Download Intussusception

Ryan Chuang
Gillian Lieberman, MD
July 2002
Intussusception
Ryan Chuang, Harvard Medical School, MS IV
Gillian Lieberman, MD
Ryan Chuang
Gillian Lieberman, MD
Intussusception: Definition
• slipping of a length of intestine into an
adjacent portion producing obstruction.
www.intellihealth.com
Intussusceptum
Intussuscipiens
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www.mayoclinic.com
Ryan Chuang
Gillian Lieberman, MD
Types of Intussusception
Anatomic Classification
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Ileocolic
Ileoileal
Colocolic
Ileoileocolic
The CIBA Collection of Medical Illustrations; Vol. 3
Digestive System, Part II, Lower Digestive Tract.
Netter, Frank, MD.
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Ryan Chuang
Gillian Lieberman, MD
Intussusception
Etiologic Classification
1) Classical “idiopathic” presentation
- Mostly between ages 3 months – 3 years
- Occurs more often in males than females
- Theory of Hypertrophied Lymph Tissue Predisposition
2) Defined “lead point” cause
- Occurs in all ages
- < 10% of all cases
- Generally requires surgical intervention
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Ryan Chuang
Gillian Lieberman, MD
Possible Lead Points
• Meckel’s diverticulum
• Intestinal polyp
• Intramural hematoma
• Enteric duplication
• Lipoma
Can occur in pts w/ lymphomas, HenochSchönlein purpura, Peutz-Jeghers Syndrome, etc.
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Ryan Chuang
Gillian Lieberman, MD
Patient #1
• 48 yo male w/ hx of tuberous sclerosis,
mental retardation, and a seizure disorder
• Chief complaint on presentation:
increased seizures, fever
• Incidental finding: “rigid abdomen”
• Therefore, an abdominal CT was performed
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Ryan Chuang
Gillian Lieberman, MD
Patient #1: CT Images
Small bowel-small bowel intussusception
Target Sign
Courtesy of the BIDMC Radiology Department
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Ryan Chuang
Gillian Lieberman, MD
Patient #1: CT Reconstruction
Intussusception,
Coronal View
Courtesy of the BIDMC Radiology Department
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Ryan Chuang
Gillian Lieberman, MD
Patient #2
• 38 yo female w/ severe abdominal cramping
and several episodes of bloody diarrhea
presented at the Lahey ER
• Given IV fluids; Tolerated BRAT diet but
24 hours later, presented to PCP w/ RUQ &
peri-umbilical pain, relieved by eating,
radiating to back.
• No further diarrhea, no BRBPR, no melena
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Ryan Chuang
Gillian Lieberman, MD
Patient #2
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On PE, pt had mild RUQ tenderness
No guarding, no rebound, no masses felt
Bowel sounds are NL
On U/S, liver, spleen, and gallbladder all
appeared NL
• Stool Cultures Pending
• Family Hx negative for IBD or Colitis
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Ryan Chuang
Gillian Lieberman, MD
Patient #2
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Pt referred to the BIDMC
More history elicited…
No fevers or chills
No nausea or vomiting
Positive flatus and bowel movements
Had 2x similar episodes within past month;
Both resolved spontaneously. Most recent
one associated with 3X of bloody stools
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Ryan Chuang
Gillian Lieberman, MD
Patient #2
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Pt takes no medications
Pt had no significant PMH
Pt had no history of surgeries
Colonoscopy done 2 yrs earlier was NL
Vital signs stable; Labs unremarkable
TIME TO IMAGE!!! ☺
Abdominal CT and BE were performed
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Ryan Chuang
Gillian Lieberman, MD
Patient #2: CT Scan
Mid-Transverse Colon Intussusception w/ associated mesentary stranding.
Lead point: 3.5x4.7 cm fatty mass representing an intraluminal lipoma.
Lipoma
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Courtesy of the BIDMC Radiology Department
Ryan Chuang
Gillian Lieberman, MD
Patient #2: Barium Enema
Barium enema performed next day showed contrast freely
through the sigmoid and descending colon to the level of
the mid-transverse colon and a large, rounded, intraluminal
filling defect w/in the mid-transverse colon.
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Courtesy of the BIDMC Radiology Department
Ryan Chuang
Gillian Lieberman, MD
Patient #2: Barium Enema
Colocolic Intussusception
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Courtesy of the BIDMC Radiology Department
Ryan Chuang
Gillian Lieberman, MD
Patient #2: Barium Enema
• Barium enema has often been used to
diagnosis and treat intussusception
• Standard method of reduction: rule of 3s
- barium placed 3 feet above pt
- let hang for 3 minutes
- 3 tries before going to surgery
• If suspect bowel perforation, use H20soluble contrast
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Ryan Chuang
Gillian Lieberman, MD
Patient #2
• For this pt, surgery treatment necessary
• A right hemicolectomy w/ the lipoma
removed was performed a day after the
barium enema
• Pt tolerated surgery well
• Pt went home POD #3 in stable condition
with Percocet for pain
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Ryan Chuang
Gillian Lieberman, MD
Patient #3
• 14 yo boy w/ a 6 month hx of intermittent
abdominal pain.
