Intussusception

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Intussusception occurs when one segment of bowel is pulled into itself or a neighbouring loop of bowel by peristalsis.

It is an important cause of an acute abdomen in children and merits timely ultrasound examination and reduction to preclude significant sequelae including bowel necrosis.

~~Intussusception may also occur~~ When occurring in the adult population ~~where it~~, intussusception is usually caused by a focal lesion acting as a lead point.

Epidemiology

The vast majority of intussusceptions occur in children (95%), usually after the first three months of life ¹³.

Clinical presentation

While the classic triad of intermittent abdominal pain, vomiting, and right upper quadrant mass, plus occult or gross blood on rectal examination has great positive predictive value for intussusception in children ¹, these findings are seen in less than 20% of intussusception cases ². Approximately 15% (range 13-22%) of patients with intussusception do not even present with abdominal pain ^3,4.

Pathology

A proximal part of the bowel is pulled into the distal lumen and propulsed forwards as if it were a bolus of food. The prolapsing part of the bowel is described as the intussusceptum while the distal segment of bowel receiving the intussusceptum is described as the intussuscipiens. As the mesentery is incorporated into the intussusception, venous return is compromised resulting in oedema and further restriction to blood flow. Eventually, arterial supply to the bowel is interrupted and ischaemia and necrosis ensue.

Aetiology

In children, a lead point is not identified in 90% of cases, and this is most frequently thought to relate to hypertrophic lymphoid tissue following an infection. This potentially explains the relative rarity of the condition in the first three months of life, when passive immunity is still paramount.

In infants and adults, a lead point is more frequently identified with up to 90% of adult cases having a lead point (which is usually malignant in the large bowel and benign in the small bowel ¹³).

Lead points are numerous and include ^9,11,13:

gastrointestinal malignancy (most common cause in adults, accounting for 65% of cases ¹³)
- colorectal carcinoma (most common)
- metastases, e.g. malignant melanoma, breast cancer, lung cancer
- small bowel lymphoma/Burkitt lymphoma
benign neoplasms
- gastrointestinal stromal tumour (GIST)
- intestinal polyps
- intestinal lipoma
- polypoid haemangioma
congenital
inflammatory
- periappendicitis
trauma
- mural haematoma

Radiographic features

Intussusception can occur essentially anywhere. In adults no pattern of distribution is present as such as in the vast majority of cases a lead point lesion is present, and thus the location will depend on the location of that lesion. In children there is a strong predilection for the ileocolic region:

ileocolic: most common (75-95%), presumably due to the abundance of lymphoid tissue related to the terminal ileum and the anatomy of the ileocaecal region
ileoileocolic: second most common
ileoileal and colocolic: uncommon
gastric intussusception: rare, but documented ¹³

Plain radiograph

Abdominal x-rays may demonstrate an elongated soft tissue mass (typically in the upper right quadrant in children) with a bowel obstruction (and therefore air-fluid levels and bowel dilation) proximal to it. There may be an absence of gas in the distal collapsed bowel.

Fluoroscopy

A contrast enema remains the gold standard, demonstrating the intussusception as an occluding mass prolapsing into the lumen, giving the "coiled spring” appearance (barium in the lumen of the intussusceptum and in the intraluminal space). The main absolute contraindication for an enema is perforation, which needs to be treated surgically.

Ultrasound

Ultrasonography has a false-negative rate approaching zero and is a reliable screening tool for children at low risk for intussusception ^5-9. Children with classic findings of intussusception, however, need to be investigated with contrast enema, which is both diagnostic (the gold standard in the diagnosis of intussusception) and therapeutic.

