58 y/o male with no significant past medical history has a 3 day history of intermittent cramping abdominal pain, vomiting,

and diarrhea.

Abdominal Radiograph

Erect Abdominal Radiograph

Barium Study

Intussusception
The Invagination or telescoping of a proximal segment of bowel (intussusceptum) into the lumen of a distal segment (intussuscipiens)

Pathophysiology
The invaginated segment is carried distally by peristalsis. Mesnetery and vessels become involved with the intraluminal loop and are squeezed within the engulfing segment causing venous congestion. Types: enteroenteric, enterocolic, and colocolic.

Epidemiology (Children)
Most common in infants and children Accounts for 95% of all cases of intussusception Ranks 2nd to appendicitis as a cause of acute abdomen 90% of the cases in children are idiopathic Most common in children of 6 months to 2 years in age

Epidemiology (Adults)
Rare in adults: accounts for 0.003% to 0.02% of all hospital admissions Accounts for 1% of all bowel obstructions in adults 80-90% of cases have and underlying cause 65% are due to neoplasm

Epidemiology
Location
Adults: ileoileal > ileocolic > colocolic Children: ileocolic > ileoileal > colocolic

Etiology
Idiopathic (most common in children) Neoplasm
Benign (more common in small bowel)
Polyp, Leiomyoma, Lipoma, Lymphoma, Adenoma of appendix, Appendiceal stump granuloma

Malignant
Primary (more common in colon) Metastatic (more common in small bowel)

Etiology
Postoperative (more common in small bowel) Meckels diverticulum Colitis Many cases thought to be related to viral gastroenteritis in children

History and Physical

Children:
Well nourished infant Cramping abdominal pain Poor feeding / Vomiting Diarrhea (often currant-jelly stools) A palpable, tender, sausage shaped mass in the abdomen Hx of abdominal surgery

History and Physical

Adults
Intermittent pain Nausea and vomiting Often red blood per rectum Often nonspecific complaints

Abdominal Studies
Abdominal films often show signs of small bowel obstruction

Abdominal Studies
Erect films often show fluid levels in the small bowel

Barium Studies
Show a classic coiled spring appearance due to trapping of contrast between layers of bowel.

Ultrasound

Ultrasound: transverse scan shows a target sign

CT (see-tee)
Target sign is also seen in CT. Can also see a sausage shaped mass

Imaging
CT is the most accurate detecting 78% of the cases. Ultrasound is often used in children Barium studies are also very useful

Treatment (children)
Air reduction is the treatment of choice for children and is successful 75-90% of the time Contrast reduction was more frequently used a decade ago

Treatment (Adults)
Adults require surgical exploration and resection of the intussuscepted bowel loops Reduction is not recommended in adults due to the risk of spreading/seeding malignant cells, potential perforation of the intussuscepted bowel, and venous embolization at the ulcerated mucosa area

References
Alfred Chahine, MD Intussusception

Emedicine: http://www.emedicine.com/ped/topic1208.htm Edwin C. Ouyang, Ileocolonic Intussusception

Medscape: http://www.medscape.com/viewarticle/510397_1