Background • Fever is a late finding and is suggestive of enteric sepsis.

Intussusception is the telescoping or prolapse of one portion of the bowel into

an immediately adjacent segment. Contrast enema can reduce the Causes
intussusception in approximately 75% of cases.
Most cases are idiopathic. In neonates and in patients older than 3 years, a
Pathophysiology mechanical lead point usually can be found.
Intussusception most commonly occurs at the terminal ileum (ie, ileocolic).
The telescoping proximal portion of bowel (ie, intussusceptum) invaginates • Predisposing factors
into the adjacent distal bowel (ie, intussuscipiens). o Recent upper respiratory illness
The mesentery of the intussusceptum is compressed, and the ensuing o Recent diarrheal illness
swelling of the bowel wall quickly leads to obstruction. Venous engorgement o Henoch-Schönlein purpura
and ischemia of the intestinal mucosa cause bleeding and an outpouring of o Cystic fibrosis
mucous, which results in the classic description of red "currant jelly" stool. o Chronic indwelling GI tubes
Most cases (90%) are idiopathic, with no identifiable lesion acting as the lead • Processes that result in a mechanical lead point
point or pathological apex of the intussusceptum. o Meckel diverticulum
o Intestinal polyp (eg, Peutz-Jeghers syndrome, familial
Frequency polyposis coli, juvenile polyposis)
United States o Intestinal lymphosarcoma
Intussusception is the predominate cause of intestinal obstruction in persons o Blunt abdominal trauma with intestinal or mesenteric
aged 3 months to 6 years. The estimated incidence is 1-4 per 1000 live hematomas
births. o Hemangioma
o Foreign body
Mortality/Morbidity
o Henoch-Schönlein purpura (small bowel hematomas
Most patients recover if treated within 24 hours. Mortality with treatment is 1- cause small bowel intussusception)
3%. If left untreated, this condition is uniformly fatal in 2-5 days. Recurrence o Kaposi sarcoma1
is observed in 3-11% of cases. Most recurrences involve intussusceptions
that were reduced with contrast enema.
• Is the invagination or telescoping of a portion of the intestine into a
Sex adjacent, more distal section of the intestine causing mechanical
Overall, the male-to-female ratio is approximately 3:1. With advancing age, obstruction.
gender difference becomes marked; in patients older than 4 years, the male- • The cause may be idiopathic (unknown but following a viral
to-female ratio is 8:1. infection); lead point (change in the mucosa from another condition
such as cystic fibrosis, Meckel’s diverticulum, or hematoma); or
Age post operative.
Intussusception is most common in infants aged 3-12 months, with an • It occurs in children younger than age 3, most commonly ages 5 to
average age of 7-8 months. Two thirds of the cases occur before the patient's 10 months.
first birthday. Intussusception occurrence is rare in persons younger than 3 • Without prompt treatment, necrosis of the involved segment leads
months, and it becomes less common in persons older than 36 months. to shock, perforation, and peritonitis.
Clinical
Assessment:
History
1. Paroxysmal abdominal pain; legs drawn up, child is inconsolable;
• The typical presentation of intussusception is a previously healthy may be comfortable between episodes.
infant boy aged 6-12 months with sudden onset of colicky 2. Blood in stool, or later “currant jelly” stools containing sloughed
abdominal pain with vomiting. mucosa, blood, and mucus.
3. Vomiting.
• Paroxysms of pain occur 10-20 minutes apart. 4. Increasing absence of stools.
• Initially, loose or watery stools are present concurrent with vomiting 5. Abdominal distention, bowel sound diminished, absent or high
and, within 12-24 hours, blood or mucous is passed rectally. pitch.
• Early in the course, the patient appears completely well between 6. Sausage like mass palpable in abdomen (Dance’s sign).
the episodes of abdominal pain. 7. Unusual looking anus; may look like rectal prolapse.
8. Dehydration and fever
• Lethargy may dominate the initial presentation. However, lethargy 9. Shock like state with rapid pulse, pallor, and marked sweating.
usually occurs later in the process.
• The classic triad of colicky abdominal pain, vomiting, and red
Diagnostic Evaluation:
currant jelly stools occurs in only 21% of cases.

1. X-ray of abdomen may show absence of gas or mass in right upper

Physical
quadrant.
2. Barium enema is done if there is no appearance of peritonitis;
• Usually, the abdomen is soft and nontender early but eventually shows a concave filling defect (will help reduce the invagination).
becomes distended and tender. 3. Ultrasonogram may be done to locate area of telescoped bowel.
• A vertically oriented mass may be palpable in the right upper 4. Color Doppler sonography determines whether reducible. Absence
quadrant. of blood flow indicates ischemia and, therefore, enema reduction
should be avoided.
• Currant jelly stools are observed in only 50% of cases.
• Most patients (75%) without obviously bloody stools have stools
that test positive for occult blood. Surgical Intervention:
 1. Intussusception can be surgically reduced, resection may be • lethargy (i.e., drowziness or sluggishness)
necessary if bowel is nonviable.

