Kate Nelson, HMSIIIGillian Lieberman, MD

Intussusception Intussusception in Children and Adultsin Children and Adults

Kate Nelson, Harvard Medical School, Year IIIKate Nelson, Harvard Medical School, Year IIIGillian Lieberman, MDGillian Lieberman, MD

January 2006January 2006

22

Kate Nelson, HMSIIIGillian Lieberman, MD

May be precipitated by a lead pointMay be precipitated by a lead pointCommon cause of acute abdomen in children 3 Common cause of acute abdomen in children 3 months to 3 years old (2months to 3 years old (2ndnd only to appendicitis).only to appendicitis).Classic triad: abdominal pain, palpable mass and Classic triad: abdominal pain, palpable mass and currant jelly stoolcurrant jelly stool

A loop of bowel A loop of bowel infoldsinfolds into the lumen immediately into the lumen immediately distal to itdistal to it

The Essentials of IntussusceptionThe Essentials of Intussusception

IntussusceptumIntussusceptum IntussuscipiensIntussuscipiens

33

Kate Nelson, HMSIIIGillian Lieberman, MD

18 month old girl with a one day history of 18 month old girl with a one day history of intermittent abdominal pain and bloody stools.intermittent abdominal pain and bloody stools.

Pediatric Patient #1Pediatric Patient #1

44

Kate Nelson, HMSIIIGillian Lieberman, MD

Plain FilmPlain Film Pediatric Patient #1Pediatric Patient #1

Paucity of airPaucity of air

Dilated Dilated loopsloops

Open Open epiphysisepiphysis

Courtesy of Dr. Geary, BIDMC

?

Absent Absent liver edgeliver edge

55

Kate Nelson, HMSIIIGillian Lieberman, MD

Classic signs on plain filmClassic signs on plain film

Bowel obstructionBowel obstructionNo RLQ air or stool in colonNo RLQ air or stool in colon

Absent liver edge Absent liver edge Target sign/soft tissue massTarget sign/soft tissue massCrescent signCrescent sign“Lateralization” of ileum“Lateralization” of ileum

http://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.htmlhttp://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.html

Target Target signsign

Crescent Crescent signsign

No stool No stool in colonin colonNo RLQ No RLQ

airair

??

Air is trapped hereAir is trapped here

66

Kate Nelson, HMSIIIGillian Lieberman, MD

UltrasoundUltrasound Pediatric Patient #1Pediatric Patient #1

Courtesy of Dr. Geary, BIDMC Courtesy of Dr. Geary, BIDMC

Longitudinal U/SLongitudinal U/S Transverse U/STransverse U/S

HyperechoicHyperechoic

mesenteric fatmesenteric fat

Doughnut sign:Doughnut sign:Concentric ringsConcentric rings

IntussusceptumIntussusceptum: : internal ringinternal ring

IntussuscipiensIntussuscipiens: : external ringexternal ring

PseudokidneyPseudokidney

sign:sign:Sandwich like thin lines with varying Sandwich like thin lines with varying echogenecityechogenecity

77

Kate Nelson, HMSIIIGillian Lieberman, MD

Pediatric Treatment by Reduction Pediatric Treatment by Reduction Pediatric Patient #1Pediatric Patient #1

Only 3Only 3--10% have lead points allowing non10% have lead points allowing non--surgical reductionsurgical reductionReduction successful in 80Reduction successful in 80--90% of cases90% of casesFactors decreasing the likelihood of successFactors decreasing the likelihood of success

Symptoms >24hSymptoms >24hRectal bleedingRectal bleedingSBOSBONo blood flowNo blood flow

88

Kate Nelson, HMSIIIGillian Lieberman, MD

Examination of bowel viabilityExamination of bowel viability Pediatric Patient #1Pediatric Patient #1

