Intussusception
A pediatric emergency where the bowel folds into itself like a telescope, causing severe cramping and blocking the intestine.
Emergency Management: Perforation during enema reduction, requiring immediate cessation of the procedure and emergent surgical laparotomy.
Intussusception is a life-threatening pediatric emergency where a proximal segment of the intestine invaginates (telescopes) into the lumen of the adjacent distal segment, causing bowel obstruction and potentially mesenteric ischemia.
Detailed Overview
It is the most common cause of intestinal obstruction in children between 6 and 36 months of age. The invagination drags the mesentery along with it, leading to venous congestion, bowel wall edema, subsequent arterial compromise, and if untreated, bowel necrosis and perforation. The most common site is the ileocecal junction.
Epidemiology & Demographics
Incidence is 1 to 4 in 1,000 live births. Peak age is 5 to 9 months. It is more common in males (ratio 3:1).
Etiological Mechanism
In 90% of pediatric cases, it is idiopathic, commonly associated with hypertrophied Peyer's patches following a viral illness (adenovirus, rotavirus). In adults, a pathological lead point (e.g., tumor, polyp) is found in >90% of cases.
Primary Causes
Idiopathic lymphoid hyperplasia (most common in children)
Meckel's diverticulum
Intestinal polyps or lipomas
Henoch-Schönlein purpura (HSP) bowel hematoma
Malignancy (lymphoma or adenocarcinoma, mostly in adults)
A 'lead point' (whether hypertrophied lymphoid tissue or a pathological lesion) is caught by peristaltic waves and dragged forward into the distal bowel. The intussusceptum (proximal segment) enters the intussuscipiens (distal segment). This mechanical invagination compresses the trapped mesentery. Initially, lymphatic and venous return is obstructed, causing massive mural edema. This leads to mucosal bleeding ('currant jelly' stool). Eventually, arterial inflow is cut off, causing ischemic necrosis, transmural gangrene, and perforation leading to peritonitis.
Diagnostic Criteria & Guidelines
Clinical picture combined with an ultrasound showing the classic 'target' or 'doughnut' sign, or diagnosis during therapeutic air/contrast enema.
1. Immediate fluid resuscitation with IV Normal Saline (20 mL/kg bolus). 2. Non-operative reduction: Fluoroscopic or Ultrasound-guided Air (Pneumatic) or Hydrostatic Enema. Air enema is generally preferred (max pressure 120 mmHg) due to lower risk of severe peritoneal contamination if perforation occurs.
Second-Line & Adjunctive Therapy
If non-operative reduction fails, or if there is evidence of peritonitis/perforation: Emergency laparotomy for manual reduction (milking the bowel backwards) or bowel resection with primary anastomosis if tissue is non-viable.
Surgical & Procedural Management
Laparotomy with manual reduction. Resection is mandatory if a pathological lead point is found, if the bowel is gangrenous, or if manual reduction is unsuccessful.
Patient Counseling & Advice
Inform parents that recurrence happens in about 10% of cases, usually within the first few days, and they must return immediately if symptoms reappear.
Follow-Up & Monitoring Schedule
Admit to the hospital for 12-24 hours post-reduction for observation and rehydration. Tolerate clear liquid diet before discharge.
Preventive Strategies
Prompt management of gastrointestinal illnesses.
Excellent if recognized and reduced early (mortality <1%). Delay in diagnosis rapidly increases the risk of bowel resection and mortality.