Pediatr Radiol (2003) 33: 79–85

DOI 10.1007/s00247-002-0832-2 REVIEW

Alan Daneman Intussusception

Oscar Navarro

Part 1: A review of diagnostic approaches

Received: 29 March 2002

Accepted: 6 September 2002
Published online: 19 November 2002
Ó Springer-Verlag 2002
A. Daneman (&) Æ O. Navarro
Department of Diagnostic Imaging, The
Hospital for Sick Children, 555 University
Avenue, Toronto, Ontario M5G 1X8,
Canada
E-mail: alan.daneman@sickkids.ca
Abstract The vast majority of symp-
tomatic intussusceptions in children
arise in the ileum and are either
ileocolic or ileoileocolic. The clinical
diagnosis of these ‘‘idiopathic’’
intussusceptions may be difficult to
make. Failure to make a prompt
diagnosis and initiate appropriate
treatment may lead to bowel isch-
emia, perforation, peritonitis, shock
and even death. The clinician, there-
fore, may have to rely on imaging
procedures to diagnose or exclude the
presence of intussusception promptly
and accurately. The imaging diagno-
sis of intussusception can be made
with sonography or plain abdominal
radiographs or by contrast (including
air) enema examinations of the colon.
This article highlights the current
concepts and some controversial is-
sues related to the imaging diagnosis
of intussusception.
Keywords Intussusception Æ
Diagnosis Æ Imaging Æ Children

Introduction bowel ischemia, perforation, peritonitis, shock and even

The vast majority of symptomatic intussusceptions in
children arise in the ileum because of hyperplasia of the
lymphoid tissue in the Peyer patches and are either
ileocolic or ileoileocolic. The comments in this article
refer to the diagnosis of these symptomatic ileocolic and
ileoileocolic intussusceptions, which are often referred to
as ‘‘idiopathic’’ intussusceptions. There are other types
of intussusceptions, some of which may be asymptom-
atic or may reduce spontaneously (usually limited to the
small bowel), others that may be due to pathologic lead
points or gastrojejunostomy tubes, and those that are
seen in the postoperative period. These other types will
not be included in this discussion.
The clinical diagnosis of ileocolic and ileoileocolic
intussusception may be difficult to make. The classic
clinical triad of abdominal pain, red currant jelly stool
and palpable abdominal mass is present in fewer than
50% of children with this condition. Furthermore, a
significant number of children may in fact be free of pain
at the time of presentation. Failure to make a prompt
diagnosis and initiate appropriate treatment may lead to
death. The clinician, therefore, may have to rely on
imaging procedures to diagnose or exclude the presence
of intussusception promptly and accurately.
The imaging diagnosis of intussusception can be
made with sonography or plain abdominal radiographs
or by contrast (including air) enema examinations of the
colon. This article highlights the current concepts and
some controversial issues related to the imaging diag-
nosis of intussusception. The detailed imaging appear-
ances of intussusception using the various modalities are
beyond the scope of this article, as these have already
been documented in the literature exceptionally well [1,
2, 3, 4].
Diagnostic modalities
Sonography
In 1987, Pracros et al. [1] reported 100% accuracy of
sonography for the diagnosis of intussusception and
since that time this accuracy rate has been verified by
80
several reports [3, 5, 6, 7, 8, 9]. Verschelden et al. [5]
reported 100% negative predictive value in 83 patients
in a prospective study and showed that none of their
patients with a normal sonogram had an intussusception
at contrast enema examination.
Intussusception has a characteristic sonographic ap-
pearance [1, 3, 4, 5] that makes its sonographic diagnosis
or exclusion extremely easy (Fig. 1a). When searching
for an intussusception, the radiologist is looking for a
mass of 3–5 cm in diameter that permits easy detection.
Fig. 1a, b Transverse sonograms of right upper quadrant with
linear array transducers in two children. In both, the mass created
by the intussusception, shown by arrows in a and electronic cursors
in b, is easily found just deep to the abdominal wall. In both, the
mass measures several centimeters in diameter and has the
characteristic doughnut sonographic appearance of an intussus-
ception. In a, M represents hyperechoic mesenteric fat and L
represents mesenteric lymph node, both of which have been drawn
into the intussusception by the bowel. In b, the arrow indicates the
characteristic crescentic shape of the indrawn hyperechoic mesen-
teric fat
The intussusceptions are usually found just deep to the
abdominal wall mostly on the right side of the abdomen.
The quality of the study and its interpretation are
operator dependent, causing some concern about the use
of sonography in this situation by some radiologists who
may lack confidence in this technique [10]. Although the
literature may suggest that sonographic recognition of
intussusception requires great experience on the part
of the operator, Verschelden et al. [5] showed that a
100% accuracy rate could be achieved by third- and
fourth-year radiology residents who have completed a
3–5-month training period in adult sonography. Our
own experience has shown a similar high accuracy rate
when the sonographic studies have been performed by
appropriately trained pediatric radiology fellows, all of
whom have completed 4 years of residency training and
who have been given practical training regarding intus-
susception detection and evaluation with sonography in
our department.
When properly performed, a normal sonogram thus
obviates unnecessary diagnostic enemas and the use of
the enema can then be limited to therapeutic practice [5].
Because of this, the use of sonography as the modality of
choice for the diagnosis or exclusion of intussusception
has spread quite widely around the world.
The sonographic appearances of other intra-abdom-
inal conditions and structures, which mimic intussus-
ception in transverse or longitudinal scans, have been
reported as the source of occasional false-positive ex-
amination results [5]. These conditions include any cause
of bowel wall thickening, such as inflammation, edema,
and hematoma or an area of volvulus. Even stool and
the psoas muscle may rarely be mistaken for intussus-
ception. An extremely useful differentiating sonographic
feature is the fact that these entities lack the very char-
acteristic appearance on transverse scans of the eccen-
tric, semilunar, hyperechoic mesenteric fat that is pulled
with vessels and lymph nodes into the intussusception by
the intussusceptum. del-Pozo et al. [3] have called this
characteristic feature of intussusception the ‘‘crescent-in-
doughnut’’ sign (Fig. 1b). With the appropriate training
in sonography and with the use of high-frequency, high-
resolution transducers (particularly linear array), the
diagnosis of an intussusception and its differentiation
from other entities can be achieved.
In a patient suspected of having an intussusception,
the role of sonography is not simply limited to the
diagnosis or exclusion of this entity. In this regard,
sonography can also be extremely effective for docu-
menting the presence or absence of pathologic lead
points [11, 12] and for depicting other pathology unre-
lated to intussusception [1]. In the review of pathologic
lead points by Navarro et al. [12], sonography depicted a
lead point in 23 of 35 (66%) patients, whereas barium
enema depicted the lead point in 6 of 15 (40%) and
air enema in 3 of 28 (11%) patients. Not only was