Ultrasound signs include:

target sign (also known as the doughnut sign)
pseudokidney sign
crescent in a doughnut sign

~~Fluoroscopy~~

A ~~contrast enema~~ remains the gold standard, demonstrating the intussusception as an occluding mass prolapsing into the lumen, giving the "coiled spring” appearance (barium in the lumen of the intussusceptum and in the intraluminal space). The main absolute contraindication for an enema is ~~perforation, which needs to be treated surgically.~~

CT

CT has become the modality of choice for assessment of acute abdomen in adults, and thus most frequently images intussusception. Also, short length transient intussusception is a frequent incidental finding.

The appearance of intussusception on CT is characteristic and depends on the imaging plane and where along the bowel the images are obtained.

Best known is the so-called bowel-within-bowel configuration, in which the layers of the bowel are duplicated forming concentric rings (CT equivalent of the ultrasonographic target sign) when imaged at right angles to the lumen, and a soft tissue sausage when imaged longitudinally ¹³.

At the proximal end of the intussusception, there will be two concentric enhancing/hyperdense rings, formed by the inner bowel and the folded edge of the outer bowel. As one images further along the intussusception the mesentery (fat and vessels) will form a crescent of tissue around the compressed innermost lumen, surrounded by the two layers of the outer enveloping bowel. Even further distally the lead point (if present) will be visualised ¹³.

Treatment and prognosis

In children, intussusception reduction can be achieved without recourse to surgery in most cases. Using a water ~~soluble~~-soluble medium or air introduced via a rectal catheter, retrograde pressure can be exerted to reduce the intussusception. If symptoms have been protracted, rectal blood is present; there are signs of peritonitis or enema reduction is unsuccessful then surgical intervention is usually required. With no surgical treatment, there can be recurrence rates of up to 30%.

In adults, a laparotomy is usually required, especially as in most cases a lead point requiring treatment is present.

Differential diagnosis

On imaging the appearances on ultrasound and CT are characteristic. The main differential is that of transient intussusception, which is an incidental finding requiring no treatment or follow-up.

Other conditions to be considered in adults include:

primary bowel tumour
metastases and lymphoma
intestinal lipoma (without intussusception)
Meckel diverticulum
gallstone ileus (cholesterol stones can have a layered appearance with fat density)
endometrial implant

