IntussusceptionIntussusception
Ryan Chuang, Harvard Medical School, MS IVRyan Chuang, Harvard Medical School, MS IV
Gillian Lieberman, MDGillian Lieberman, MD
Ryan Chuang
Gillian Lieberman, MD July 2002
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IntussusceptionIntussusception: Definition: Definition
Ryan Chuang
Gillian Lieberman, MD
• slipping of a length of intestine into an
adjacent portion producing obstruction.
www.intellihealth.com
www.mayoclinic.com
Intussusceptum
Intussuscipiens
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Types of Types of IntussusceptionIntussusception
Ryan Chuang
Gillian Lieberman, MD
Anatomic Classification
– 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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IntussusceptionIntussusception
Ryan Chuang
Gillian Lieberman, MD
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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Possible Lead PointsPossible Lead Points
Ryan Chuang
Gillian Lieberman, MD
• Meckel’s diverticulum
• Intestinal polyp
• Intramural hematoma
• Enteric duplication
• Lipoma
Can occur in pts w/ lymphomas, Henoch-
Schönlein purpura, Peutz-Jeghers Syndrome, etc.
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Patient #1Patient #1
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #1: CT ImagesPatient #1: CT Images
Ryan Chuang
Gillian Lieberman, MD
Small bowel-small bowel intussusception
Target Sign
Courtesy of the BIDMC Radiology Department
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Patient #1: CT ReconstructionPatient #1: CT Reconstruction
Ryan Chuang
Gillian Lieberman, MD
Courtesy of the BIDMC Radiology Department
Intussusception,
Coronal View
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Patient #2Patient #2
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #2Patient #2
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #2Patient #2
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #2Patient #2
Ryan Chuang
Gillian Lieberman, MD
• 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!!! TIME TO IMAGE!!! ☺☺
Abdominal CT and BE were performedAbdominal CT and BE were performed
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Patient #2: CT ScanPatient #2: CT Scan
Ryan Chuang
Gillian Lieberman, MD
Mid-Transverse Colon Intussusception w/ associated mesentary stranding.
Lead point: 3.5x4.7 cm fatty mass representing an intraluminal lipoma.
Lipoma
Courtesy of the BIDMC Radiology Department
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Patient #2: Barium EnemaPatient #2: Barium Enema
Ryan Chuang
Gillian Lieberman, MD
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.
Courtesy of the BIDMC Radiology Department
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Patient #2: Barium EnemaPatient #2: Barium Enema
Ryan Chuang
Gillian Lieberman, MD
Courtesy of the BIDMC Radiology Department
Colocolic Intussusception
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Patient #2: Barium EnemaPatient #2: Barium Enema
Ryan Chuang
Gillian Lieberman, MD
• 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 H2 0-
soluble contrast
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Patient #2Patient #2
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #3Patient #3
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #3Patient #3
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #3: Plain FilmPatient #3: Plain Film
Ryan Chuang
Gillian Lieberman, MD
Courtesy of the Children’s Hospital, Boston
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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Patient #3: Abdominal CTPatient #3: Abdominal CT
Ryan Chuang
Gillian Lieberman, MD
• Pt failed to improve, so a repeat abdominal CT was performed
Ileoileal Intussusception
Courtesy of the Children’s Hospital, Boston
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Patient #3Patient #3
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #4Patient #4
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #4Patient #4
Ryan Chuang
Gillian Lieberman, MD
• 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, currant-
jelly stools, and a sausage-shaped
abdominal mass in R side of abdomen
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Patient #4: UltrasoundPatient #4: Ultrasound
Ryan Chuang
Gillian Lieberman, MD
Pt had U/S exam in ER:
Courtesy of the Children’s Hospital, Boston
RUQ Transverse View
“Bull’s eye” / “Coiled spring” sign of Intussusception
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Patient #4: UltrasoundPatient #4: Ultrasound
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #4: Air EnemaPatient #4: Air Enema
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #4: Air EnemaPatient #4: Air Enema
Ryan Chuang
Gillian Lieberman, MD
Courtesy of the Children’s Hospital, Boston
Pt in prone position on exam table
L R
Crescent Sign
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Patient #4: Air EnemaEnema
Ryan Chuang
Gillian Lieberman, MD
• 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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Patient #4: Air EnemaPatient #4: Air Enema
Ryan Chuang
Gillian Lieberman, MD
Courtesy of the Children’s Hospital, Boston
Pt in Supine Position on Exam Table
L LRR
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Patient #4Patient #4
Ryan Chuang
Gillian Lieberman, MD
• 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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IntussusceptionIntussusception: Overview: Overview
Ryan Chuang
Gillian Lieberman, MD
• 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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IntussusceptionIntussusception: Overview: Overview
Ryan Chuang
Gillian Lieberman, MD
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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ReferencesReferences
Ryan Chuang
Gillian Lieberman, MD
Lecture:Lecture:
“Intussusception.” Children’s Department Radiology Rounds,
Dr. Carlo Buonomo. July 18, 2002
Web Sites:Web Sites:
www.uptodate.com
www.mayoclinic.com
www.intellihealth.com
Literature: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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AcknowledgementsAcknowledgements
SPECIAL THANKS TO:SPECIAL THANKS TO:
The BIDMC Radiology DepartmentThe 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.Children’s Hospital, Boston, Radiology Dept.
Dr. Carlo Buonomo, MD
Dr. Michael Callahan, MD
And Christian Dancz, HMS III
Ryan Chuang
Gillian Lieberman, MD
THE END!!! THE END!!! ☺☺
Intussusception
Intussusception: Definition
Types of Intussusception
Intussusception
Possible Lead Points
Patient #1
Patient #1: CT Images
Patient #1: CT Reconstruction
Patient #2
Patient #2
Patient #2
Patient #2
Patient #2: CT Scan
Patient #2: Barium Enema
Patient #2: Barium Enema
Patient #2: Barium Enema
Patient #2
Patient #3
Patient #3
Patient #3: Plain Film
Patient #3: Abdominal CT
Patient #3
Patient #4
Patient #4
Patient #4: Ultrasound
Patient #4: Ultrasound
Patient #4: Air Enema
Patient #4: Air Enema
Patient #4: Air Enema
Patient #4: Air Enema
Patient #4
Intussusception: Overview
Intussusception: Overview
Slide Number 34
Acknowledgements