Intussusception
Key points
Age <2 years
Peak 5-9 months
Causes
Pathological lead points in 10% - mostly in age >5
Most common: Meckels, polyps, lymphoma
Check history for viral illness, Henoch-Schonlein Purpura (HSP)
Postoperative intussusception - rare - lead point from a suture line, appendiceal stump, extensive retroperitoneal dissection e.g. Wilms nephrectomy
Examination findings
Dance's sign - emptiness in RLQ
Mass usually in RUQ
Extussusception - when intussuscepted bowel protrudes from anus or stoma. To differentiate from prolapse, can insert probe alongside bowel into anus or stoma - cannot do this in prolapse
Check for HSP rash
USS is gold standard for diagnosis - targget sign
Plain radiograph findings
Intraluminal mass
Obscure liver margin
Crescent sign
Management
Incidental intussusception - should be asymptomatic, no lead point, no proximal dilatation - manage conservatively
Assess whether patient is suitable for air reduction enema
Older patients may not tolerate - perform laparoscopy in these cases
If perforated/peritonitic - perform laparotomy
Air enema example protocol
American college of radiology guidelines: 3 x 5 minute attempts at sustained pressures of 80-120 mmHg
If partially successful air reduction - can wait 2-4 hours and try again. Minimal benefit after 3 attempts
If recurs (Approx 10% recurrence - mostly within 48h) - repeat air enema
Successful air reduction does not exclude lead point
At laparotomy:
Open reduction +/- resection/anastomosis if bowel necrosis
Do not routinely perform incidental appendicectomy - leads to higher costs and longer stays
If lymphoma found as the lead point - resect completely along with affected nodes - 2011 Retrospective study Kim et al - diffuse B cell lymphoma - surgery + chemotherapy superior survival vs chemotherapy alone
References
Jain S, Haydel MJ. Child Intussusception. [Updated 2023 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431078/
Beres, Alana, and Abd-elrahman Hassan. "Intussusception." Pediatric Surgery NaT, American Pediatric Surgical Association, 2021. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829041/all/Intussusception.