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The role of US in finding intussusception and alternative diagnosis: a report of 100 pediatric cases
Kyoung Ja Lim, Kwanseop Lee, Dae Young Yoon, Jin Hee Moon, Hyun Lee, Min-Jeong Kim and Sam Soo Kim
Acta Radiol published online 13 February 2014
DOI: 10.1177/0284185114524088

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Acta Radiol OnlineFirst, published on February 13, 2014 as doi:10.1177/0284185114524088

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! The Foundation Acta Radiologica
The role of US in finding intussusception 2014
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DOI: 10.1177/0284185114524088
of 100 pediatric cases acr.sagepub.com

Kyoung Ja Lim1,2, Kwanseop Lee3, Dae Young Yoon1,

Jin Hee Moon3, Hyun Lee3, Min-Jeong Kim3 and Sam Soo Kim2

Abstract
Background: The clinical diagnosis of intussusception remains challenging, because many children with intussusception
may present with non-specific signs and symptoms, which overlap with other conditions. Therefore imaging, in particular
ultrasonography (US), plays a significant role in the management of these patients.
Purpose: To evaluate how US can contribute to the diagnosis in clinically suspected intussusception and finding alter-
native diagnosis.
Material and Methods: We retrospectively reviewed reports of US examinations and medical records of 100 patients
(51 boys, 49 girls; mean age, 23.0  12.1 months) who underwent abdominal US for clinically suspected intussusception.
Each US study was assessed for the presence or absence of intussusception and for a possible alternative diagnosis in
cases interpreted as negative for intussusception.
Results: Thirty-seven patients had US findings consistent with intussusception, which was confirmed by air enema. In
seven patients, US studies were normal. Alternative diagnoses were identified by US for each of the remaining 56 patients,
including ileocolitis (n 20), terminal ileitis (n 18), mesenteric lymphadenitis (n 13), choledochal cyst (n 1), acces-
sory spleen torsion (n 1), small bowel ileus (n 1), midgut volvulus with bowel ischemia (n 1), and hydronephrosis
(n 1).
Conclusion: With the high sensitivity and specificity of this study we conclude that US is valuable in detecting
intussusception and finding the alternative diagnosis.

Keywords
Intussusception, ultrasonography, alternative diagnosis
Date received: 25 April 2013; accepted: 24 January 2014

signs and symptoms that overlap with other conditions

Introduction (4,5). Therefore imaging studies play a signicant role
Intussusception is one of the most common causes of
acute abdominal diseases in infants and young children,
1
with the peak age being between 5 and 24 months (1,2). Department of Radiology, Hallym University College of Medicine,
Kangdong Seong-Sim Hospital, Seoul, Republic of Korea
If it is not diagnosed promptly and appropriately trea- 2
Department of Radiology, Kangwon National University College of
ted, this obstructive process can lead to bowel ischemia, Medicine, Kangwon-do, Republic of Korea
necrosis, and even perforation. While the classic triad 3
Department of Radiology, Hallym University College of Medicine,
of symptoms in intussusception is abdominal pain, a Hallym University Sacred Heart Hospital, Gyonggi-do, Republic of Korea
palpable abdominal mass, and redcurrant-jelly stool,
this combination of features is found in only about Corresponding author:
Kwanseop Lee, Department of Radiology, Hallym University Sacred
one-third of patients (3). The clinical diagnosis of intus- Heart Hospital, 896, Pyungchon-dong, Dongan-gu, Anyang, Gyonggi-do,
susception remains challenging, because many children 431-070, Republic of Korea.
with intussusception may present with non-specic Email: radiol_l@naver.com

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2 Acta Radiologica 0(0)

