• Classic triad (present in <50% of patients):
  • Abdominal pain
  • Vomiting, often bilious
  • Stools have blood and mucus (“currant jelly” stools)
• Recurrent painful episodes accompanied by pallor and drawing up of the legs; intermittent fits of sudden intense pain with screaming and flexion of legs:
  • Occur in 5-20 min intervals
• Mental status changes:
  • Irritability
  • Lethargy or listlessness; child can be limp or have a rag doll appearance
  • May precede abdominal findings
• Stool variable:
  • Heme-positive (occult), bloody, or “currant jelly”
• Preceding illness several days or weeks prior to the onset of abdominal pain:
  • Diarrhea
  • Viral syndrome
  • Henoch-Schönlein purpura
• Recurrent intussusception occurs in <10% of patients

• Fever
• Abdomen distended and swollen:
  • A “sausage” mass may be palpated in the right upper quadrant
  • May have absent cecum in right iliac fossa
  • Peristaltic wave may be present
  • Rectal exam may reveal bloody stool and palpable mass
• Dependent on the time from onset to diagnosis; perforation with peritonitis and sepsis may be present

• CBC
• Serum electrolytes, BUN
• Type and cross-match

• Abdominal radiograph:
  • Abnormal in 35-40% of patients
  • Decreased bowel gas and fecal material in the right colon
  • Abdominal mass
  • Apex of intussusceptum outlined by gas
  • Small bowel distention and air-fluid levels secondary to mechanical obstruction
  • May aid in excluding intestinal perforation
• Enema:
  • Often both diagnostic and therapeutic. Reoccurrences do happen
    • 74% successful if intussusception present ≤24 hr
    • 32% effective when present >24 hr
    • The more distal the intussusception, the lower is the ability to reduce it radiographically
    • Recurrent disease (up to 10%) has similar success to initial episode
  • Complications include bowel perforation, reduction of necrotic bowel, incomplete reduction with delay in surgery, and overlooking pathologic lead point
  • Hypovolemic shock reported following reduction secondary to endotoxins and cytokines
  • Air or saline:
    • Fluoroscopic guidance
    • Avoids peritoneal contamination if perforation
    • Used for diagnosis and treatment
  • Barium:
    • Fluoroscopic guidance
    • Diagnosis and treatment using water soluble contrast
    • Characteristic coiled-spring appearance
  • Contraindications:
    • Peritonitis
    • Perforation
    • Unstable patients secondary to sepsis or shock
• US is highly accurate and may be useful as a screening technique; if done by experienced operator:
  • Typical appearance is a “donut,” “target sign,” “coiled spring,” or “bull's eye” structure, with hyperechoic core surrounded by hypoechoic rim of homogeneous thickness
  • Diagnostic no therapeutic

If enema is unsuccessful in reducing, surgery is required on an emergent basis

• Ampicillin: 100-200 mg/kg/d q4h IV
• Clindamycin: 30-40 mg/kg/d q6h IV
• Gentamicin: 5-7.5 mg/kg/d q8h IV
• Ampicillin/sulbactam 100-200 mg/kg/d q6h IV

• Patients undergoing successful enema reduction should be observed for complications or recurrence for prolonged period of observation
• Patients undergoing surgery

• May be considered after a very prolonged period of observation following successful enema reduction:
  • Stable patient with normal mental status
  • Symptomatic relief of abdominal pain during the postreduction period
  • Parents have appropriate understand ing to watch for potential reoccurrence, even after prolonged period observation

Surgeon should be consulted and aware of patients with potential diagnosis of intussusception