Intussusception

Intussusception occurs when one segment of bowel is pulled into itself or a neighbouring loop of bowel by peristalsis. It is also known as bowel telescoping into itself.

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 in the adult population where it is usually caused by a focal lesion acting as a lead point. 

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

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.

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 ischemia and necrosis ensue.

In children, no lead point can usually be identified (90%), and this is most frequently thought to relate to enlarged 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 or adults, a lead point is more frequently identified (up to 90% of the time in adults, usually malignant in the large bowel and benign in the small bowel 13). Lead points are numerous and include 9,11,13:

Intussusception can occur essentially anywhere. In adults, no such distribution is present 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 

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.

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:

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 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.

In children, intussusception reduction 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%.

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

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:

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Article information

rID: 1526
Section: Pathology
Synonyms or Alternate Spellings:
  • Ileocolic intussusception
  • Colocolic intussusception
  • Ileoileal intussusception
  • Intussusception - general
  • Intussusceptions

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Cases and figures

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    Extended right he...
    Figure 1: gross pathology: caecal intussusception
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    Case 1: with crescent in a doughnut sign
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    Pseudokidney sign...
    Case 2: with pseudokidney sign
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    Case 3: presenting as a right upper quadrant mass
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    Intussusception
    Case 4
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    Case 5
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    Case 6: with water soluble enema
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    Case 7: with therapeutic air enema
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    Case II: Intussus...
    Case 8
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    Intussusception
    Case 9: with lymphoma as lead point
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    Colorectal intuss...
    Case 10: secondary to colorectal carcinoma (adult)
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    Case 11
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    Case 12: sigmoido-rectal : in adult from carcinoma
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    Case 13: with small bowel lipomas
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    Mass in ascending...
    Case 14: colocolic intussusception
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    Case 15
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    Case 16
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    Case 17: with caecal adecocarcinoma
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    Case 18: on bowel lymphoma
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    Case 19: colo-colic intussusception
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    Case 20: jejuno-jejunal
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    Case 21: with caecal carcinoma
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    Case 22: ileocolic intussusception
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    Case 23: paediatric intussusception
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    Case 24
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    Case 25: due to caecal adenocarcinoma
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    Case 26: appendiceal intussusception
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    Case 27: ileo-colic
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    Case 28: ileo-ileal
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    Case 29: adult colo-colic
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    Case 30: ileo-ileal
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    Case 31: ileocolic intussusception due to appendix mucocele
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    Rounded filling d...
    Case 32: water soluble enema reduction
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    Case 33: sigmoid colocolic
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    Case 34: tubulovillous adenoma
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    Case 35: adenocarcinoma
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