in the management of patients with clinically suspected abdominal radiography and abdominal US; one patient
intussusception. each underwent contrast-enhanced abdomen-pelvis CT
Plain abdominal radiographs are still the rst ima- and magnetic resonance (MR) cholangiopancreatogra-
ging study performed when pediatric patients pre- phy. Because plain radiographs were revealed less
sent with non-specic abdominal complaints (6,7). useful in diagnosing intussusception and alternative
However, plain radiographs have not been very useful diagnoses in most cases, we did not analyze the plain
in diagnosing intussusception because of the low sensi- radiographic ndings in this study.
tivity and specicity (1,8). Contrast or air enema has
been used for diagnosis of intussusception as well as
therapeutic reduction (9,10). Because of potential risk
US examination
of perforation and radiation exposure, their current use The same radiologist (KSL), with 20 years of experi-
has been more therapeutic than diagnostic. There is ence in pediatric abdominal US, performed or super-
some controversy regarding the role of computed tom- vised all of the examinations. All US examinations were
ography (CT) in investigating children with suspected performed using HDI 3000 or 5000 ultrasound units
intussusception (11). CT has been shown to be useful in (Philips Medical Systems, Bothell, WA, USA). First,
older children and adults in both making the diagnosis the bowel was assessed with a C5-8 MHz curved array
and assessing for the presence of a pathological lead or L12-5 MHz linear transducer for the presence or
point (12). Ultrasonography (US) has been used as a absence of intussusception. If intussusception was not
reliable, non-invasive primary diagnostic procedure in observed, routine abdomen and pelvis US was per-
the diagnosis of intussusception (1315). In addition, formed with a C4-7 MHz curved array transducer to
US can also be used to establish or suggest alternative nd out other possible causes for the symptoms.
diagnoses when the examination is negative for intus- Color Doppler US, in addition to routine gray-scale
susception. To our knowledge, however, there has been scanning, was also used to assess vascularity of the
only one study (16) that demonstrated the frequency lesion.
and spectrum of alternative diagnoses to intussuscep-
tion on abdominal US.
The purpose of this study was to evaluate the use-
Analysis
fulness of US in establishing alternative diagnoses in We assessed each study for the presence or absence of
patients with suspected intussusception. intussusception and for possible alternative diagnoses
that might explain the patients symptoms in cases
interpreted as negative for intussusception. To reduce
Material and Methods retrospective bias, we looked at the original US report,
The study was approved by the institutional review rather than at the images themselves. Intussusception
board. Informed consent was not required for our was dened as invagination of a segment of bowel (the
retrospective investigation. intussusceptum) into the distal bowel (the intussusci-
piens), according to published US imaging criteria
(Fig. 1) (1,2,4,16). The characteristic US features of
Patients
intussusception included a hypoechoic outer rim of
This study is based on a retrospective review of the homogeneous thickness with a central hyperechoic
hospital information system and the radiology informa- core on a transverse plane (doughnut or target sign)
tion system in a tertiary hospital. We identied 100 and a hyperechoic tubular center covered on each side
patients who underwent abdominal US for clinically by a hypoechoic rim on a longitudinal plane (pseudo-
suspected intussusception between May 2007 and kidney or sandwich sign) (1,2,6,12,17). If intussuscep-
February 2008. There were 51 boys and 49 girls with tion was diagnosed, no attempt was made to nd
the mean age of 23  12.1 months (age range, 252 additional ndings in other area of the abdomen,
months). They presented with various combinations since intussusception is a very urgent condition.
of non-specic symptoms and signs consistent with a To reach potential alternative diagnoses on US stu-
clinical diagnosis of intussusception, including redcur- dies without intussusception, the US operator system-
rant-jelly stool, cyclic irritability, vomiting, diarrhea, atically evaluated abnormalities in the small and large
fever, lethargy, or abdominal pain. The medical records bowel, liver, spleen, kidney, and pelvic organs. The
of all patients, such as medical history, original US diagnosis of ileocolitis was made when there was diuse
interpretation, other imaging examination results, hos- wall thickening of the colon and ileum with increased
pital course or outcome, surgery reports, pathology color Doppler ow as compared to adjacent normal
reports, and clinical/radiological follow-up results bowel (18,19). The diagnosis of terminal ileitis was
were reviewed. All patients underwent both plain based on evidence of diuse wall thickening with

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Lim et al. 3

Table 1. US interpretation of 100 cases with clinically

suspected intussusception.
US diagnoses Cases (n)

Intussusception 37
Ileocolitis 20
Terminal ileitis 18
Mesenteric lymphadenitis 13
Choledochal cyst 1
Accessory spleen torsion 1
Small bowel ileus 1
Midgut volvulus with bowel ischemia 1
Hydronephrosis 1
Normal ultrasonographic finding 7

