Intussusception - Causes, Symptoms, and Treatment

Introduction:

Intussusception is a disorder in which part of the intestine folds into another section beside it. Generally, the small intestine is folded, and rarely the large intestine. It occurs more regularly in children than in adults and males rather than females. The condition's cause is unknown in children, whereas it can be due to cancer in adults. Symptoms of intussusception include vomiting, bloating, abdominal pain, and bloody stool. It can also cause small intestine obstruction and perforation. The presence of 'sausage-shaped mass' or 'doughnut sign' is there on examination. Treatment of intussusception can be enema with surgery in children and removal of affected bowel in adults.

What Causes Intussusception?

The etiology behind intussusception is not clear. It can be due to anatomical factors, motility, or any infection.

Some of the known causes are:

• Anatomical Factors.

• Infection: It can be a virus that causes swelling of the intestine lining, which slips into the intestine beside it.

• Altered Motility: Abnormal intestinal contractions such as spasms.

• Meckel’s Diverticulum: This is a common congenital anomaly formed in the small intestine (gastrointestinal tract). It occurs due to incomplete obliteration of the vitelline duct (the embryonic duct that provides communication between the yolk sac and midgut during the gestation period for development). The leftover vitelline duct forms a true diverticulum in the small intestine.

• Hyperplasia of Peyer’s Patches: A group of lymphoid follicles in the mucous membrane lining the small intestine are called Peyer's patches. Enlargement of these lymphoid follicles is termed as hyperplasia of Peyer's patches.

• Appendicitis: Inflammation in the appendix (finger-like pouch projecting out from the colon of the large intestine).

• Polyps: Small, flat bump-like tissue growth in the lining of organs.

• Duplication: It is a rare congenital disorder termed duplication of the alimentary tract (DAT) by Fiorami et al. Most affected site is the small intestine.

Which Population Is Most Affected by Intussusception?

• Infancy and early childhood is the most commonly affected age.

• It is observed in the fifth month of life, at the most severe form between the fourth to the ninth month, and gradually subsides around the 18th month of life.

• Boys suffer more than girls in a ratio of approx. 3:1.

• It has less prevalence in adults, almost only 1 %, and is often associated with neoplasm.

What Is the Phenomenon of Intussusception?

In most cases, the ileum enters the cecum and it is rarely seen that part of the ileum and jejunum prolapse into each other.

• Intussusceptum: The part that displaces into the other portion.
• Intussuscipiens: The part that receives the displaced part.

In almost all cases of intussusception, the intussusceptum is located proximal to the intussuscipiens. This happens because the peristaltic action of the bowel pulls the proximal segment into the distal segment.

Generally, the blood supply of the trapped segment is cut off, which leads to ischemia (restricted blood flow to a body part). Since the mucosa is sensitive to ischemia, it causes sloughing off into the gut. Due to this sloughing, a 'red currant jelly' stool is created consisting of sloughed mucosa, blood, and mucus. However, 'red currant jelly' stool is seen in very few cases of intussusception and should be called one of the related disorders.

What Are the Symptoms of Intussusception?

The symptoms of intussusception can be differentiated as early and late depending on the time of onset and duration of disease in children.

Early Symptoms Include:

• Vomiting: The color can be green due to the presence of excessive bile.

• Nausea.

• Abdominal pain and discomfort.

• Child observed pulling his legs towards the chest.

• Intermittent pain depends on the contractions of the affected bowel segment.

Later Symptoms Can Be:

• Lethargy

• Rectal bleeding often with the presence of 'red currant jelly’ stool.

• 'Sausage-shaped mass' observed on physical examination.

• Fever is not considered as a sign of intussusception but sometimes, secondary to ischemia; there can be sepsis which can cause an increase in body temperature.

• Henoch-Schonlein Purpura: It is a condition in which there is inflammation and bleeding from the small blood vessels of organs such as the kidney, intestines, and skin. Intussusception can be a complication in a few cases of Henoch-Schonlein purpura.

How to Diagnose Intussusception?

Different diagnostic measures used for evaluating disease are:

• Observation of Dance Sign: It is a sign of retraction observed in the right lower quadrant of the abdomen, which can indicate intussusception.

• Ultrasound: Most important process for intussusception. The appearance of the 'doughnut sign' generally around 3 cm in diameter, confirms intussusception.

• Physical Examination: Of the rectum with the digits may help to feel the intussusception.

• CT-Scan: Doughnut sign is seen in CT scan. This shape is created by the hyperechoic central core of the intestine.

• Longitudinal Imaging: 'Sandwich-shaped' appearance of intussusception is observed.

• Intestinal obstruction is elevated with the help of an X-ray and air enema.

Which Diseases Are Similar to Intussusception?

• Gastric Volvulus: Abnormal rotation of the stomach on one of its axes. It can lead to gastric strangulation.

• Abdominal Hernias: Pushing of an organ through the muscle or tissue holding it in place.

• Testicular Torsion: Rotation of testicles due to twisting in the spermatic cord, which brings blood to the scrotum.

• Rectal Prolapse: Slipping of the rectum outside the muscular opening anus.

What Are the Treatments for Intussusception?

• Since it is not an immediate life-threatening disorder, it can be successfully treated non-surgically by water-soluble barium or air enema. In this procedure, air or barium solution is instilled in the rectum through a small, soft tube which creates pressure within the bowel and resolves the intussusception. Almost 80 % or more cases are successfully treated by this method, whereas up to 10 % may show recurrence within 24 hours.

• Some cases that cannot be reduced non-surgically require surgical squeezing of the part to release the obstruction.

• Laparoscopy (a small cut in the abdomen) can also be done to pull the intestine apart with forceps.

• In rare cases which are not cured by both enema and surgical squeezing, sectioning and removal of the affected part are done.

Conclusion:

Intussusception is a disorder that can get severe if left untreated. Proper evaluation and treatment are essential as the affected population is infants and children in early childhood.