-<p><strong>Intussusception</strong> occurs when one segment of bowel is pulled into itself or a neighbouring loop of bowel by peristalsis.</p><p>It is an important cause of an acute abdomen in children and merits timely ultrasound examination and reduction to preclude significant sequelae including bowel necrosis.</p><p>Intussusception may also occur in the adult population where it is usually caused by a focal lesion acting as a lead point. </p><h4>Epidemiology</h4><p>The vast majority of intussusceptions occur in children (95%), usually after the first three months of life <sup>13</sup>.</p><h4>Clinical presentation</h4><p>While the classic triad of intermittent abdominal pain, vomiting, and right upper quadrant mass, plus occult or gross blood on rectal examination has great positive predictive value for intussusception in children <sup>1</sup>, these findings are seen in less than 20% of intussusception cases <sup>2</sup>. Approximately 15% (range 13-22%) of patients with intussusception do not even present with abdominal pain <sup>3,4</sup>.</p><h4>Pathology</h4><p>A proximal part of the bowel is pulled into the distal lumen and propulsed forwards as if it were a bolus of food. The prolapsing part of the bowel is described as the <strong>intussusceptum</strong> while the distal segment of bowel receiving the intussusceptum is described as the <strong>intussuscipiens. </strong>As the mesentery is incorporated into the intussusception, venous return is compromised resulting in oedema and further restriction to blood flow. Eventually, arterial supply to the bowel is interrupted and ischaemia and necrosis ensue.</p><h5>Aetiology</h5><p>In children, a lead point is not identified in 90% of cases, and this is most frequently thought to relate to hypertrophic lymphoid tissue following an infection. This potentially explains the relative rarity of the condition in the first three months of life, when passive immunity is still paramount. </p><p>In infants and adults, a lead point is more frequently identified with up to 90% of adult cases having a lead point (which is usually malignant in the large bowel and benign in the small bowel <sup>13</sup>).</p><p>Lead points are numerous and include <sup>9,11,13</sup>:</p><ul>
+<p><strong>Intussusception</strong> occurs when one segment of bowel is pulled into itself or a neighbouring loop of bowel by peristalsis. It is an important cause of an acute abdomen in children and merits timely ultrasound examination and reduction to preclude significant sequelae including bowel necrosis. When occurring in the adult population, intussusception is usually caused by a focal lesion acting as a lead point. </p><h4>Epidemiology</h4><p>The vast majority of intussusceptions occur in children (95%), usually after the first three months of life <sup>13</sup>.</p><h4>Clinical presentation</h4><p>While the classic triad of intermittent abdominal pain, vomiting, and right upper quadrant mass, plus occult or gross blood on rectal examination has great positive predictive value for intussusception in children <sup>1</sup>, these findings are seen in less than 20% of intussusception cases <sup>2</sup>. Approximately 15% (range 13-22%) of patients with intussusception do not even present with abdominal pain <sup>3,4</sup>.</p><h4>Pathology</h4><p>A proximal part of the bowel is pulled into the distal lumen and propulsed forwards as if it were a bolus of food. The prolapsing part of the bowel is described as the <strong>intussusceptum</strong> while the distal segment of bowel receiving the intussusceptum is described as the <strong>intussuscipiens. </strong>As the mesentery is incorporated into the intussusception, venous return is compromised resulting in oedema and further restriction to blood flow. Eventually, arterial supply to the bowel is interrupted and ischaemia and necrosis ensue.</p><h5>Aetiology</h5><p>In children, a lead point is not identified in 90% of cases, and this is most frequently thought to relate to hypertrophic lymphoid tissue following an infection. This potentially explains the relative rarity of the condition in the first three months of life, when passive immunity is still paramount. </p><p>In infants and adults, a lead point is more frequently identified with up to 90% of adult cases having a lead point (which is usually malignant in the large bowel and benign in the small bowel <sup>13</sup>).</p><p>Lead points are numerous and include <sup>9,11,13</sup>:</p><ul>
-</ul><h5>Plain radiograph</h5><p>Abdominal x-rays may demonstrate an elongated soft tissue mass (typically in the upper right quadrant in children) with a <a href="/articles/bowel-obstruction">bowel obstruction</a> (and therefore air-fluid levels and bowel dilation) proximal to it. There may be an absence of gas in the distal collapsed bowel.</p><h5>Ultrasound</h5><p>Ultrasonography has a false-negative rate approaching zero and is a reliable screening tool for children at low risk for intussusception <sup>5-9</sup>. Children with classic findings of intussusception, however, need to be investigated with contrast enema, which is both diagnostic (the gold standard in the diagnosis of intussusception) and therapeutic.</p><p>Ultrasound signs include:</p><ul>
