Intussusception is the invagination of a segment
of bowel into the lumen of the adjacent bowel. It is a common
pediatric emergency, especially in younger children aged 3 months
to 3 years, and tends to affect the ileocaecal region.
The most common triad of clinical symptoms in patients with intussusception
includes crampy abdominal pain, vomiting, and bloody stools. The
child presents some-times with a palpable mass. Intussusception
can result in bowel necrosis and subsequently perforation requiring
The sensitivity of sonography in the diagnosis of intussusception
is almost 100 %.
The ultrasound appearances of bowel within bowel are characteristic
and the classic sonographic appearance of intussusception includes
the "doughnut" or target,
sign and the "pseudokidney" or "sandwich"
sign. A doughnut sign, a hypoechoic rim of homogenous thickness
and contour with a central hyperechoic core, is seen in a transverse
view of intussusception. A hyperechoic tubular center is seen
longitudinally covered by a hypoechoic ring, resembling a pseudokidney.
Longitudinal sonography reveals a sandwichlike appearance of the
alternating loops of bowel with a loop-within-loop appearance.
Free peritoneal fluid or ascites is not an uncommon finding with
intussusception. Also, dilated loops of fluid-filled obstructed
bowel may be demonstrated proximal to the intussusception.
Color flow Doppler can be used to help determine whether the involved
bowel should be reduced (cured with barium enema or fluid or air
pressure) or surgically resected. Inability to detect blood flow
in the intussusception increases the likelihood of necrosis and
predicts the need for surgery. Absent blood flow in the bowel
walls means that the bowel bas probably necrosed and will need
surgical resection. Detection of blood flow is reassuring and
if adequate color flow is seen to ail areas of the telescoping
bowel, the chances are better for a reduction.
Intussusception is a common cause of childhood intestinal obstruction
and in children, intussusceptions are usually idiopathic.
In adults, approximately 90% are associated with a lead mass of
some sort (polyp, lipoma, hamartoma, stromal tumor, lymphoma,
metastasis, cancer,). Other causes in adults include Meckel's
diverticulum and sprue.
Bowel usually bas a ring-like or target appearance. 'Abnormal
target' appearance because of asymmetric bowel thickening can
be caused by the following conditions :
- Crohn's disease.
- diverticular disease.
- Tumors (adenocarcinoma, benign bowel wall tumors, lymphoma,
carcinoid, leiomyosarcoma, implants).
- Whipple's disease.
- intramural hematoma.
- duplication cyst.
- pneumatosis coli or intestinal.
- radiation enteritis.
The diagnostic BE is therapeutic in approximately 80% of cases
because of the retrograde flow of barium through the large intestine.
As the barium fills and expands the colon, the pressure can spontaneously
reduce the intussusception.
An air enema is also used to reduce the intussusception using
inflation pressures of up to 120 mmHg.
The main contraindications to attempting a non-surgical reduction
are peritonitis and free intraperi-toneal air. A number of sonographic
features have been reported to be associated with a decreased
success rate of non-surgical reduction, including a hypoechoic
rim greater than 1 cm, absent blood flow on color flow Doppler
sonography, or a large amount of fluid trapped within the intussusception,
but these findings are not contraindications to a careful attempt
at non-surgical reduction. Approximately 10% of cases recur whether
the initial intussuception was treated surgically or non-surgically.
The overall mortality rate of intussusception is less than 1%.
Without treatment, the patient may have complications, such as
bowel obstruction, perforation, peritonitis, and vascular compromise,
which could lead to edema or gangrene of the bowel.
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