Nursing Intervention: • shallow breathing

1. Monitor I.V. fluids and intake and output to guide in fluid balance.
2. Be alert for respiratory distress due to abdominal distention. • grunting
3. Monitor vital signs, urine output, pain, distention, and general
behavior preoperatively and postoperatively. As the illness progresses, a child will become progressively weaker and may
4. Observe infant’s behavior as indicator of pain; may be irritable and develop a fever and appear to go into shock. Symptoms of shock include
very sensitive to handling or lethargic or unresponsive. Handle the lethargy, rapid heartbeat, weak pulse, low blood pressure, and rapid
infant gently. breathing.
5. Explain cause of pain to parents, and reassure them about purpose
of diagnostic tests and treatments.
6. Administer analgesic as prescribed. Causes
7. Maintain NPO status as ordered.
8. Insert nasogastric tube if ordered to decompress stomach.
9. Continually reasses condition because increased pain and bloody In infants, the causes of intussusception are unknown, although there are
stools may indicate perforation. some theories about why it occurs. Because intussusception is seen most
10. After reduction by hydrostatic enema, monitor vital signs and often in spring and fall, this seems to suggest a possible connection to the
general condition – especially abdominal tenderness, bowel kinds of viruses that children catch during these seasons, including upper
sounds, lethargy, and tolerance to fluids – to watch recurrence. respiratory infections.
11. Encourage follow up care.
12. Provide anticipatory guidance for developmental age of child.
In some cases, intussusception may follow a recent bout of gastroenteritis
(sometimes called stomach flu). Gastrointestinal infections may cause
What Is Intussusception? swelling of the infection-fighting lymph tissue that lines the intestine, which
may pull one part of the intestine into the other. Intussusception is most
Intussusception occurs when one portion of the bowel slides into the next, common around the age that infants are being introduced to solid foods. It
much like the pieces of a telescope. When this occurs, it creates an has been suggested that the introduction of new foods may also cause some
obstruction in the bowel, with the walls of the intestines pressing against one swelling of the lymph tissue in the intestines, increasing the chance of
another. This, in turn, leads to swelling, inflammation, and decreased blood developing an instussusception.
flow to the intestines involved.
Usually when an adult or a child older than 3 develops an intussusception, it's
The most common cause of intestinal obstruction in children between the often the result of enlarged lymph nodes, a tumor, or a polyp in the intestine.
ages of 3 months and 6 years, intussusception:
Diagnosis and Treatment
• occurs most often in children between 5 and 10 months
of age (80% occur before a child is 24 months old) The doctor will then perform a physical exam on the child, paying special
attention to the abdomen. Often, the doctor can feel the part of the intestine
• affects between one and four infants out of 1,000 that's involved, which is swollen and tender and often is described as a
• is three to four times more common in boys than in girls "sausage-shaped mass." Symptoms like pain, drawing up the legs, vomiting,
lethargy, and passing bloody or currant jelly stool are meaningful in helping
the doctor reach a diagnosis. In addition to doing a physical examination,
Signs and Symptoms the doctor will ask the parent about any concerns and symptoms their child
has, the child's past health, your family's health, any medications the child is
Children with an intussusception have intense abdominal pain, which often taking, any allergies the child may have, and other issues. This is called the
begins so suddenly that it causes loud, anguished crying and causes the medical history.
child to draw the knees up to the chest. The pain is usually intermittent, but
recurs and becomes stronger. As the pain subsides, a child with an
intussusception may stop crying and seem fine. If the doctor thinks an intussusception may be the cause of the child's pain, a
pediatric surgeon will be consulted to examine the child and decide about
treatment. The doctor may order an abdominal X-ray, which may or may not
Other common symptoms include: show an obstruction. An ultrasound examination may also help make the
diagnosis. If the child appears very ill, suggesting damage to the intestine,
the surgeon may opt to take the child immediately to the operating room to
• abdominal swelling or distension correct the bowel obstruction.

