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Intussusception 405

(A) (B)
Figure 68.3: (A) Red current jelly stool 8 hours post presentation. (B) A
prolapsed necrotic intussusception, which was found to be ileo-ileocolic
intraoperatively. A right hemicolectomy was carried out, and the child survived.

6. The triad of intermittent abdominal pain, vomiting, and bloody
stools is encountered in about 30% of infants with intussusception. 10,11
7. A history of diarrhoea or constipation may be given. However, the
parents may give a history of diarrhoea only just before the onset of
the bloody mucoid stools. This may lead to confusion in the diagnosis
Source: Courtesy of Francis A. Abantanga. because medical conditions such as dysentery will usually be the
Figure 68.2: Diagrammatic representation of an idiopathic intussusception. The first thing to come to mind. As a result, there is a delay in diagnosis,
apex is the lead point of the intussusception
especially if the first-line medical caregiver has a low index of
suspicion for intussusception.
blood mixes with the mucosa and mucus to give the classic “red currant 8. There may be a history of a recent immunisation using rotavirus
jelly stools”. vaccine 5,10 or of a viral illness. 3
If the swelling, oedema, and ischaemia are not relieved, the lumen 9. In older children, the major symptom is abdominal pain, which is
of the bowel will become completely occluded, and transmural necrosis present in almost all cases. Bloody stools and vomiting are reported in
of the intussusceptum will set in, leading to fluid sequestration, about 25%. The triad of abdominal pain, bloody stools, and vomiting is a
translocation of intestinal bacteria into the peritoneal cavity, perforation rare combination in this age group, and these are nonspecific symptoms. 14
of the bowel, and possibly peritonitis.
Physical Examination
Clinical Presentation Physical examination will reveal a healthy-looking child, especially if the
The usual presentation is of a healthy, well-fed infant aged between 6 patient is brought for consultation within the first few hours of the occur-
and 9 months on average. rence of the intussusception. In the presence of the typical triad of inter-
History mittent abdominal pains, vomiting, and bloody mucoid stools, there is the
There may or may not be an antecedent infection (e.g., a viral infec- need to examine the child thoroughly in order to make the right diagnosis.
tion). A good history eliciting the following findings will most often Infants and toddlers who present late (i.e., after 24 hours), which is
suggest the diagnosis. the rule and not the exception in the African subregion) will be irritable,
weak, and lethargic. To avoid delays in making a clinical diagnosis,
1. There is a sudden onset of uncontrollable/inconsolable crying,
which occurs intermittently every 10 to 30 minutes and lasts for a the presence of pallor and lethargy in a child who has cried for several
few seconds or so. This coincides with the sudden onset of colicky hours to days should alert the clinician to these subtle features of
abdominal pains, when the intussusceptum together with the mesentery intussusception in addition to the presence of any one or two symptoms
and nerves are drawn into the intussuscipiens. The screaming is high- of the classical triad mentioned above.
pitched in nature and is unexpected. The late-presenting child also will be dehydrated, or frankly in
shock with cold clammy extremities (typical of late presentation and/
2. The child stops screaming and plays normally in between attacks or late diagnosis). The degree must be assessed rapidly and corrected
until the next occurrence of colicky abdominal pain sets in. This type appropriately. In addition, the child will be febrile or anaemic.
of abdominal pain is pathognomonic of intussusception in infants In those who present early, an abdominal mass may be palpable, if
because the pattern in which that the child cries for some time, stops present. In late presenters, the abdomen is distended (sometimes grossly)
and plays, and starts crying again, is rarely seen in other conditions. and tender, and it is difficult to palpate any intraabdominal masses. If the
3. During the periods when the child screams, he or she frequently draws abdomen is tender, with rebound tenderness and guarding, one should
up the lower limbs to the abdomen as if to reduce the pain. Between the suspect the presence of peritonitis and therefore treat it appropriately (see
colicky episodes, the child may appear listless and frequently pale. the section “Treatment” later in this chapter).
4. Vomiting sets in. Vomiting tends to begin earlier in infants and is If the abdomen is not distended (i.e., it is flat or scaphoid), the right
reflex in nature. Vomiting due to intestinal obstruction is a late sign, iliac fossa feels empty—this is the Dance’s sign.
and the vomitus may be bilious. On digital rectal examination, the rectum may be empty or one may
palpate the intussusceptum or the lead point of the intussusception in
5. Stools may at first be mucoid (the sloughed-off mucosa). Blood the rectum, and on withdrawal of the examining finger, there may be
in stools may appear as early as within the first 6 hours, but it may passage of only mucus or bloody mucoid stools; the finger may or
also be absent until a day later. Blood mixed with mucus, giving the may not be stained with blood. In the late presentations, the chances
characteristic appearance of red currant jelly stools of intussusception, of passage of blood per rectum are high due to possible necrosis of the
is present in only about 30% of cases (Figure 68.3(A)). There are bowel. There may be prolapse of the intussusceptum through the anal
occasions when the bloody mucoid stools are first noticed only after a orifice in those who present very late (Figure 68.3(B)).
digital rectal examination (DRE) of the child.