Intussusception

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

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Aim

To guide PCH Emergency Department (ED) staff with the assessment and management of intussusception.

Definition¹

Intussusception occurs when a section of bowel invaginates into the lumen of the immediately distal bowel, resulting in ischaemia and gangrene of the inner bowel. It most commonly occurs at the ileocaecal junction.

Background^1,2

Peak age 5-10 months (may occur from 3 months to 5 year old)
Most common cause of acute intestinal obstruction in children 6-36 months
60% of cases are < 1 year old and 80-90% are < 2 year old.

Complications¹

Perforation of bowel, with peritonitis
Necrosis of bowel requiring bowel resection
Shock and sepsis
Re-intussusception after spontaneous or active reduction.

Assessment

History

Typically, episodes of sudden intense pain with screaming and flexion of the legs, often associated with pallor
- Episodes last several minutes and recur at 5-20 minute intervals
- Episodes may be associated with vomiting (bilious or non-bilious) and/or blood in stools
- The infant usually looks relatively well between episodes
Less commonly, episodes of lethargy, irritability, altered mental status
- May be mistaken for a child presenting with convulsions or sepsis/meningitis – the child appears floppy and semi-conscious
The classical TRIAD of pain, abdominal mass and red currant jelly stool is only seen in < 15% of cases
On third of cases present with a history of recent viral illness
Recent rotavirus vaccination (there is a small risk of intussusception in infants following the rotavirus vaccination).^3,4

Examination

The child can present as:
- Pale, lethargic and hypovolemic
- Abdomen may be distended and tender
- Palpable abdominal mass (sausage shaped) in the right upper quadrant.
- The mass can be difficult to palpate
- Dehydration or shock develops as symptoms progress
- Vomiting (may become bile-stained if bowel obstruction has occurred)
- 'Red currant jelly' stool (blood and mucous in stool) is a late sign.

Investigations

Abdominal X-ray

Mainly to look for signs of bowel obstruction or perforation
It may be normal
Signs of intussusception are:
- paucity of bowel gas on the right side of the abdomen
- distended loops of small bowel with air/fluid filled level
- look for obscured liver edge, crescent sign and target signs
- free gas if perforated.

Ultrasound (US)

Diagnostic investigation of choice – highly sensitive and specific for intussusception (a ‘target’ or ‘doughnut’ sign is classic).

Blood tests

If shocked or unwell looking
Electrolytes, urea, creatinine, blood gas
Full blood count
Cross match to be arranged in all circumstances in case surgical intervention becomes urgent.

Management

Insert IV cannula and obtain blood tests if required
If shocked, correct using IV boluses of 20 mL/kg of sodium chloride 0.9%
Nil by mouth
If signs of bowel obstruction insert nasogastric tube and leave on free drainage
Analgesia:
- IV morphine. Refer to Morphine Monograph – Medication Management Manual (internal WA Health only)
Arrange for an urgent abdominal ultrasound, and urgent surgical review
- If the abdominal ultrasound is positive:
  - Follow directly by attempted non-operative reduction by means of an air enema unless the surgeon and radiologist agree that air reduction is unsafe and operative treatment is required.
Air enema¹
- Contraindications: signs of peritonitis/perforation
- Antibiotics must be administered prior to the air enema or surgical reduction
- ED nurse +/- ED doctor should accompany child to radiology to administer IV morphine for analgesia prior to attempted reduction
- Surgical registrar must be in attendance
- Performed by an experienced radiologist (up to 95% success rate).
Surgical reduction is necessary if there are signs of peritonitis / perforation, or if air enema fails to reduce the intussusception or leads to iatrogenic perforation during the procedure.

Nursing

Complete and record a full set of observations on the observation and response tool and record additional information on the Clinical Comments Chart.
Complete a full set of neurological observations if clinically indicated.
Minimum of 1 hourly observations should be recorded whilst in the ED
Any significant changes should be reported immediately to the medical team
Ensure appropriate medication, monitoring, observations, suction, oxygen and emergency equipment is available for patient transfer and reduction procedure
Fluid input/output is to be monitored and documented.

References

Vo N and Sato T (2021) Intussusception in children. UpToDate. Accessed at www.uptodate.com
Jones' Clinical Paediatric Surgery 7thEdition By: John M. Hutson (Editor), Michael O'Brien (Editor), Spencer W. Beasley (Editor), Warwick J. eague (Editor), Sebastian K. King (Editor) 2015
Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook, Australian Government Department of Health, Canberra, 2018, immunisationhandbook.health.gov.au
Health (Notification of Intussusception) Regulations 2007 – Repealed 20 Sept 2017 - HealthNotfctnOfIntussusceptionRegs2007_00-e0-00.docx (legislation.wa.gov.au)

Reviewer/Team:	ED HOD, ED Consultants, Consultant General Paediatric Surgery, ED CNM, ED CNS	Last reviewed:	Jan 2022
		Review date:	Sep 2025
Endorsed by:	Nurse Co-director, Surgical Services	Date:	Apr 2022

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