Intussusception (medical disorder)
Encyclopedia
An intussusception is a medical condition in which a part of the intestine has invaginated into another section of intestine, similar to the way in which the parts of a collapsible telescope
slide into one another. This can often result in an obstruction. The part that prolapses into the other is called the intussusceptum, and the part that receives it is called the intussuscipiens.
, vomiting
(sometimes bile stained (green color), pulling legs to the chest area, and intermittent moderate to severe cramping abdominal pain
. Pain is intermittent not because the intussusception temporarily resolves, but because the intussuscepted bowel segment transiently stops contracting. Later signs include rectal bleeding
, often with "red currant jelly" stool (stool mixed with blood and mucus), and lethargy. Physical examination may reveal a "sausage-shaped" mass felt upon palpation
of the abdomen.
In children or those too young to communicate their symptoms verbally, they may cry
, draw their knees up to their chest or experience dyspnea
(difficult or painful breathing) with paroxysms of pain.
Fever
is not a symptom of intussusception. However, intussusception can cause a loop of bowel to become necrotic
, secondary to ischemia
due to compression to arterial blood supply. This leads to perforation and sepsis
, which causes fever.
. Per rectal examination is particularly helpful in children as part of the intussusceptum may be felt by the finger. A definite diagnosis often requires confirmation by diagnostic imaging modalities. Ultrasound
is today considered the imaging modality of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation. A target-like mass, usually around 3 cm in diameter, confirms the diagnosis. An x-ray
of the abdomen may be indicated for evaluation of intestinal obstruction or the presence of free intraperitoneal gas; the latter finding would imply that bowel perforation has already occurred. In some institutions, air enema is used for diagnosis as the same procedure can be used for treatment.
These are acute gastroenteritis
, Henoch–Schönlein purpura, and rectal prolapse
. Abdominal pain, vomiting, and stool with mucus and blood are present in acute gastroenteritis, but diarrhea is the leading symptom. Rectal prolapse can be differentiated by projecting mucosa that can be felt in continuity with the perianal skin, whereas in intussusception the finger may pass indefinitely into the depth of sulcus. Henoch–Schönlein purpura presents the characteristic rash.
or an air-contrast enema, which both confirms the diagnosis of intussusception, and in most cases successfully reduces it. The success rate is over 80%. However, approximately 5–10% of these recur within 24 hours.
If it cannot be reduced by an enema or if the intestine is damaged, then a surgical reduction is necessary. In a surgical reduction, the abdomen is opened and the part that has telescoped in is squeezed out (rather than pulled out) manually by the surgeon or if the surgeon is unable to successfully reduce it or the bowel is damaged, the affected section will be resected
. More often, the intussusception can be reduced by laparoscopy
, whereby the segments of intestine are pulled apart by forceps.
if not treated early, as it will eventually cause death if not reduced. In developing countries where medical hospitals are not easily accessible, especially when the occurrence of intussusception is complicated with other problems, death becomes almost inevitable. When intussusception or any other severe medical problem is suspected, the person must be taken to a hospital immediately.
The outlook for intussusception is excellent when treated quickly, but when untreated it can lead to death within 2–5 days. Fast treatment is a necessity, because the longer the intestine segment is prolapsed the longer it goes without bloodflow, and the less effective a non-surgical reduction will be. Prolonged intussusception also increases the likelihood of bowel ischemia and necrosis, requiring surgical resection.
Telescope
A telescope is an instrument that aids in the observation of remote objects by collecting electromagnetic radiation . The first known practical telescopes were invented in the Netherlands at the beginning of the 1600s , using glass lenses...
slide into one another. This can often result in an obstruction. The part that prolapses into the other is called the intussusceptum, and the part that receives it is called the intussuscipiens.
Symptoms
Early symptoms can include nauseaNausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, vomiting
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
(sometimes bile stained (green color), pulling legs to the chest area, and intermittent moderate to severe cramping abdominal pain
Abdominal pain
Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...
. Pain is intermittent not because the intussusception temporarily resolves, but because the intussuscepted bowel segment transiently stops contracting. Later signs include rectal bleeding
Rectal bleeding
Rectal bleeding can refer to:* Lower gastrointestinal bleeding* Hematochezia* Fecal occult blood* Melena...