Doppler U/SDoppler U/S

Courtesy of Dr. Geary, BIDMC

Areas of flow Areas of flow suggest that suggest that bowel can be bowel can be reduced by reduced by air/barium air/barium

enema without enema without increase risk of increase risk of

rupturerupture

99

Kate Nelson, HMSIIIGillian Lieberman, MD

Method of ReductionMethod of Reduction

Typically air enema with a Typically air enema with a maximum air pressure of maximum air pressure of 120mmHg120mmHgComplication is perforationComplication is perforationContraindications: Contraindications: pneumoperitoneum, pneumoperitoneum, peritonitisperitonitisIntussusceptions may recur, Intussusceptions may recur, necessitating repetition of necessitating repetition of reductionreduction

http://www.hopkinshttp://www.hopkins--

gi.org/images/shared/disease/database/shared_6784_CoCgi.org/images/shared/disease/database/shared_6784_CoC--11.jpg11.jpg

SetSet--up for barium enemaup for barium enema

1010

Kate Nelson, HMSIIIGillian Lieberman, MD

Courtesy of Dr. Geary, BIDMC Courtesy of Dr. Geary, BIDMC

Fluoroscopic View 1Fluoroscopic View 1 Fluoroscopic View 2Fluoroscopic View 2

Air enema under fluoroscopyAir enema under fluoroscopy Pediatric Patient #1Pediatric Patient #1

Flow defect Flow defect Defect size Defect size decreasingdecreasing

Dilated loopDilated loop Less dilatationLess dilatation

1111

Kate Nelson, HMSIIIGillian Lieberman, MD

Air enema continuedAir enema continued Pediatric Patient #1Pediatric Patient #1

Fluoroscopic view 3Fluoroscopic view 3 Fluoroscopic view 4Fluoroscopic view 4

Resolved flow defectResolved flow defect Regular peristalsis has returnedRegular peristalsis has returnedCourtesy of Dr. Geary, BIDMC Courtesy of Dr. Geary, BIDMC

1212

Kate Nelson, HMSIIIGillian Lieberman, MD

Adult Patient #1Adult Patient #1

39 year old man with a four day history of 39 year old man with a four day history of abdominal pain and progressively abdominal pain and progressively decreasing stools decreasing stools On exam, abdomen is distended and On exam, abdomen is distended and diffusely tenderdiffusely tenderWbcWbc 12,50012,500

1313

Kate Nelson, HMSIIIGillian Lieberman, MD

Intussusception in AdultsIntussusception in Adults

Presents in ~1% of adult patients with Presents in ~1% of adult patients with bowel obstructionbowel obstructionNot part of the differential diagnosis for Not part of the differential diagnosis for adults with abdominal pain; generally adults with abdominal pain; generally found on CT workupfound on CT workup8080--90% are secondary to underlying 90% are secondary to underlying pathologypathology

1414

Kate Nelson, HMSIIIGillian Lieberman, MD

Diagnosis by CTDiagnosis by CT Adult Patient #1Adult Patient #1

CrossCross--section 1section 1 CrossCross--section 2section 2

PACS, BIDMCPACS, BIDMC PACS, BIDMCPACS, BIDMC

PathognomonicPathognomonic RUQ target mass (blue circle)RUQ target mass (blue circle)Small bowel does not appear obstructedSmall bowel does not appear obstructed——loops not dilated (yellow arrows)loops not dilated (yellow arrows)Question of Question of pneumotosispneumotosis vs. vs. intralumenalintralumenal air (green arrow)air (green arrow)

1515

Kate Nelson, HMSIIIGillian Lieberman, MD

Plain film proxy Plain film proxy (for comparison with pediatric case)(for comparison with pediatric case)

Adult Patient #1Adult Patient #1CT Scout filmCT Scout film

PACS, BIDMCPACS, BIDMC

Paucity of Paucity of gas in RUQ gas in RUQ consistent consistent with the with the

