Ileo-Colic Intussusception

6 Month Old with Abdominal Pain • Xray of the Week

History:

There was a baby from Cali, who had a pain in his belly.

For a BE, it's time; 'cause of a target sign,

and his stool looks like currant jelly.

Figure 1. Left image: Target sign on ultrasound due to intussusception.

Right image: Spot view from water soluble contrast enema showing the filling defect in the transverse colon due to ileo-colic intussusception.

Figure 2. The pseudokidney sign. Long axis ultrasound image of intussusception showing the layers of ileum inside the cecum in the right lower quadrant.

Figure 3. Intussusception is reduced with contrast in the terminal ileum.

Figure 4. Actual currant jelly

Figure 5. Bloody stool in diaper (aka nappy) that looks like currant jelly

Intussusception is a common cause of abdominal pain in children and is caused by a segment of bowel pulled into itself by peristalsis. The classic triad of intermittent abdominal pain, vomiting and right upper quadrant mass, plus occult or gross blood on rectal examination is seen in less than 20% of intussusception cases. Bloody stool may have the appearance of currant jelly due to the presence of mucus in the stool [Fig. 4,5]. If prolonged, ischemia and necrosis with eventual perforation may occur. 90% of cases in children aged less than 2 years old have no lead point. Ultrasound demonstrates the target sign in the short axis view [Fig. 1] and the pseudokidney sign in the long axis view [Fig.2] due to alternating bands of hyperechoic mucosa and hypoechoic submucosa. Definitive diagnosis and treatment is reduction with water soluble contrast or air enema [Fig. 3]. When seen in adults, there is almost invariably a neoplasm as a pathologic lead point, thus requiring surgery.

References:

1. Lioubashevsky N, Hiller N, Rozovsky K, et al. Ileocolic versus Small-Bowel Intussusception in Children: Can US Enable Reliable Differentiation? Radiology. 269 (3): 266-271

2. Kim YH, Blake MA, Harisinghani MG et-al. Adult intestinal intussusception: CT appearances and identification of a causative lead point. Radiographics. 26 (3): 733-44

3. Anderson DR. The pseudokidney sign. Radiology. 1999;211 (2): 395-7.

4. del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in diagnosis and enema reduction. RadioGraphics 1999;19(2):299–319.

5. Swischuk LE, Hayden CK, Boulden T. Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney signs. Pediatr Radiol 1985;15(6):388–391.

6. Rubinstein JC, Lucy Liu L, Caty MG. Pathologic Leadpoint Is Uncommon in Ileo-Colic Intussusception Regardless of Age. J Pediatr Surg. 2015 Oct;50(10):1665-7. DOI: 10.1016/j.jpedsurg.2015.03.048

7. McDermott VG, Taylor T, Mackenzie S, et al. Pneumatic Reduction of Intussusception: Clinical Experience and Factors Affecting Outcome. Clin Radiol. 1994 Jan;49(1):30-4. doi: 10.1016/s0009-9260(05)82910-1.

Related case: Intussusception in melanoma

Kevin Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

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