Kate Nelson, HMSIII
Gillian Lieberman, MD
Intussusception Intussusception
in Children and Adultsin Children and Adults
Kate Nelson, Harvard Medical School, Year IIIKate Nelson, Harvard Medical School, Year III
Gillian Lieberman, MDGillian Lieberman, MD
January 2006January 2006
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Kate Nelson, HMSIII
Gillian Lieberman, MD
May be precipitated by a lead pointMay be precipitated by a lead point
Common 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, HMSIII
Gillian 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
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Kate Nelson, HMSIII
Gillian 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
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Kate Nelson, HMSIII
Gillian Lieberman, MD
Classic signs on plain filmClassic signs on plain film
Bowel obstructionBowel obstruction
No 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 mass
Crescent 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
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Kate Nelson, HMSIII
Gillian 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
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Kate Nelson, HMSIII
Gillian 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 reduction
Reduction successful in 80Reduction successful in 80--90% of cases90% of cases
Factors decreasing the likelihood of successFactors decreasing the likelihood of success
Symptoms >24hSymptoms >24h
Rectal bleedingRectal bleeding
SBOSBO
No blood flowNo blood flow
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Kate Nelson, HMSIII
Gillian 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
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Kate Nelson, HMSIII
Gillian 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
120mmHg120mmHg
Complication is perforationComplication is perforation
Contraindications: Contraindications:
pneumoperitoneum, pneumoperitoneum,
peritonitisperitonitis
Intussusceptions 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
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Kate Nelson, HMSIII
Gillian 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
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Kate Nelson, HMSIII
Gillian 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 returned
Courtesy of Dr. Geary, BIDMC Courtesy of Dr. Geary, BIDMC
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Kate Nelson, HMSIII
Gillian 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 tender
WbcWbc 12,50012,500
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Kate Nelson, HMSIII
Gillian Lieberman, MD
Intussusception in AdultsIntussusception in Adults
Presents in ~1% of adult patients with Presents in ~1% of adult patients with
bowel obstructionbowel obstruction
Not 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 workup
8080--90% are secondary to underlying 90% are secondary to underlying
pathologypathology
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Gillian 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)
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Kate Nelson, HMSIII
Gillian Lieberman, MD
Plain film proxy Plain film proxy (for comparison with pediatric case)(for comparison with pediatric case)
Adult Patient #1Adult Patient #1
CT 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
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Kate Nelson, HMSIII
Gillian Lieberman, MD
SagittalSagittal ReconstructionReconstruction
Adult Patient #1Adult Patient #1
PACS, BIDMCPACS, BIDMC
TargetTarget--like like
massmass
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Gillian 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
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Gillian 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 massmass
Lymphoma / other malignancyLymphoma / other malignancy
Meckel’s Meckel’s diverticulmdiverticulm
Duplication cystsDuplication cysts
PolypsPolyps
HemmorhageHemmorhage (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.
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Gillian Lieberman, MD
Operative FindingsOperative Findings
Adult Patient #1Adult Patient #1
IleocolicIleocolic intussusception with obstruction, intussusception with obstruction,
but no necrosisbut no necrosis
Mass consistent with Mass consistent with appendicealappendiceal
mucocelemucocele
Decompression of intussusception Decompression of intussusception
followed by right followed by right hemicolectomyhemicolectomy
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Kate Nelson, HMSIII
Gillian 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.
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Gillian Lieberman, MD
AcknowledgementsAcknowledgements
VaiboVaibo KhasgiwalaKhasgiwala, MD, MD
Mike Geary, MDMike Geary, MD
Gillian Lieberman, MDGillian Lieberman, MD
Pamela LepkowskiPamela Lepkowski
Larry Barbaras, webmasterLarry Barbaras, webmaster
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Gillian Lieberman, MD
ReferencesReferences
Byrne, 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.
Slide Number 1
The Essentials of Intussusception
Plain Film�Pediatric Patient #1
Classic signs on plain film
Ultrasound�Pediatric Patient #1
Pediatric Treatment by Reduction �Pediatric Patient #1
Examination of bowel viability�Pediatric Patient #1
Method of Reduction
Air enema under fluoroscopy�Pediatric Patient #1
Air enema continued�Pediatric Patient #1
Adult Patient #1
Intussusception in Adults
Diagnosis by CT�Adult Patient #1
Plain film proxy (for comparison with pediatric case) �Adult Patient #1
Sagittal Reconstruction�Adult Patient #1
Coronal Reconstruction�Adult Patient #1
Adult Treatment by Surgery
Operative Findings�Adult Patient #1
Summary
Acknowledgements
References