A barium or air enema is often used to both diagnose and treat a suspected
• passing stools (or poop) mixed with blood and mucus, intussusception. During a barium enema, a liquid mixture containing barium
known as currant jelly stool (60% percent of infants with an is given through a catheter tube into the child's rectum, and special X-rays
intussusception will pass currant jelly stool) are taken. Barium outlines the bowels on the X-rays and, if an
intussusception is present, shows the doctors the telescoping piece of
intestine.
• vomiting

In many instances, the barium enema not only shows the intussusception,
• vomiting up bile, a bitter-tasting fluid secreted by the liver but the pressure from putting it in the bowel may also unfold the bowel that
that's often golden-brown to greenish in color has been turned inside out, instantly curing the obstruction. An air enema,
given rectally in a similar way as barium, can also be used to diagnosis and
treat an intussusception.
The radiologist usually decides which test is most appropriate to perform. Causes
Both procedures are very safe and usually well tolerated by the child, Most commonly intussusceptions are associated with some problem that
although there is a very small risk of infection or bowel perforation. There's a causes inflammation of the intestine (enteritis). Common causes of enteritis
10% risk of recurrence, which usually occurs within 72 hours following the are intestinal parasites (hookworms, whipworms, and roundworms),
procedure. protozoal, bacterial or viral infections (Giardia, Salmonella, canine distemper,
and parvovirus), intestinal foreign bodies (bones, plastic toys, etc.), abrupt
dietary changes, intestinal masses (tumors) and any surgical procedure
If the barium or air enema procedures aren't successful or the child is too ill performed on the intestine. Increased motility in a segment of intestine
to attempt the enema, the child will undergo surgery. Enemas are less (hypermotility) which is adjacent to a segment that has lack of motility (ileus)
successful in older children, and they're more likely to require surgery to treat can cause the hypermotile segment to telescope into the segment with ileus,
intussusception. Surgeons will try to fix the obstruction but if too much resulting in an intussusception.
damage has been done, that part of the bowel will be removed.
Incidence and Prevalence
Some babies with intussusception may be given antibiotics to prevent Intussusceptions occur mostly in dogs and rarely in cats. The German
infection. Babies who have been treated for intussusception will be kept in shepherd dog may have a higher incidence of intussusception than other
the hospital and given intravenous feedings until they're able to eat and have breeds. More commonly, intussusception occurs in young dogs, (less than a
normal bowel function. year of age) possibly because of the higher incidence of parasite problems
and viral enteritis (distemper and parvovirus)

Complications Signs and Symptoms.

Dogs that develop intussusceptions have generally been having episodes of
If left untreated, intussusception can cause severe complications. diarrhea or vomiting before the intussusception occurs. Small volumes of
Complications are directly related to the amount of time that passes from bloody diarrhea, abdominal pain, or a palpable abdominal mass are
when the intussusception occurred until it's treated. Most infants who are suggestive of an intussusception. The severity of the clinical signs depends
treated within the first 24 hours recover completely from an intussusception somewhat on the location of the intussusception, with problems lower in the
with no problems. Further delay increases the risk of complication which intestinal tract causing less severe clinical signs. Intussusceptions can be
include irreversible tissue damage, perforation of the bowel, infection, and chronic or intermittent, meaning that they will reduce themselves
death. spontaneously and then reform.

When to seek Veterinary care

When to Call Your Child's Doctor Dogs or cats with a history of vomiting or diarrhea for more than a day or two
should be evaluated by a veterinarian, particularly if associated with
Intussusception is a medical emergency. If you're concerned that your child depression, and loss of appetite.
has some or all of the symptoms of intussusception, such as abdominal pain,
vomiting, or passing of currant jelly stool, call your child's doctor or
emergency medical services immediately. Physical Exam, Testing, and Differential Diagnosis
Intussusception should be a consideration in a patient with a history of
vomiting or diarrhea that has a palpable mass in the abdomen. The mass
The outcome for most infants with intussusception is very good, and with can be felt as a thickened sausage shaped intestinal loop. Occasionally the
early treatment, complications are much less likely to develop. Do not delay, small bowel can be felt entering the mass. Radiographs will show a typical
though — in many cases, early diagnosis can mean a child can be pattern of intestinal obstruction with gas and fluid filled dilated loops of bowel
successfully treated without surgery. if the obstruction caused by the intussusception is complete. In cases of
partial obstruction, there may not be significant signs on plain radiographs
and a barium contrast study may be needed to identify the problem. If
INTUSSUSCEPTION ultrasound examination of the abdomen s available, the intussusception area
can often be identified, (Figures 3a and 3b) making this exam preferential to
the barium series which requires multiple X-rays, more time, and creates a
Overview problem of liquid barium at the surgery site if a section of bowel has to be
The term intussusception (pronounced in-tuh-sus-sep-shun) is used to removed to repair the problem.
describe a condition in which one segment of the intestine (the
intussusceptum) telescopes or invaginates into the lumen of and adjacent
segment of intestine (the intussuscipiens). Intussusceptions may occur at any
location in the gastrointestinal tract from the stomach to the large intestine, Figure 3a,b: Ultrasound views of an intussusception. Figure 3a shows a
however, most commonly the bowel segments involved are the jejunum (in transverse view. Alternating hyperechoic and hypoechoic concentric rings are
the middle of the small intestine) or the ileocecocolic junction (where the present within the lumen of a distended loop of bowel, giving the typical
small intestine joins the large intestine or colon. Generally the "target" sign.
intussusceptum is a more proximal portion of bowel (i.e. closer to the mouth)
which telescopes into a more distal (closer to the anus) segment. This pattern
follows the normal direction of peristalsis. The reverse, however, is
occasionally found.
Figure 3b shows a longitudinal view of the intussusception. Notice that
multiple layers of bowel wall are within the lumen of the intussuscipiens.