RUQ massRUQ mass

Otherwise, Otherwise, gas is gas is

throughout throughout suggesting suggesting he is not he is not currently currently

obstructedobstructed

1616

Kate Nelson, HMSIIIGillian Lieberman, MD

SagittalSagittal ReconstructionReconstruction Adult Patient #1Adult Patient #1

PACS, BIDMCPACS, BIDMC

TargetTarget--like like massmass

1717

Kate Nelson, HMSIIIGillian Lieberman, MD

Coronal ReconstructionCoronal Reconstruction Adult Patient #1Adult Patient #1

SausageSausage--shaped shaped massmass

PACS, BIDMCPACS, BIDMC

Target appearance Target appearance on both axial and on both axial and

sagittalsagittal

cuts cuts explained by explained by

oblique orientationoblique orientation

1818

Kate Nelson, HMSIIIGillian Lieberman, MD

Adult Treatment by SurgeryAdult Treatment by Surgery

MUST consider likely pathologic lead point in MUST consider likely pathologic lead point in patients >12 yearspatients >12 years

AppendicealAppendiceal massmassLymphoma / other malignancyLymphoma / other malignancyMeckel’s Meckel’s diverticulmdiverticulmDuplication cystsDuplication cystsPolypsPolypsHemmorhageHemmorhage (HSP)(HSP)

Because of the high likelihood of pathology, the Because of the high likelihood of pathology, the treatment of treatment of intussusceptionintussusception in adults is surgery.in adults is surgery.

1919

Kate Nelson, HMSIIIGillian Lieberman, MD

Operative FindingsOperative Findings Adult Patient #1Adult Patient #1

IleocolicIleocolic intussusception with obstruction, intussusception with obstruction, but no necrosisbut no necrosisMass consistent with Mass consistent with appendicealappendicealmucocelemucoceleDecompression of intussusception Decompression of intussusception followed by right followed by right hemicolectomyhemicolectomy

2020

Kate Nelson, HMSIIIGillian Lieberman, MD

SummarySummary

Intussusception in children is common and Intussusception in children is common and generally idiopathic. It is diagnosed by generally idiopathic. It is diagnosed by plain film and ultrasound, and it is reduced plain film and ultrasound, and it is reduced by air enema.by air enema.Intussusception in adults usually has a Intussusception in adults usually has a causative pathologic lead point. It is rare, causative pathologic lead point. It is rare, diagnosed by CT, and treated by surgery.diagnosed by CT, and treated by surgery.

2121

Kate Nelson, HMSIIIGillian Lieberman, MD

AcknowledgementsAcknowledgements

VaiboVaibo KhasgiwalaKhasgiwala, MD, MDMike Geary, MDMike Geary, MDGillian Lieberman, MDGillian Lieberman, MDPamela LepkowskiPamela LepkowskiLarry Barbaras, webmasterLarry Barbaras, webmaster

2222

Kate Nelson, HMSIIIGillian Lieberman, MD

ReferencesReferencesByrne, AT, et al. The imaging of intussusception. Byrne, AT, et al. The imaging of intussusception. Clinical RadiologyClinical Radiology 2005; 2005; 60: 3960: 39--46. 46. Gayer, G, et al. Adult intussusceptionGayer, G, et al. Adult intussusception——a CT diagnosis. a CT diagnosis. The British Journal The British Journal of Radiology of Radiology 2002; 75:1852002; 75:185--190.190.DanemanDaneman, A, Alton, DJ. Intussusception: Issues and controversies relate, A, Alton, DJ. Intussusception: Issues and controversies related to d to diagnosis and reduction. diagnosis and reduction. The Radiologic Clinics of North America The Radiologic Clinics of North America 1996; 34 1996; 34 (4): 743(4): 743--56.56.Wood, BP. Intussusception, Child. Wood, BP. Intussusception, Child. http://www.emedicine.com/radio/topic366.comhttp://www.emedicine.com/radio/topic366.com..

Accessed 1/17/06.Accessed 1/17/06.Yamamoto, LG. Find the Intussusception Target and Crescent SignsYamamoto, LG. Find the Intussusception Target and Crescent Signs. . Radiology Cases in Pediatric Emergency MedicineRadiology Cases in Pediatric Emergency Medicine. . http://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.htmlhttp://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.html. Accessed . Accessed 1/18/06.1/18/06.