Intussusception is a form of intestinal (bowel) obstruction most commonly seen in infants and toddlers.  This occurs when a segment of the small intestine telescopes into another portion of the small or large intestine.  The intestine’s normal contractions that work to push food through the gut, in this condition, also push the intussuscepted loop of bowel further into the large intestine, making the blockage worse.

These contractions of the intestines cause the child to experience very severe, cramp-like abdominal pains.  When the bowel relaxes between contractions, the pain goes away, and the child will typically be very restful, and sometimes even sleepy or lethargic.

The abdominal pain in children with intussusception has several characteristics that can be identified.  In addition to the above mentioned cramp-like episodic type of pain, characterized by the child drawing up his legs, there may be other signs of intestinal obstruction including:

• abdominal distension from gas that is normally swallowed that cannot find its way past the blockage;
• vomiting of backed-up food and possibly greenish bile
• blood-tinged stools which may contain clear mucus. Diarrhea is not a common finding with intusscusception.

If some or all of these signs and symptoms are present, intussusception should be suspected and the child should be seen by a physician.

Although the condition is well known to pediatricians and pediatric surgeons, and its treatment is very effective (see below), the cause of most cases of intussusception is still unknown. It almost always occurs in children between the ages of 4 months and 2 years (sometimes a little older, rarely younger) and will not happen later in life. While a lesion, tumor or polyp inside the small intestine can act as a lead point and cause an intussusception (the most common type of such lesions is a Meckel’s diverticulum), this mechanism is only responsible for 10% of all cases. In all others, the condition is idiopathic, meaning that the true cause of it is not (yet) known. Much research has been done to discover the cause of idiopathic intussusception, and several theories exist, but none has proved to be satisfactory.

Treatment:
Intussusception is a true intestinal obstruction, and requires immediate attention. If left untreated, it will progress to bowel distention, damage, necrosis and rupture, followed by peritonitis (inflammation of the abdominal cavity), severe infection and shock. However, this is one of the few forms of obstruction that do not always require an operation.  In about 70% of the cases, the intussusception can be un-telescoped by running liquid (typically, barium) or air into the rectum under tightly controlled pressure, while the child’s abdomen and intestines are being monitored by X-rays.  Performing a barium enema in a child suspected of having intussusception therefore helps to establish the diagnosis (the blockage can be seen on X-ray) and treat the condition.

Prior to the barium or air enema, your child will have to be hydrated (between the vomiting, the poor appetite and the obstruction itself, your child will have become moderately to severely dehydrated). This will be done using IV fluids.

If X-ray reduction is too dangerous or unsuccessful, your child will need to be operated on emergently to relieve the intestinal obstruction.  Your child will then undergo an operation under general anesthesia. An incision will typically be made in the child’s right lower abdomen, not unlike what is done for appendicitis. The obstruction will be found and corrected, by gently separating the telescoped loops of bowel. Rarely, a portion of the bowel will be so diseased that it is safer to remove it.

Postoperative Course:
Once the intussusception is reduced (with X-ray or surgically), your child will gradually recover. He will be kept fasting initially, to allow his intestines to rest.  Depending on whether or not your child required an operation, feeding will be started within hours or the following day(s).  As soon as a regular diet is tolerated, your child will be discharged home.

Risks of the operation:
As in any operation there is a risk of bleeding and infection.  Because the bowel that is involved in the intussusception may be severely inflamed and swollen, there is a risk of perforating the bowel and the possibility that a segment of bowel may need to be removed.

Medications:
Your surgeon will give your child a prescription for a mild narcotic pain medication which can be given every four to six hours as needed.  These medications can be irritating to your child’s stomach so it is best to take them with food.  It is important to give your child plenty of fluids in order to keep him well-hydrated and to avoid constipation.

Any other medications your child required before the operation should be continued on the regular schedule afterward.

Diet:
Your child should continue the regular diet that was started prior to their discharge.  It is important to give your child plenty of fluids in order to keep him well-hydrated and to avoid constipation.

Wound care:
Always wash your hands before touching or cleaning the incision area.  Some blood staining of the paper tapes on the incision is common.  If the blood is dry and not spreading, the staining is not a problem.  If the blood seems fresh, the amount is increasing, or if the paper tape is blood soaked and partially floating above the skin, apply gentle pressure with a clean washcloth for five to six minutes.  If the bleeding does not stop after five minutes, call your surgeon at (602) 254-5561.

The clear plastic dressing covering the incision may be removed 48 hours after the operation.  No other dressing or band aid needs to be placed on the incision after this dressing is removed.

Bathing:
No tub baths should be given for at least two days after the operation. Sponge bathing for infants and showering for older children are permitted the day following the operation.  Carefully pat dry the incision tapes after showering.

When to call your child’s surgeon:

• Fever above 101oF that does not come down with Tylenol (mild fever is common)
• Difficulty breathing, with or without a croupy cough
• Active bleeding from the incision
• Redness, swelling, or persistent pain in the incision
• Continued vomiting

Follow-up:
A clinic appointment needs to be scheduled one to two weeks after the operation. Please call (602) 254-5561 to schedule this appointment.

Glossary

• Meckel’s diverticulum – An outpouching of the small intestine that occurs in 10% of the population. It may serve as a lead-point for an intussusception.
• Barium enema – A procedure in which a radiolucent dye is placed into the rectum and x-rays are taken to evaluate the rectum and large intestine. In the case of intussusception, it is both diagnostic and therapeutic. The pressure of the dye will often un-telescope (reduce) the piece of bowel that is causing the obstruction.