Overview

Intussusception is a common cause of childhood

intestinal obstruction, occurring more frequently in
white children aged 6 months to 2 years and in more
males than in females (3:1-2). [1, 2] When this condition
occurs in neonates and in children older than 2 years,
there is a high incidence of associated bowel
abnormality that serves as an initiating lead point for
intussusception (about 5% of patients are found to
have a lead point). In addition, intussusception is
known to occur with greater frequency in children who
have undergone recent abdominal surgery, either
intraperitoneal or retroperitoneal operations. It is
thought that early adhesions or focal edema of the
bowel wall create a lead point for the intussusception.
Invagination of a bowel segment (usually, the small
bowel) into the lumen of the more distal bowel
(usually, the colon) occurs. The invaginated segment
(intussusceptum) is carried distally by peristalsis.
Mesentery and vessels become involved with the
intraluminal loop and are squeezed within the
engulfing segment (intussuscipiens). Almost all
occurrences are acute, and bowel obstruction is often
the presenting sign of intussusception (see the image
below).
Upright and supine anteroposterior abdominal radiographs in an
infant with crying and bloody diarrhea for 12 hours show a small
bowel obstruction pattern and little gas in the cecal region.
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Anatomy
A loop of bowel infolds (and inverts) more distally into
the lumen of the bowel and is then carried distally by
peristalsis. Approximately 90% of intussusceptions
are ileocolic, in which the terminal ileum is carried
through the ileocecal valve into the colon; it may
reach the rectum. Idiopathic intussusceptions usually
lack an identifiable lead point and occur in children
aged 6 months to 2 years. Lymphoid hyperplasia or
hypertrophic lymph nodes have been postulated but
not proven. Lead points in nonidiopathic
intussusception may include the following:
• Meckel diverticulum

• Lymphoma of bowel

• Leukemia involving bowel

• Henoch-Schonlein purpura with intramural
hemorrhage

• Hemolytic uremic syndrome

• Cystic fibrosis with inspissated bowel content

• Postoperative complication following retroperitoneal
surgery

• Post abdominal trauma

• Inflammatory bowel disease

• Polyps

• Peutz-Jeghers syndrome appendix (normal or
appendicitis)

• Recent rotavirus immunization [3] 


Preferred examination
In some countries, history and physical findings are
sufficient criteria for undertaking reduction procedures
for intussusception. However, abdominal radiography
and ultrasonography may be useful studies, and in
some institutions, reduction of the intussusception
takes place under ultrasonographic guidance with
fluid or air. [4, 5, 6, 7]
Abdominal radiography may used to search for dilated
small bowel and an absence of gas in the region of
the cecum (see the image below). In some cases, a
mass impression within the colonic gas indicates an
intraluminal mass created by the intussuscepting
loop.
Left: Radiograph from a 14-month-old boy who experienced blood in
the stool for 3 days. An absence of cecal air and an obstruction
pattern are seen. Right, top: A spot radiograph during an air reduction
shows the intussusceptum. Right, bottom: The reduced
intussusception with air in the small bowel is seen.
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Transverse ultrasonograms show a mass with a

swirled appearance of alternating sonolucent and
hyperechoic bowel wall of the loop-within-a-loop. On
longitudinal ultrasonograms, the intussuscipiens and
the intussusceptum have the appearance of a
submarine sandwich. There appear to be multiple
layers, which represent the walls of the
intussuscepted bowel loops, as seen in the image
below.

Longitudinal ultrasonograms of a patient with suspected

intussusception shows the layered bowel walls of the outer and inner
loop, the intussuscipiens, and the intussusceptum.
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Limitation of techniques
Intussusception may not be apparent on plain-film
abdominal radiography. Radiographs may appear
indeterminate or normal; therefore, the presence of an
unremarkable abdominal radiograph should not be
the basis for excluding a diagnosis of intussusception.

