Intussusception

The Lopez family has a new family member, baby Kelly. Both parents are very hands-on and doting on Kelly. Few months of changing diapers and breastfeeding, Mr. and Mrs. Lopez noticed that Kelly was always crying as if in pain during bowel movements, and seems comfortable when she is done. They also noticed that Kelly’s belly is protruding abnormally. They decided to consult her pediatrician, and after undergoing a lot of painful tests, the conclusion was that Kelly has intussusception.

Description


Intussusception usually appears in healthy babies without any demonstrable cause.

  • Intussusception is a process in which a segment of intestine invaginates or telescopes into the adjoining intestinal lumen, causing bowel obstruction.
  • It occurs most commonly at the juncture of the ileum and the colon, although it can appear elsewhere in the intestinal tract.
  • The invagination is from above downward, the upper portion slipping over the lower portion pulling the mesentery along with it.

Pathophysiology


The pathogenesis of intussusception is not well established.

  • It is believed to be secondary to an imbalance in the longitudinal forces along the intestinal wall.
  • As a result of an imbalance in the forces of the intestinal wall, an area of the intestine invaginates into the lumen of the adjacent bowel.
  • The invaginating portion of the intestine (ie, the intussusceptum) completely “telescopes” into the receiving portion of the intestine (ie, the intussuscipiens); this process continues and more proximal areas follow, allowing the intussusceptum to proceed along the lumen of the intussuscipiens.
  • If the mesentery of the intussusceptum is lax and the progression is rapid, the intussusceptum can proceed to the distal colon or sigmoid and even prolapse out the anus.
  • The mesentery of the intussusceptum is invaginated with the intestine, leading to the classic pathophysiologic process of any bowel obstruction.

Statistics and Incidences


A wide geographic variation in the incidence of intussusception among countries and cities within countries make determining a true prevalence of the disease difficult.

  • Its estimated incidence is approximately 1 case per 2000 live births.
  • In Great Britain, incidence varies from 1.6-4 cases per 1000 live births.
  • Overall, the male-to-female ratio is approximately 3:1.
  • With advancing age, gender difference becomes marked; in patients older than 4 years, the male-to-female ratio is 8:1.
  • Two-thirds of children with intussusception are younger than 1 year; most commonly, intussusception occurs in infants aged 5-10 months.
  • Intussusception is the most common cause of intestinal obstruction in patients aged 5 months to 3 years.
  • Intussusception can account for as many as 25% of abdominal surgical emergencies in children younger than 5 years, exceeding the incidence of appendicitis.

Causes


In most cases, however, no cause can be identified for intussusception.

  • Hyperperistalsis. The normal wave-like contractions of the intestine grab this lead point and pull it and the lining of the intestine into the bowel ahead of it.
  • Digestive system activities. The unusual mobility of the cecum and ileum normally present in early life may also cause intussusception.

Clinical Manifestations


The constellation of signs and symptoms of intussusception represents one of the most classic presentations of any pediatric illness; however, the classic triad of vomiting, abdominal pain, and passage of blood per rectum occurs in only one-third of patients.

  • Abdominal pain. In rare circumstances, the parents report 1 or more previous attacks of abdominal pain within 10 days to 6 months prior to the current episode; pain in intussusception is colicky, severe, and intermittent.
  • Vomiting. Initially, vomiting is nonbilious and reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious.
  • Currant jelly stool. Parents also report the passage of stools that look like currant jelly; this is a mixture of mucus, sloughed mucosa, and shed blood.
  • Lethargy. Lethargy is a relatively common presenting symptom with intussusception; the reason lethargy occurs is unknown because lethargy has not been described with other forms of intestinal obstruction.

Assessment and Diagnostic Findings


The care provider usually can make a diagnosis from:

  • Rectal examination. The healthcare provider may perform a rectal examination during a calm interval.
  • Palpation. A baby is often unwilling to tolerate palpation, and sedation may be ordered; a sausage-shaped mass can be often felt through the abdominal wall.
  • Radiographs. Plain abdominal radiography reveals signs that suggest intussusception in only 60% of cases; as the disease progresses, the earliest radiographic evidence includes an absence of air in the right lower and upper quadrants and a right upper quadrant soft tissue density present in 25-60% of patients.
  • Ultrasonography. One study reported that the overall sensitivity and specificity of ultrasonography for detecting ileocolic intussusception was 97.9% and 97.8%, respectively; the authors concluded that ultrasonography should be used as a first-line examination for the assessment of possible pediatric intussusception.
  • CT scanning. Computed tomography (CT) scanning has also been proposed as a useful tool to diagnose intussusception; however, CT scan findings are unreliable, and CT scanning carries risks associated with intravenous contrast administration, radiation exposure, and sedation.
  • Contrast enema. The traditional and most reliable way to make the diagnosis of intussusception in children is to obtain a contrast enema (either barium or air); contrast enema is quick and reliable and has the potential to be therapeutic.

Medical Management


Unlike pyloric stenosis, intussusception is an emergency in the sense that prolonged delay is dangerous.