• Most recent episode of pain started one wk
before presentation and associated w/
nausea and 2x emesis
• No fever, diarrhea, hematemesis,
hematochezia nor melena
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Ryan Chuang
Gillian Lieberman, MD
Patient #3
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On PE, abdomen was diffusely tender
No masses palpable
No blood in stool
Prior CT at outside facility reportedly NL
Initial plain films of the abdomen taken…
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Ryan Chuang
Gillian Lieberman, MD
Patient #3: Plain Film
Plain film:
Some small bowel
distention w/ multiple
air-fluid levels in the
small bowel and
paucity of gas in the
large bowel
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Courtesy of the Children’s Hospital, Boston
Ryan Chuang
Gillian Lieberman, MD
Patient #3: Abdominal CT
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Pt failed to improve, so a repeat abdominal CT was performed
Ileoileal Intussusception
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Courtesy of the Children’s Hospital, Boston
Ryan Chuang
Gillian Lieberman, MD
Patient #3
• CT scan revealed an ileoileal intussusception
• Pt went to the operating room
• Findings in the OR: Straw-colored ascites fluid,
an ileoileal intussusception, and an inverted
Meckel’s diverticulum
• The intussusception was manually reduced
• Meckel’s was resected, incidental appy performed,
and pt did well post-op.
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Ryan Chuang
Gillian Lieberman, MD
Patient #4
• 5 yo child presents with one week history of
severe, intermittent, cramping abdominal
pain, nausea and vomiting and 1x episode
of blood in stool.
• Pt thought to have constipation – given 1x
Fleet Enema for Children
• Pain felt worse, pt came to the Boston
Children’s Hospital ER
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Ryan Chuang
Gillian Lieberman, MD
Patient #4
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Except for age, this is a more classical
presentation of intussusception
Common symptoms include intermittent,
severe, crampy abdominal pain, vomiting
and bloody stools
Classic triad of abdominal pain, currantjelly stools, and a sausage-shaped
abdominal mass in R side of abdomen
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Ryan Chuang
Gillian Lieberman, MD
Patient #4: Ultrasound
Pt had U/S exam in ER:
RUQ Transverse View
“Bull’s eye” / “Coiled spring” sign of Intussusception
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Courtesy of the Children’s Hospital, Boston
Ryan Chuang
Gillian Lieberman, MD
Patient #4: Ultrasound
• U/S sensitivity and specificity for
intussusception approaches 100%
• Classic U/S image: “bull’s eye” or “coiled
spring” lesions representing layers of
intestine within intestine.
• Lack of perfusion in intussusceptum
detected w/ color duplex imaging may
indicate development of ischemia
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Ryan Chuang
Gillian Lieberman, MD
Patient #4: Air Enema
• With positive dx of Intussusception on U/S,
the pt proceeded to an air enema
• Technique introduced in N. America by
Chinese physicians in 1970s
• Perforation rate of <1%
• Maximum P from air enema – 120 mmHg
• 75-90% success rate
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Ryan Chuang
Gillian Lieberman, MD
Patient #4: Air Enema
Pt in prone position on exam table
Crescent Sign
L
R
Courtesy of the Children’s Hospital, Boston
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Ryan Chuang
Gillian Lieberman, MD
Patient #4: Air Enema
• Crescent Sign – leading edge of the
intussusceptum in the intussuscepiens
• Place child in prone position for air enema,
hold down tightly, can feel a characteristic
“pop” upon reduction
• If not working in prone position, can flip
child over to supine and try again…
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Ryan Chuang
Gillian Lieberman, MD
Patient #4: Air Enema
Pt in Supine Position on Exam Table
R
L
R
L
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Courtesy of the Children’s Hospital, Boston
Ryan Chuang
Gillian Lieberman, MD
Patient #4
• Ileocecal intusussception successfully
reduced in supine position!!! ☺
• Recurrence after successful nonoperative
reduction is approximately 10%
• Recurrences should be handled as if it were
an original episode
• Recurrences after surgery are <1%
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Ryan Chuang
Gillian Lieberman, MD
Intussusception: Overview
• Common cause of intestinal obstruction in
young children (typically 3 mo – 3 yrs)
• Affects boy greater than girls
• Most often seen in spring and fall
• Symptoms include intense abdominal pain,
vomiting, fever, irritability, lethargy, and
currant jelly stool.
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Ryan Chuang
Gillian Lieberman, MD
Intussusception: Overview
Role of Radiology: Diagnosis and CURE!
• Abdominal X-ray – May show obstruction
• Abdominal CT – Better at showing lesion
• Ultrasound – Very sensitive AND specific
• Barium Enema – Diagnostic and Curative!
• Air Enema – Also Diagnostic and Curative!
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Ryan Chuang
Gillian Lieberman, MD
References
Lecture:
“Intussusception.” Children’s Department Radiology Rounds,
Dr. Carlo Buonomo. July 18, 2002
Web Sites:
www.uptodate.com
www.mayoclinic.com
www.intellihealth.com
Literature:
The CIBA Collection of Medical Illustrations. Vol. 3 Digestive System, Part II
Lower Digestive Tract. P. 134 “Intussusception.” Netter, Frank, MD.
The Radiologic Clinics of North America: Imaging the Acute Abdomen (Sept. ’94),
Pediatric Gastrointestinal Radiology (July ’96), and the Imaging of the Acute
Pediatric Abdomen (July ’97). W.B. Saunders Co.
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Ryan Chuang
Gillian Lieberman, MD
Acknowledgements
SPECIAL THANKS TO:
The BIDMC Radiology Department
Gillian Lieberman, MD; Course Director
Pamela Lepkowski, Course Assistant
Larry Barbaras and Cara Lyn D’amour, Webmasters
Residents Daniel Saurborn, MD; Michelle Swire, MD
Residents Matthew Spencer, MD; Michael Goldfinger, MD
Children’s Hospital, Boston, Radiology Dept.
Dr. Carlo Buonomo, MD
Dr. Michael Callahan, MD
And Christian Dancz, HMS III
THE END!!! ☺
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