
Etiology Most cases, particularly in infants, are idiopathic. In older children and adults, intussusception is often caused by a lead point such as lymphoma, polyps, lipomas, hypertrophied lymphoid tissue, Meckel diverticulum, viral infections such as adenovirus or rotavirus, parasites, foreign bodies, Henoch–Schönlein purpura, or underlying conditions such as celiac disease or cystic fibrosis.
Diagnosis
Signs and symptoms The classic triad of abdominal pain, vomiting, and bloody “currant jelly” stools occurs in fewer than half of patients. Abdominal pain is typically sudden, severe, intermittent, and associated with screaming and drawing up of the legs. Vomiting may be bilious. Stools may be grossly bloody or only occult blood positive. Mental status changes such as irritability, lethargy, or listlessness are common and may precede abdominal findings. Fever and abdominal distention may occur as the disease progresses.
Physical exam The abdomen may be distended and tender, and a sausage-shaped mass is sometimes palpable in the right upper quadrant. The right lower quadrant may feel empty. Rectal examination may reveal blood or a mass. In advanced cases, signs of peritonitis or sepsis from bowel perforation may be present.
Essential workup The diagnosis is suggested by the clinical presentation and confirmed radiographically. A heme-positive stool can support the diagnosis, particularly in patients presenting with lethargy.
Diagnosis tests and interpretation Laboratory studies typically include a CBC, electrolytes, BUN, and type and cross-match if surgery is anticipated. Abdominal radiographs are abnormal in only 35–40% of cases but may show decreased gas in the right colon, bowel obstruction, or free air if perforation has occurred. Ultrasound is the preferred initial diagnostic test and is highly sensitive and specific, demonstrating a “target” or “donut” sign. Contrast or air enema is both diagnostic and therapeutic and is successful in approximately 75–80% of cases when performed within 24 hours of symptom onset. Enema reduction is contraindicated in patients with perforation, peritonitis, or hemodynamic instability. Surgical intervention is required when enema reduction fails or is contraindicated, or when a pathologic lead point is suspected.
Differential diagnosis Conditions to consider include acute gastroenteritis, appendicitis, pneumonia, pyelonephritis, colic, malrotation with volvulus, strangulated hernia, Hirschsprung disease, inflammatory bowel disease, Henoch–Schönlein purpura, trauma, and intestinal ischemia.
Treatment
Prehospital care Management includes establishing IV access and administering isotonic fluid boluses for hypovolemia when indicated. The diagnosis is rarely confirmed in the prehospital setting.
Initial stabilization In the emergency department, IV access is obtained, fluid resuscitation initiated, and a nasogastric tube placed for decompression if needed. Early surgical consultation is essential.
Emergency department management Stabilization of airway, breathing, and circulation is followed by imaging and radiologic reduction with air or contrast enema when appropriate. Broad-spectrum antibiotics are initiated if there is concern for perforation, peritonitis, or sepsis. Surgical reduction is required if nonoperative management fails.
Follow-up and disposition Patients who undergo successful enema reduction should be admitted for observation due to the risk of recurrence. All patients requiring surgery should be admitted. Discharge may be considered only after prolonged observation, complete resolution of symptoms, normal mental status, and reliable caregivers who understand the signs of recurrence.
Pearls and pitfalls Intussusception may present primarily with lethargy rather than abdominal pain, and the classic triad is often absent. Delayed diagnosis increases the risk of bowel necrosis, perforation, and sepsis. Recurrence occurs in up to 10% of cases and may still be amenable to repeat enema reduction.
Basics
Description Intussusception occurs when a proximal segment of bowel telescopes into a distal segment, leading to bowel obstruction, ischemia, infarction, and possible gangrene. More than 80% of cases involve the ileocecal region. It is the most common cause of intestinal obstruction in the first 2 years of life. Mortality is less than 1% with prompt treatment, but morbidity increases significantly with delayed diagnosis.