Ultrasonographic examination is almost always

positive, although overlying loops of air-containing
bowel may obscure intussusception (see the following
image).
Note the typical mass creates a curved density to the air in the
transverse colon.
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Differential diagnosis and other problems to

be considered
The differential diagnosis should include appendicitis
and cecal volvulus. Other conditions that should be
considered include inflammatory bowel disease,
appendicitis with or without perforation, incarcerated
inguinal hernia, internal hernia, appendicitis, Henoch-
Schonlein purpura, hemolytic uremic syndrome, small
bowel obstruction, cecal/sigmoid volvulus, and
abdominal wall hernia.

Radiologic interventions
Prolonged intussusception may result in bowel
necrosis and/or perforation. Once the patient is
stabilized, reduction procedures should be initiated
immediately; radiographic examination and physical
examination should be performed to ensure that
neither free air nor peritonitis is present. It should be
ascertained by physical examination that no peritonitis
is present.

Unless perforation, peritonitis, or Henoch-Schonlein

purpura is present, radiologic reduction should be
attempted. The success rate is 50-85%, depending on
factors such as the length of time of the
intussusception and degree of edema of the loop and
ileocecal valve. Reduction is still possible, although
more difficult, in intussusceptions that have been in
place for longer than 48 hours. In patients older than
2 years, it should be assumed that intussusception
has a lead point etiology; in such cases, further
investigation should be undertaken. [8, 9, 10]

Spontaneous reduction has been reported, but it is

unusual and surgery is advised when radiologic
reduction is unsuccessful. Despite positive results
from reduction through the use of imaging techniques,
reduction or re-intussusception may be unsuccessful,
necessitating surgery. Rarely, complications from
reduction with imaging techniques (perforation)
require emergency surgery. The use of air, gas, or
water-soluble contrast to reduce the intussusception
decreases potential complications. [11, 12]

In the current method of air reduction, room air is

introduced through a rectal catheter and is taped well
in place. A manometer is attached to a Y-connector to
monitor pressure in the colon. Pressure should never
exceed 110 mm Hg. The air pressure on the
intussusception usually forces the inverted bowel
back through the ileocecal valve and into its proper
position. When reduction occurs, the observed
pressure falls precipitously.

Contrast reduction was widely used until the current

decade. A large rectal tube is taped firmly in place,
and dilute water-soluble contrast is introduced slowly
by gravity drip into the rectum; hydrostatic pressure is
used to reduce the intussusception. The fluid is
placed a maximum of 3 feet above the level of the
radiography table. No more than 3 attempts at
reduction are undertaken, and the column is pressed
against the intussusception mass no longer than 3
minutes at each attempt. Visualization of the small
bowel usually indicates that intussusception has been
reduced. The following rules need to be observed:
• The fluid level should be maintained at no more than
3 feet above the patient.

• Palpation of the abdomen should be avoided during
reduction.

• Pressure should be maintained no longer than 3
 minutes against a nonmoving intussusception.


Reduction may proceed at an uneven rate, and it may

slow at various locations; this is particularly true at the
ileocecal valve, which is swollen and often resists
passage of the intussusception (see the images
below). To ensure reduction, contrast should be
observed entering the ileum. Once contrast enters the
ileum, it often proceeds quickly through the ileum.
Vomiting is a frequent side effect of reduction.

Reduction of an intussusceptum through the ileocecal valve is the

most difficult part of the reduction. The mass is seen in the cecum.
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Same patient as in the previous image. On the second attempt at

reduction, the intussusceptum still extends through the ileocecal
valve. Reduction was unsuccessful.
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The ileocecal valve is usually quite edematous after an
intussusception has occurred; it may remain large for several days. In
this patient, the ileocecal valve was mistaken for an intussusception,
although barium had entered the ileum.
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The appendix usually fills before the ileum and should

not be confused with the ileal reflux of contrast. If
there is a problem with reduction across the ileocecal
valve, the patient should be allowed to evacuate, and
the ileum should then be refilled; this relaxes the
valve and allows for better control on refilling. A
swollen ileocecal valve may appear unreduced;
therefore, identifying air or contrast material in the
ileum is important (see the following image below).

From the same patient as in the previous image. The appearance of

the ileocecal valve at resection is edematous and enlarged.
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Special concerns
One should be aware of conditions that lead to
intussusception and that also are predictive of
perforation (eg, Henoch-Schonlein purpura). Contrast
enema procedures should be avoided in patients with
these conditions.