, often with "red currant jelly" stool (stool mixed with blood and mucus), and lethargy. Physical examination may reveal a "sausage-shaped" mass felt upon palpation
Palpation
Palpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...
of the abdomen.
In children or those too young to communicate their symptoms verbally, they may cry
Cry
Cry usually refers to crying, the act of shedding tears.Cry may also refer to:* Cry, Yonne, a commune in France* CRY , worldwide non-profit organization-Songs:* "Cry" , 1951...
, draw their knees up to their chest or experience dyspnea
Dyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
(difficult or painful breathing) with paroxysms of pain.
Fever
Fever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
is not a symptom of intussusception. However, intussusception can cause a loop of bowel to become necrotic
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
, secondary to ischemia
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
due to compression to arterial blood supply. This leads to perforation and sepsis
Sepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
, which causes fever.
Diagnosis
Intussusception is often suspected based on history and physical exam, including observation of Dance's signDance's sign
Dance's sign is an eponymous medical sign consisting of an investigation of the right lower quadrant of the abdomen for retraction, which can be an indication of intussusception, i.e. those with intussusception may have retraction of the right iliac fossa....
. Per rectal examination is particularly helpful in children as part of the intussusceptum may be felt by the finger. A definite diagnosis often requires confirmation by diagnostic imaging modalities. Ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
is today considered the imaging modality of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation. A target-like mass, usually around 3 cm in diameter, confirms the diagnosis. An x-ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
of the abdomen may be indicated for evaluation of intestinal obstruction or the presence of free intraperitoneal gas; the latter finding would imply that bowel perforation has already occurred. In some institutions, air enema is used for diagnosis as the same procedure can be used for treatment.
Differential diagnosis
Intussusception has three main differential diagnoses.These are acute gastroenteritis
Gastroenteritis
Gastroenteritis is marked by severe inflammation of the gastrointestinal tract involving both the stomach and small intestine resulting in acute diarrhea and vomiting. It can be transferred by contact with contaminated food and water...
, Henoch–Schönlein purpura, and rectal prolapse
Rectal prolapse
Rectal prolapse normally describes a medical condition wherein the walls of the rectum protrude through the anus and hence become visible outside the body.-Types:There are three chief conditions which come under the title rectal prolapse:...
. Abdominal pain, vomiting, and stool with mucus and blood are present in acute gastroenteritis, but diarrhea is the leading symptom. Rectal prolapse can be differentiated by projecting mucosa that can be felt in continuity with the perianal skin, whereas in intussusception the finger may pass indefinitely into the depth of sulcus. Henoch–Schönlein purpura presents the characteristic rash.
Treatment
The condition is not usually immediately life-threatening. The intussusception can be treated with either a barium or water-soluble contrast enemaEnema
An enema is the procedure of introducing liquids into the rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and...
or an air-contrast enema, which both confirms the diagnosis of intussusception, and in most cases successfully reduces it. The success rate is over 80%. However, approximately 5–10% of these recur within 24 hours.
If it cannot be reduced by an enema or if the intestine is damaged, then a surgical reduction is necessary. In a surgical reduction, the abdomen is opened and the part that has telescoped in is squeezed out (rather than pulled out) manually by the surgeon or if the surgeon is unable to successfully reduce it or the bowel is damaged, the affected section will be resected
Resection
Resection may refer to:*Segmental resection , the partial removal of an organ or other body structure*Resection , a means of establishing a location...
. More often, the intussusception can be reduced by laparoscopy
Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...
, whereby the segments of intestine are pulled apart by forceps.
Prognosis
Intussusception may become a medical emergencyMedical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
if not treated early, as it will eventually cause death if not reduced. In developing countries where medical hospitals are not easily accessible, especially when the occurrence of intussusception is complicated with other problems, death becomes almost inevitable. When intussusception or any other severe medical problem is suspected, the person must be taken to a hospital immediately.
The outlook for intussusception is excellent when treated quickly, but when untreated it can lead to death within 2–5 days. Fast treatment is a necessity, because the longer the intestine segment is prolapsed the longer it goes without bloodflow, and the less effective a non-surgical reduction will be. Prolonged intussusception also increases the likelihood of bowel ischemia and necrosis, requiring surgical resection.