Epidemiology Most cases occur between 5 and 9 months of age, with an incidence of approximately 2.4 per 1,000 live births. There is a male predominance of about 2:1. Children older than 2 years are more likely to have a pathologic lead point, and in children older than 6 years, lymphoma is the most common lead point. Adults almost always have an identifiable pathologic lead point.
Alert Any infant or child presenting with episodic abdominal pain, vomiting, lethargy or altered mental status, or heme-positive stool should be evaluated for intussusception.
Etiology Most cases, particularly in infants, are idiopathic. In older children and adults, intussusception is often caused by a lead point such as lymphoma, polyps, lipomas, hypertrophied lymphoid tissue, Meckel diverticulum, viral infections such as adenovirus or rotavirus, parasites, foreign bodies, Henoch–Schönlein purpura, or underlying conditions such as celiac disease or cystic fibrosis.
Diagnosis
Signs and symptoms The classic triad of abdominal pain, vomiting, and bloody “currant jelly” stools occurs in fewer than half of patients. Abdominal pain is typically sudden, severe, intermittent, and associated with screaming and drawing up of the legs. Vomiting may be bilious. Stools may be grossly bloody or only occult blood positive. Mental status changes such as irritability, lethargy, or listlessness are common and may precede abdominal findings. Fever and abdominal distention may occur as the disease progresses.
Physical exam The abdomen may be distended and tender, and a sausage-shaped mass is sometimes palpable in the right upper quadrant. The right lower quadrant may feel empty. Rectal examination may reveal blood or a mass. In advanced cases, signs of peritonitis or sepsis from bowel perforation may be present.
Essential workup The diagnosis is suggested by the clinical presentation and confirmed radiographically. A heme-positive stool can support the diagnosis, particularly in patients presenting with lethargy.
Diagnosis tests and interpretation Laboratory studies typically include a CBC, electrolytes, BUN, and type and cross-match if surgery is anticipated. Abdominal radiographs are abnormal in only 35–40% of cases but may show decreased gas in the right colon, bowel obstruction, or free air if perforation has occurred. Ultrasound is the preferred initial diagnostic test and is highly sensitive and specific, demonstrating a “target” or “donut” sign. Contrast or air enema is both diagnostic and therapeutic and is successful in approximately 75–80% of cases when performed within 24 hours of symptom onset. Enema reduction is contraindicated in patients with perforation, peritonitis, or hemodynamic instability. Surgical intervention is required when enema reduction fails or is contraindicated, or when a pathologic lead point is suspected.
Differential diagnosis Conditions to consider include acute gastroenteritis, appendicitis, pneumonia, pyelonephritis, colic, malrotation with volvulus, strangulated hernia, Hirschsprung disease, inflammatory bowel disease, Henoch–Schönlein purpura, trauma, and intestinal ischemia.
Treatment
Prehospital care Management includes establishing IV access and administering isotonic fluid boluses for hypovolemia when indicated. The diagnosis is rarely confirmed in the prehospital setting.
Initial stabilization In the emergency department, IV access is obtained, fluid resuscitation initiated, and a nasogastric tube placed for decompression if needed. Early surgical consultation is essential.
Emergency department management Stabilization of airway, breathing, and circulation is followed by imaging and radiologic reduction with air or contrast enema when appropriate. Broad-spectrum antibiotics are initiated if there is concern for perforation, peritonitis, or sepsis. Surgical reduction is required if nonoperative management fails.
Follow-up and disposition Patients who undergo successful enema reduction should be admitted for observation due to the risk of recurrence. All patients requiring surgery should be admitted. Discharge may be considered only after prolonged observation, complete resolution of symptoms, normal mental status, and reliable caregivers who understand the signs of recurrence.
Pearls and pitfalls Intussusception may present primarily with lethargy rather than abdominal pain, and the classic triad is often absent. Delayed diagnosis increases the risk of bowel necrosis, perforation, and sepsis. Recurrence occurs in up to 10% of cases and may still be amenable to repeat enema reduction.
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