Intussusception By The Numbers

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Patient Presentation
A pediatrician heard from a colleague about a 4-year-old male with intussusception who was successfully reduced by air enema but recurred 8 hours later. The child again was successfully reduced but recurred several days later. The colleague noted that the evaluation for a potential anatomic pathological lead point was negative and fortunately the child had not recurred again. The pediatrician started thinking about the rates of recurrence, radiological reduction success, and the causes of pathological lead points.

Discussion
Intussusception occurs when one segment of the gastrointestinal tract telescopes into an adjacent segment. The outer receiving segment of bowel is known as the intussuscipiens and the inner inverting segment is known as the intussusceptum. It occurs most often in children between 2 months to 5 years, with a peak incidence between 4-10 months. Males are more often affected than females by 3:2. It also occurs more often after abdominal operations particularly in the first 2 weeks. It is the second most common acute abdominal emergency in children after appendicitis. In adults ~80% have an underlying cause or lead point such as a polyp, tumor, fibrosis, endometriosis, etc.. The cause is usually idiopathic in children (95%) but it is hypothesized that in children it is caused by a viral induced edema of the Peyer’s patches in the ileum that serves as a lead point, but this hypothesis has not been confirmed. It commonly occurs near the ileocecal valve.

A review of intussusception presentations can be found here.

Learning Point
The numbers are positive for intussusception patients. There is a high rate of spontaneous reduction and even better rates for radiological reduction. Recurrence rates are relatively low and pathological causes are even lower.

Intussusception numbers

  • Natural history
    • Spontaneous reduction = 17% or higher
    • Perforation risk = 0-6% with most series being <1% for spontaneous perforation
  • Radiological reduction
    • Successful reduction can be as high as 99% with barium enema and 92% with air enema depending on patient characteristics
  • Recurrence
    • Recurrence rate = ~20% overall that occur at any age, age at first episode of intussusception is not predictive of recurrence risk
      • Recurrence risk in first 24 hours is 2.2 – 3.9% and in first 48 hours is 2.7 – 6.6%
    • Pathological lead points are 1.5-12% of intussusceptions, they are more common in older ages (5-14 years)

Potential causes of pathological lead points in intussusception include:

  • Meckel’s diverticulum **
  • Polyps **
    • Single, idiopathic
    • Familial polyposis
    • Peutz-Jeghers syndrome
  • Gastrointestinal duplication**
  • Vascular
    • Henoch-Schonlein purpura
    • Hemangioma
    • Intramural hematoma
    • Lymphangectasia
  • Appendix
    • Appendicitis or periappendicitis
    • Appendix invagination
  • Ectopic tissues
    • Gastric mucosa
    • Pancreas
  • Infectious diseases
    • Adenovirus
    • Calcivirus
    • Echovirus
    • Escherichia coli
    • Rotavirus
    • Tuberculosis
  • Suture line or stricture
  • Tumors
    • Adenocytoma
    • Hamartoma
    • Kaposi sarcoma
    • Lymphoma **
  • Other
    • Catheters
    • Celiac disease
    • Colitis
      • Hirschsprung
      • Neutropenic
    • Cystic Fibrosis
    • Massive lymphoid hyperplasia

** = most common causes of pathological lead point
Questions for Further Discussion
1. Using ultrasound, what is the radiological sign for intussusception called?
2. Describe how the barium or air enema is done for intussusception.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Intestinal Obstruction and Abdominal Pain.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Navarro O, Daneman A. Intussusception. Part 3: Diagnosis and management of those with an identifiable or predisposing cause and those that reduce spontaneously. Pediatr Radiol. 2004 Apr;34(4):305-12.

Maazoun K, Mekki M, Sahnoun L, Hafsa S, Ben Brahim M, Belghith M, Zakhama A, Jouini R, Golli M, Krichene I, Nouri A. Intussusception owing to pathologic lead points in children: report of 27 cases. Arch Pediatr. 2007 Jan;14(1):4-9.

Justice FA, Nguyen LT, Tran SN, Kirkwood CD, Thi NT, Carlin JB, Bines JE. Recurrent intussusception in infants. J Paediatr Child Health. 2011 Nov;47(11):802-5.

Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.

Rubinstein JC, Liu L, Caty MG, Christison-Lagay ER. Pathologic leadpoint is uncommon in ileo-colic intussusception regardless of age. J Pediatr Surg. 2015 Mar 26.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

Published