  • Intravenous fluid.  For all children, start intravenous fluid resuscitation and nasogastric decompression as soon as possible.
  • Therapeutic enema. Therapeutic enemas can be hydrostatic, with either barium or water-soluble contrast, or pneumatic, with air insufflation; therapeutic enemas can be performed under fluoroscopic or ultrasonographic guidance; the technique chosen is not important as long as the radiologist performing the enema is comfortable with the method.
  • Surgical reduction. If a nonoperative reduction is unsuccessful or if obvious perforation is present, promptly refer the infant for surgical care; risk of recurrence of the intussusception after operative reduction is less than 5%.
  • Laparoscopy. Laparoscopy has been added to the surgical armamentarium in the treatment of intussusception; laparoscopy can be performed in all cases of intussusception; reduction of the intussusception, confirmation of radiologic reduction, and detection of lead points have all been reported.

Pharmacologic Management

Drug therapy is not currently a component of the standard of care for intussusception. Medications are limited to those used for pain control after surgery. In the immediate postoperative period, weight-adjusted intravenous morphine is usually administered.

Nursing Management


Nursing management of a child with intussusception includes:

Nursing Assessment

Assessment of a child with intussusception includes:

  • Physical examination. The hallmark physical findings in intussusception are a right hypochondrium sausage-shaped mass and emptiness in the right lower quadrant (Dance sign).
  • History. The patient with intussusception is usually an infant, often one who has had an upper respiratory infection, who presents with vomiting, abdominal pain, passage of blood and mucus, lethargy, and palpable abdominal mass.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

Nursing Care Planning and Goals

Main Article: 3 Intussusception Nursing Care Plans

The major nursing care planning goals for a child with intussusception are:

  • The patient will have stable vital signs.
  • The patient will exhibit balanced intake and output.
  • The patient’s pain will decrease and will be comfortable.
  • The patient’s pattern of breathing will become effective.
  • The caregiver’s anxiety will be resolved.

Nursing Interventions

Nursing interventions appropriate for the infant are:

  • Intravenous fluids. Administer IV fluids as ordered; if the patient is in shock, give blood or plasma as ordered.
  • Decompression. A nasogastric tube is inserted to decompress the bowel.
  • Monitor I&O. Replace volume lost as ordered, and monitor the intake and output accordingly.
  • Education. Educate the family caregivers on what happens during intussusception and about the surgery, and answer questions to reduce the anxiety.

Evaluation

Goals are met as evidenced by:

  • The patient shows stable vital signs.
  • The patient exhibits balanced intake and output.
  • The patient’s pain decreases and is comfortable.
  • The patient’s pattern of breathing is effective.
  • The caregiver’s anxiety is resolved.

Documentation Guidelines

Documentation in a child with intussusception include:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Intake and output.
  • Characteristics of vomitus.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcome.

Practice Quiz: Intussusception


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1. Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information?

A. Abdominal palpation
B. Pain pattern
C. Family history
D. Stool inspection

1. Answer: C. Family history

  • Option C: Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information.
  • Options A, B, & D: Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. “Currant jelly” stools, containing blood and mucus, are an indication of intussusception. Acute, episodic abdominal pain is characteristic of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

2. A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

A. “Ribbon-like” stools
B. “Currant jelly” stools
C. Palpable mass over the flank
D. Projectile vomiting

2. Answer: B. “Currant jelly” stools

  • Option B:  The child with intussusception has stools that contain blood and mucus, which are described as “currant jelly” stools.
  • Option A: Answer A is a symptom of Hirschsprung’s; therefore, it is incorrect.
  • Option C: Answer C is a symptom of Wilms tumor; therefore, it is incorrect.
  • Option D: Answer D is a symptom of pyloric stenosis; therefore, it is incorrect.

3. Which question would be most helpful in obtaining a nursing history from the mother of an infant with suspected intussusception?

A. Is your child eating normally?
B. How often has your child been vomiting?
C. What do your child’s stools look like?
D. When did your child last urinate?

3. Answer: C. What do your child’s stools look like?

  • Option C: Intussusception is known for producing “currant jelly” stools, due to inflammation and hemorrhage within the bowel.
  • Options A, B, D: Information about urination, feeding, and vomiting would not produce information relevant to intussusception.

4. A nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child’s record and expects to note which symptom of this disorder documented?

A. Watery diarrhea
B. Ribbon-like stools
C. Profuse projectile vomiting
D  Bright red blood and mucus in the stools

4. Answer: D. Bright red blood and mucus in the stools.

  • Option D: Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly–like stools.
  • Options A & B:  Watery diarrhea and ribbon-like stools are not manifestations of this disorder.
  • Option C: Vomiting may be present but is not projectile.

5. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?

A. Complete blood count.
B. Guaiac test.
C. Vital signs.
C. Abdominal girth.

5. Answer: B. Guaiac test.

  • Option B: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test.
  • Option A: A complete blood count does not provide immediate results and does not always immediately reflect blood loss.
  • Option C: Changes in vital signs may be caused by factors other than blood loss.
  • Option D: Abdominal girth is unrelated to blood loss.

See Also


Related topics to this study guide:

Further Reading


Recommended resources and books for pediatric nursing:
  1. PedsNotes: Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides)
  2. Pediatric Nursing Made Incredibly Easy
  3. Wong's Essentials of Pediatric Nursing
  4. Pediatric Nursing: The Critical Components of Nursing Care