Intussusception

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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Aim

To guide staff with the assessment and management of intussusception.

Definition

Intussusception occurs when a section of bowel invaginates into the lumen of the immediately distal bowel, resulting in infarction and gangrene of the inner bowel. It most commonly occurs at the ileocaecal junction.

Background

  • Peak age 5-10 months (may occur from 3 months to 5 year old)
  • Most common cause of acute intestinal obstruction in children 6-36 months
  • 60% of cases are < 1 year old and 80-90% are < 2 year old.

Complications

  • Perforation of bowel, with peritonitis
  • Necrosis of bowel requiring bowel resection
  • Shock and sepsis
  • Re-intussusception after spontaneous or active reduction.

Assessment

History

  • Typically, episodes of sudden intense pain with screaming and flexion of the legs, often associated with pallor
    • Episodes last several minutes and recur at 5-20 minute intervals
    • The infant usually looks relatively well between episodes
  • Less commonly, episodes of lethargy, irritability, altered mental status
    • May be mistaken for a child presenting with convulsions or sepsis/meningitis – the child appears floppy and semi-conscious
  • The classical TRIAD of pain, abdominal mass and red currant jelly stool is only seen in < 15% of cases
  • 1/3 of cases present with a history of recent viral illness
  • Recent rotavirus vaccination (there is a small risk of intussusception in infants following the rotavirus vaccination).

Examination

  • The child can present as:
    • Pale, lethargic and hypovolemic
    • Abdomen may be distended and tender
    • Palpable abdominal mass (sausage shaped) in the right quadrant.
    • The mass can be difficult to palpate
    • Dehydration or shock develops as symptoms progress
    • Vomiting (may become bile-stained if bowel obstruction has occurred)
    • 'Red currant jelly' stool (blood and mucous in stool) is a late sign.

Investigations

Abdominal X-ray

  • Mainly to look for signs of bowel obstruction or perforation
  • It may be normal
  • Signs of intussusception are:
    • paucity of bowel gas on the right side of the abdomen
    • distended loops of small bowel with air/fluid filled level
    • look for obscured liver edge, crescent sign and target signs
    • free gas if perforated.

Ultrasound (USS)

  • Diagnostic investigation of choice – highly sensitive and specific for intussusception (a ‘target’ or ‘doughnut’ sign is classic).

Blood tests

  • If shocked or unwell looking
  • Electrolytes, urea, creatinine, blood gas
  • FBC
  • Cross match if ‘red currant jelly’ stool.

Management

  • Insert intravenous (IV) cannula and obtain blood tests if required
  • If shocked, correct using IV boluses of 20 mL/kg of 0.9% saline
  • Nil by mouth
  • If signs of bowel obstruction insert nasogastric tube and leave on free drainage
  • Analgesia:
    • IV morphine 0.05mg/kg to 0.1 mg/kg titrated
  • Arrange for an urgent abdominal ultrasound, and urgent surgical review
    • If the abdominal ultrasound is positive:
      • Follow directly by attempted non-operative reduction by means of an air enema unless the surgeon and radiologist agree that air reduction is unsafe and operative treatment is required.
  • Air enema
    • Contraindications: signs of peritonitis/perforation
    • Antibiotics must be administered prior to the air enema or surgical reduction
    • ED nurse +/- emergency doctor should accompany child to radiology to administer IV morphine for analgesia prior to attempted reduction
    • Surgical registrar must be in attendance
    • Performed by an experienced radiologist (up to 95% success rate).
  • Surgical reduction is necessary if there are signs of peritonitis / perforation, or if air enema fails to reduce the intussusception
    • Prepare the patient for theatre.

Nursing

  • Baseline observations include heart rate, respiratory rate, temperature and pain score. Blood pressure, oxygen saturations and neurological observations if clinically indicated.
  • Minimum of 1 hourly observations should be recorded whilst in the ED
  • Any significant changes should be reported immediately to the medical team
  • Ensure appropriate medication, monitoring, suction, oxygen and emergency equipment is available for transfer and reduction procedure
  • Fluid input/output is to be monitored and documented.

Bibliography

  1. Kitagawa S and Miqdady M (2014) Intussusception in children. UpToDate. Accessed at www.uptodate.com 
  2. National Health and Medical Research Council. Australian Immunisation Handbook, 10th Edition 2013. Department of Health and Ageing
  3. Jones' Clinical Paediatric Surgery 7thEdition By: John M. Hutson (Editor), Michael O'Brien (Editor), Spencer W. Beasley (Editor), Warwick J. eague (Editor), Sebastian K. King (Editor) 2015

Reviewer/Team: Director, Emergency Department
Last reviewed: Mar 2018


Review date: Mar 2021
Endorsed by:
Director, Emergency Department Date:  Jun 2017


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