Intussusception must be differentiated from all other causes of intestinal

Figure 1. Illustration of an intussusception showing the invaginated obstruction. These include:
intussusceptum (blue) and the invaginating intussuscipiens (red) . (A)
demonstrates a direct or normograde intussusception occurring in the
direction of normal peristalsis. (B) demonstrates an indirect or retrograde • Intestinal foreign bodies
intussusception occurring against the normal direction of peristalsis. • Intestinal volvulus (a twisting of the intestine)
• Intestinal tumors

Figure 2: An intra-operative view of an intussusception Notice that one • Intestine trapped in a hernia
section of the small intestine has telescoped into the adjoining section. • Intestinal infections causing marked thickening or abscess
formation
 • Ileus (loss of motility from any cause-frequently seen with
parvoviral enteritis

Treatment options
Occasionally intussusceptions can be manually reduced by manipulation of
the affected bowel through the abdomen. They will also occasionally reduce
themselves spontaneously. In most cases, however, surgery is required to
treat this problem. Recurrence of intussusceptions is common, so even the
intussusception can be manually reduced, surgery is often recommended to
perform procedures designed to decrease the incidence of recurrence.
During surgery the affected area bowel is easily identified (Figure ). It is
occasionally possible for the surgeon to manually reduce the intussusception.
Many times, however, either the intussusception cannot be reduced, or the
bowel is so badly damaged that resection of the affected bowel is required. In
this case, the area of damaged bowel is removed and the cut ends of the
intestine are joined together with sutures or staples (a procedure called an
intestinal anastomosis).

Because most patients that develop intussusceptions have had episodes of

vomiting and diarrhea, the hydration and electrolyte status of the patients
should be addressed prior to surgery if possible. This involves some blood
chemistry analysis and treatment with an appropriate intravenous fluid.
Treatment of animals with intussusception can be complicated and difficult.
Many veterinarians prefer to send these patients to a surgical specialist for
care. To find an ACVS Veterinary Surgeon in your area, click here.

Prognosis and Complications Following Treatment

The prognosis following surgical repair of an intussusception depends on
several factors including the duration of the problem, the amount of intestine
involved, the location of the problem and the extent of the blockage that has
been caused. Intussusceptions that are chronic almost always require
removal of a section of bowel and anastomosis of the ends to re-establish
bowel integrity. Anytime bowel has to be removed there is a chance of
leakage from the surgery site which can result if potentially fatal peritonitis.
Patients that are in poor condition because of the intussusception may have
a diminished ability to heal, making leakage more likely. If large amounts of
bowel have to be removed, the patient may not do well because of the
relatively short length of bowel left behind. Generally a high obstruction,
(close to the stomach) will cause more severe vomiting and result in more
serious dehydration and electrolyte disturbances, which may make
anesthesia a more risky procedure. If an intussusception only causes a
partial obstruction, the patient will not have nearly the extent of clinical signs
that are present in those with a complete obstruction.

The prognosis for patients with an intussusception are good as long as

recurrence of the problem can be prevented, and excessive amounts of
bowel do not have to be removed. It has been reported that between 11%
and 20% of dogs will have a recurrence of the problem following surgical
correction. The incidence is higher (25%) if only manual reduction and no
surgery is done. A procedure known as enteroplication can be performed to
prevent recurrence of the intussusception, however, may make the patient
more susceptible to other complications such as intestinal obstructions with
foreign material that may have been able to pass without complication if the
bowel had not been plicated.

Aftercare
Post-operative care following intussusception involves efforts to manage
pain, generally with opioids, which help to slow bowel motility as well. Re-
establishment of hydration and normal electrolyte values is essential and
appropriate intravenous fluids are generally used until the patient is back
eating normally. Antibiotics may be required depending on the amount of
contamination from the surgery and the preference of the surgeon.