Pediatric Intussusception
Comprehensive emergency evaluation and protocolized management of pediatric intussusception (ages 3 months to 3 years): classic ileocolic telescoping, idiopathic viral lymphoid hyperplasia (Peyer's patches) vs. pathologic lead points (Meckel's diverticulum, Henoch-Schönlein purpura/IgA vasculitis, lymphoma, duplication cysts), classic intermittent colicky abdominal pain triad, ultrasound target/donut sign sensitivity, pneumatic (air) vs. hydrostatic contrast enema reduction, peritonitis contraindications, and recurrence protocols.
Resuscitation Quick Actions • First 2 Minutes
Ultrasound Target Sign
POCUS sensitivity > 98%; transverse view shows concentric bowel wall rings ('target', 'donut', or 'bullseye' sign > 3 cm diameter)
Pneumatic (Air) Enema
First-line reduction method (air pressure max 80–120 mmHg); higher success rate (85–90%) and lower complication rate than hydrostatic contrast
Enema Contraindications
Peritonitis, abdominal rigidity, septic shock, or free intraperitoneal air on abdominal radiograph = STAT SURGICAL OR LAPAROTOMY
Post-Reduction Recurrence
Recurrence occurs in 5–10% of cases, typically within the first 24–48 hours; repeat pneumatic enema is effective for recurrences
Pathologic Lead Point (> 3 yr)
Children > 3 years or recurrent episodes: suspect pathologic lead point (Meckel diverticulum, duplication cyst, polyp, Burkitt lymphoma)
IV Crystalloid Resuscitation
Administer 10–20 mL/kg isotonic fluid bolus prior to reduction; maintain NPO and place NG tube for decompression
Target Sign and Doughnut Sign
Classic concentric alternating hyperechoic/hypoechoic rings on transverse ultrasound; diagnostic of intussusception. Air-contrast enema reduction is successful in >80-90% of cases.
Bottom-Line Clinical Pearl
Intussusception is the most common cause of intestinal obstruction in children aged 3 months to 3 years. It occurs when a proximal bowel segment (intussuscipiens) invaginates into a distal segment (intussusceptum), compressing mesenteric vessels and producing venous congestion, edema, and bowel ischemia. The classic triad—paroxysmal severe colicky pain with knees drawn up, palpable 'sausage-shaped' abdominal mass, and 'currant jelly' stool (mucus + sloughed ischemic mucosa + blood)—is present in only 15–20% of cases! Point-of-care ultrasound is the diagnostic study of choice (> 98% sensitive and specific, revealing the classic 'target' or 'donut' sign). Treatment is non-operative Pneumatic (Air) Enema reduction under fluoroscopic guidance; contraindications are peritonitis, perforation (free air), or hemodynamic shock.
Intussusception involves the telescoping of a proximal loop of intestine into an adjacent distal segment. Approximately 90% of cases are ileocolic (terminal ileum invaginating through the ileocecal valve into the colon).
In infants and young children (peak age 6 to 12 months), the vast majority are idiopathic, precipitated by hypertrophied lymphoid tissue (Peyer's patches) in the terminal ileum following an acute viral illness (adenovirus, rotavirus). In older children ($> 3\text{ to }5\text{ years}$), or in neonates, an identifiable pathologic lead point is present in $> 50\%$ of cases: Meckel's diverticulum (#1 pathologic lead point), intestinal duplication cysts, polyps, Henoch-Schönlein purpura (submucosal intramural hematomas), or Burkitt lymphoma.
The classic textbook triad comprises: (1) intermittent, paroxysmal, severe abdominal pain with drawing up of the legs into the chest followed by periods of complete calm/lethargy; (2) a sausage-shaped mass in the right upper quadrant or epigastrium with emptiness in the right lower quadrant (Dance's sign); and (3) gross 'currant jelly' stools (a late sign representing mucosal necrosis, venous congestion, and sloughed tissue). However, all three components are present in fewer than 20% of children at initial presentation! Lethargy alone can be the sole presenting sign of intussusception.
| Phase of Care | Procedure & Technique | Diagnostic Findings & Safety Thresholds |
|---|---|---|
| Bedside Ultrasound | High-frequency linear transducer placed across right upper quadrant and transverse colon | Diagnostic Gold Standard (> 98% sensitive): Transverse view shows the 'target'/'donut' sign (concentric hypoechoic and hyperechoic rings $> 3\text{ cm}$); longitudinal view shows the 'pseudokidney' or 'sandwich' sign. |
| Pre-Reduction Resuscitation | NPO, place large-bore IV, infuse 10–20 mL/kg balanced crystalloids, consult pediatric surgery backup | Ensure patient is hemodynamically stable; screen for peritonitis or pneumoperitoneum. |
| Fluoroscopic Pneumatic (Air) Enema | Catheter placed into rectum with balloon taped tightly; insufflate air under fluoroscopy | Pressure limit: 80 to 120 mmHg (never exceed 120 mmHg). Successful reduction is confirmed by rapid, free reflux of air into multiple loops of the terminal ileum. Success rate: 85–90%. |
| Post-Reduction Observation | Observe in ED for 4 to 6 hours or admit for short-stay observation | Begin oral fluids once fully awake. Educate parents that 5–10% will recur, most frequently within the first 24–48 hours. |
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