+</ul><h5>Plain radiograph</h5><p>Abdominal x-rays may demonstrate an elongated soft tissue mass (typically in the upper right quadrant in children) with a <a href="/articles/bowel-obstruction">bowel obstruction</a> (and therefore air-fluid levels and bowel dilation) proximal to it. There may be an absence of gas in the distal collapsed bowel.</p><h5>Fluoroscopy</h5><p>A <a href="/articles/single-contrast-barium-enema">contrast enema</a> remains the gold standard, demonstrating the intussusception as an occluding mass prolapsing into the lumen, giving the "coiled spring” appearance (barium in the lumen of the intussusceptum and in the intraluminal space). The main absolute contraindication for an enema is <a href="/articles/bowel-perforation-summary">perforation</a>, which needs to be treated surgically.</p><h5>Ultrasound</h5><p>Ultrasonography has a false-negative rate approaching zero and is a reliable screening tool for children at low risk for intussusception <sup>5-9</sup>. Children with classic findings of intussusception, however, need to be investigated with contrast enema, which is both diagnostic (the gold standard in the diagnosis of intussusception) and therapeutic.</p><p>Ultrasound signs include:</p><ul>
-</ul><h5>Fluoroscopy</h5><p>A <a href="/articles/single-contrast-barium-enema">contrast enema</a> remains the gold standard, demonstrating the intussusception as an occluding mass prolapsing into the lumen, giving the "coiled spring” appearance (barium in the lumen of the intussusceptum and in the intraluminal space). The main absolute contraindication for an enema is <a href="/articles/bowel-perforation-summary">perforation</a>, which needs to be treated surgically.</p><h5>CT</h5><p>CT has become the modality of choice for assessment of acute abdomen in adults, and thus most frequently images intussusception. Also, short length <a href="/articles/transient-intussusception">transient intussusception</a> is a frequent incidental finding. </p><p>The appearance of intussusception on CT is characteristic and depends on the imaging plane and where along the bowel the images are obtained. </p><p>Best known is the so-called bowel-within-bowel configuration, in which the layers of the bowel are duplicated forming concentric rings (CT equivalent of the ultrasonographic <a href="/articles/target-sign-intussusception">target sign</a>) when imaged at right angles to the lumen, and a soft tissue sausage when imaged longitudinally <sup>13</sup>. </p><p>At the proximal end of the intussusception, there will be two concentric enhancing/hyperdense rings, formed by the inner bowel and the folded edge of the outer bowel. As one images further along the intussusception the mesentery (fat and vessels) will form a crescent of tissue around the compressed innermost lumen, surrounded by the two layers of the outer enveloping bowel. Even further distally the lead point (if present) will be visualised <sup>13</sup>.</p><h4>Treatment and prognosis</h4><p>In children, <a href="/articles/intussusception-reduction">intussusception reduction</a> can be achieved without recourse to surgery in most cases. Using a water soluble medium or air introduced via a rectal catheter, retrograde pressure can be exerted to reduce the intussusception. If symptoms have been protracted, rectal blood is present; there are signs of peritonitis or enema reduction is unsuccessful then surgical intervention is usually required. With no surgical treatment, there can be recurrence rates of up to 30%.</p><p>In adults, a laparotomy is usually required, especially as in most cases a lead point requiring treatment is present. </p><h4>Differential diagnosis</h4><p>On imaging the appearances on ultrasound and CT are characteristic. The main differential is that of <a href="/articles/transient-intussusception">transient intussusception</a>, which is an incidental finding requiring no treatment or follow-up. </p><p>Other conditions to be considered in adults include:</p><ul>
+</ul><h5>CT</h5><p>CT has become the modality of choice for assessment of acute abdomen in adults, and thus most frequently images intussusception. Also, short length <a href="/articles/transient-intussusception">transient intussusception</a> is a frequent incidental finding. </p><p>The appearance of intussusception on CT is characteristic and depends on the imaging plane and where along the bowel the images are obtained. </p><p>Best known is the so-called bowel-within-bowel configuration, in which the layers of the bowel are duplicated forming concentric rings (CT equivalent of the ultrasonographic <a href="/articles/target-sign-intussusception">target sign</a>) when imaged at right angles to the lumen, and a soft tissue sausage when imaged longitudinally <sup>13</sup>. </p><p>At the proximal end of the intussusception, there will be two concentric enhancing/hyperdense rings, formed by the inner bowel and the folded edge of the outer bowel. As one images further along the intussusception the mesentery (fat and vessels) will form a crescent of tissue around the compressed innermost lumen, surrounded by the two layers of the outer enveloping bowel. Even further distally the lead point (if present) will be visualised <sup>13</sup>.</p><h4>Treatment and prognosis</h4><p>In children, <a href="/articles/intussusception-reduction">intussusception reduction</a> can be achieved without recourse to surgery in most cases. Using a water-soluble medium or air introduced via a rectal catheter, retrograde pressure can be exerted to reduce the intussusception. If symptoms have been protracted, rectal blood is present; there are signs of peritonitis or enema reduction is unsuccessful then surgical intervention is usually required. With no surgical treatment, there can be recurrence rates of up to 30%.</p><p>In adults, a laparotomy is usually required, especially as in most cases a lead point requiring treatment is present. </p><h4>Differential diagnosis</h4><p>On imaging the appearances on ultrasound and CT are characteristic. The main differential is that of <a href="/articles/transient-intussusception">transient intussusception</a>, which is an incidental finding requiring no treatment or follow-up. </p><p>Other conditions to be considered in adults include:</p><ul>