Total 100

presentation. In the remaining seven cases, no denite

diagnosis could be substantiated on US.
The frequency and types of alternative diagnoses
identied for each of the 56 studies are listed in
Fig. 1. Intussusception in a 29-month-old boy with cyclic irrit- Table 1. The most frequent alternative ndings were
ability. Short-axis (a) and long-axis (b) US images demonstrate acute ileocolitis and terminal ileitis, which were identi-
the intussuscipiens (arrows) contains the infolded intussuscep- ed in 38 cases (Fig. 2). Thirteen cases had mesenteric
tum (). lymphadenitis (Fig. 3) diagnosed by US; no abnormality
of the adjacent bowel or solid organ was detected in
increased color Doppler ow in the terminal ileum these cases. The remaining ve cases had alternative
(18,19). The diagnosis of mesenteric lymphadenitis diagnoses that were not directly related to inammation
was made in the presence of mesenteric lymph of bowel or mesentery. The miscellaneous abnormalities
node(s) > 5 mm in short axis diameter and in the in these patients included choledochal cyst (n 1), acces-
absence of abnormality in the adjacent bowel or solid sory spleen torsion (n 1) (Fig. 4), small bowel ileus
organs (20). (n 1), midgut volvulus with bowel ischemia (n 1),
The nal diagnosis of intussusception was conrmed and hydronephrosis of unknown cause (n 1).
by air enema or surgery. For the purpose of this study, All 37 patients with positive US results were con-
if patients with negative US remained well at a 3-month rmed to have intussusception and treated by air
review, they were considered not to have had intussus- enema and no one went to surgery in our series. All
ception. In the group that did not undergo surgery, 63 patients with negative US results were proved not
conrmation of alternative diagnoses was based on a to have intussusception by subsequent clinical review
combination of clinical ndings, laboratory results, and follow-up results. None of these patients re-pre-
ndings of other imaging studies, and clinical/radio- sented to the hospital with suspected intussusception
logical follow-up, as well as on response to therapy. at a later date. Thus none of our patients was false
positive or false negative, giving a sensitivity of 100%
(37/37) and specicity of 100% (63/63).
Results
Of 100 cases evaluated for suspected intussusception
with abdominal US, 37 (37%) were interpreted as posi-
Discussion
tive for intussusception and the mean age was 9.5  6.4 US is being increasingly used as the primary imaging
months (range, 229). Sixty-three cases (63%) were modality for children presenting with acute abdominal
interpreted as negative for intussusception and the pain, including those with symptoms suggestive of
mean age was 30.9  18.1 months (range, 352 intussusception (7,21). US is useful not only for diag-
months). In 56 (88.9%) of these 63 negative cases, add- nosing intussusception but also for identifying the
itional US of the abdomen and pelvis depicted alterna- pathologic lead points of the intussusception, which
tive ndings that accounted for the clinical may inuence the treatment decision in such patients.

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4 Acta Radiologica 0(0)

Fig. 3. Mesenteric lymphadenitis in a 15-month-old girl with

irritability and vomiting. Transverse sonogram shows multiple
enlarged lymph nodes (arrow) in right lower quadrant and no
definite abnormal bowel wall thickening.

To our best knowledge, however, only one study has

been published reporting the frequency and spectrum of
alternative diagnoses in children whose US results are
negative for intussusception. Pracros et al. (16)
reported that a variety of alternative diagnoses was
identied by US in patients without intussusception,
including urinary tract pathology, ovarian cyst, small
bowel volvulus, necrotizing enterocolitis, cyst of the
common bile duct, and viral hepatitis. In their series,
the frequency of alternative diagnoses on US was 6.0%
(17/281), which is much lower than the rate (88.9%)
reported in our series; it is likely that the dierences
in results may reect recent technologic advances with
Fig. 2. Ileocolitis in a 52-month-old boy presenting with episode higher resolution US equipment and high-frequency
of bloody stool. Longitudinal sonograms show diffuse symmetric transducer, compared with the older-model US
wall thickening of the ascending (a) and descending (b) colon. machines used in the previous study.
(c) Color Doppler imaging shows prominent vascular flow in the In this series of pediatric patients imaged with US
ascending colon, consistent with acute inflammation.
for suspected intussusception, inammation of the
small and large bowel and/or the mesenteric lymph
Common pathologic lead points of intussusception nodes were the most common alternative diagnoses.
include Meckels diverticulum, intestinal polyp, dupli- The characteristic imaging features of enterocolitis
cation cyst, or lymphoma (22). An important advan- include diuse thickening of the bowel wall, which
tage of US is the lack of ionizing radiation exposure, may show increased blood ow on color Doppler ima-
which is a major advantage in pediatric practice (23). ging, and enlargement of the mesenteric lymph nodes,
Other advantages include non-invasiveness, quick all of which may be assessed with US in the pediatric
examination time, and no requirement for contrast population (1820). But these are non-specic ndings,
media. The value of US in the diagnosis of intussuscep- which can be due to infectious, ischemic, inammatory,
tion has been well documented in the literature, with a or tumoral etiologies. In this study, most of these diag-
high reported sensitivity (98100%) and specicity (88 noses could be substantiated by the identication
100%) (1,8,17). The overall sensitivity (100%) and spe- of spontaneous resolving after only symptomatic
cicity (100%) of US in the present study compares treatment.
favorably with other reported studies. A variety of alternative diagnoses which can clinic-
In clinical practice, however, the majority of patients ally mimic intussusception may be detected throughout
suspected of having intussusception will not have the the abdomen by US examination. Our ndings thus
condition. It is therefore important to reach an alterna- emphasize the importance of the screening of the
tive diagnosis in patients without intussusception. entire abdomen and pelvis in an eort to identify an

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Lim et al. 5

more stringent criteria for imaging patients with sus-

pected intussusception, we would have observed a
higher positivity rate for intussusception and a lower
frequency of alternative diagnoses.
In conclusion, US is valuable in establishing various
diagnosis in patients with symptoms of suspected intus-
susception. Although acute ileocolitis and terminal
ileitis are the most common diseases found when intus-
susception is excluded, many other alternative diag-
noses should be considered.

Funding
This research received no specic grant from any funding
agency in the public, commercial, or not-for-prot sectors.

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