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406 Intussusception
Investigations There are definite signs on US that will influence nonoperative
In resource-poor settings, the physician may not have access to the management (i.e., hydrostatic or pneumatic reduction); the details of
investigations described here, in which case a high clinical acumen these are beyond the scope of this book but can be obtained from the
and index of suspicion is the next best alternative. Our management literature. 17–23 Ultrasound may pick up a PLP (Figure 68.6).
algorithm for the child with intussusception is illustrated in Figure 68.4. Generally, trapped fluid 17,18 on US scan and the absence of blood
Characteristically, diagnostic investigations include abdominal flow at Doppler imaging, 6,17,24,25 where available, are indicators of
ultrasound (US) scans in axial and longitudinal views. This is accurate ischaemia, and irreducibility of the intussusception and should be
in detecting intussusception with a certainty of up to 100% and can also carefully considered in any further management of the lesion.
show additional pathologies such as the presence of a PLP. 6,15,16 It also In the absence of ultrasound, other investigations can be used.
allows the operator to be able to say whether the intussusception is in Contrast Enema Examination
the small intestine or the large bowel. The contrast most frequently used is barium solution, but an air enema
In the axial/transverse view, the intussusception is seen as a target can also be used. The two main classic signs of intussusception at
lesion or has a doughnut sign (Figure 68.5). In the longitudinal view, enema examination are the meniscus sign produced by the rounded
there is a pseudokidney or sandwich appearance. When the radiologist apex of the intussusceptum protruding into the column of contrast
or ultrasonographer sees these two signs, the abdominal mass is likely material and the coiled spring sign formed when the oedematous muco-
an intussusception. In most cases, the radiologist is able to tell whether sal folds of the returning limb of the intussusceptum are outlined by
there is a PLP or not. contrast material in the lumen of the colon. 6

History

Abdominal pain, irritability, intermittent and
incessant crying, bloody mucoid stools,
preceding viral infection

Physical Findings: Healthy-looking infant; abdominal
mass; abdomen may or may not be distended; DRE
may be normal or blood on EF; a mass may or may
not be felt in the rectum

Clinical diagnosis

Diagnostic/supportive investigations

Abdominal x-ray
Abdominal ultrasound scan or
Air under Signs of intestinal contrast enema
diaphragm obstruction
Target lesion or Intussusception
pseudokidney sign excluded
Continue
resuscitation
Manage
Radiologic reduction Reduction appropriately
Laparotomy in operation
theatre
Ultrasound-guided Fluoroscopic-guided
Closure of
perforation or Not successful Successful
resection and Reduced Not reduced after 3 attempts
anastomosis
Observe for 24
hours and
Repeat reduction Laparotomy discharge home
Observe for 24
hours and
discharge home Manual reduction Resection and anastomosis

(DRE = digital rectal examination; EF = examining finger)
Figure 68.4: Algorithm for the management of a child with intussusception