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intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/56075387/110053_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":56274490,"studyId":113359,"caseSlug":"ileoileal-intussusception-due-to-meckel-diverticulum","caption":"Case 32: ileoileal, due to Meckel diverticulum","thumbnail":"https://prod-images-static.radiopaedia.org/images/56274490/COR_065_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":58595225,"studyId":121512,"caseSlug":"ileocolocolic-intussusception-due-to-tumoural-infiltration","caption":"Case 33: ileocolocolic intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/58595225/21._big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":58730141,"studyId":122114,"caseSlug":"meckel-diverticulum-causing-intussusception","caption":"Case 34: small bowel, due to Meckel's diverticulum","thumbnail":"https://prod-images-static.radiopaedia.org/images/58730141/92fac4592d4323eea807d159c9cd1b14259b87aa05209c585abf8c1fdd0762cf_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":58844616,"studyId":122663,"caseSlug":"colocolic-intussusception-due-to-tumoural-infiltration-2","caption":"Case 35: colocolic intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/58844616/43._big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":58863108,"studyId":122742,"caseSlug":"rectosigmoid-intussusception-due-to-tumoral-infiltration","caption":"Case 36: rectosigmoid intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/58863108/6ac58faaef4b56ca56cfb89b628f93c9ff173bcec93747740efbef4259d64a33_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":59124794,"studyId":124094,"caseSlug":"intestinal-intussusception-associated-with-caecum-adenocarcinoma","caption":"Case 37: ileocolic intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/59124794/78b6d167faf79e3dc7faea24ffbb4d6e777892bfee9141e6bc30b4c6eb3a1a4f_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":58453631,"studyId":120870,"caseSlug":"ileoileal-intussusception-due-to-gastrointestinal-stromal-tumour","caption":"Case 38: ileoileal intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/58453631/81._big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":60239392,"studyId":129101,"caseSlug":"colocolic-intussusception-due-to-the-tumoural-infiltration","caption":"Case 39: colocolic intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/60239392/fe4b0034fff7d4c21feef7f0c1e90a36304c8ec1642ae35cdb0dfbde2d1141b5_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":61074300,"studyId":131960,"caseSlug":"colocolic-intussusception-due-to-the-tumoural-infiltration-3","caption":"Case 40: colocolic intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/61074300/e7a9f865cb2ce50422d93fda5b3d3e67a8183440f7fa1b128ae4130a39f7a9ed_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":55048642,"studyId":106696,"caseSlug":"colocolic-intussusception-6","caption":"Case 41: colocolic intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/55048642/110059_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":62721744,"studyId":138347,"caseSlug":"colocolic-intussusception-due-to-tumoural-infiltration-3","caption":"Case 42: due to tumoral infiltration","thumbnail":"https://prod-images-static.radiopaedia.org/images/62721744/34b91f72c75a93775b75f1406486b5e753e3806ab6b8b332140672aa9bbd1857_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"}],"ddx_inclusions":[{"imageId":581352,"studyId":38723,"caseSlug":"intussusception-transient-3","caption":"Transient non-obstructing intussusception","thumbnail":"https://prod-images-static.radiopaedia.org/images/581352/e6169375d3c490a591f9d86c97e5ab_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"}],"lang":"us"}