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ACUTE INTUSSUSCEPTION IN CHILDHOODBy A. ELLIOT-SMITH, M.A., F.R.C.S.

Surgeon, The Radcliffe Infirmary, Oxford

and J. N. WARD-MCQUAID, M.S., F.R.C.S.Nuffield Department of Surgery, University of Oxford

Intussusception has been recognised for over2,000 years. Both the operative and the hydro-static methods of reduction used today are saidto have been suggested at that time by the Greeksof Cos. The first successful operative reductionwas performed in this country by Sir JonathanHutchinson in i87I. Gross and Ware, of Boston,reported in I948 a mortality of below 3 per cent.,compared with one of 59 per cent. some 30 yearsago, and some recent series, especially from largecentres (Jones, Hindmarsh, Court and Jackson,I953; Forshall and Rickham, I953), had a mor-tality as low as i per cent. On the other hand,other recent series, especially those including thewar years, show a mortality of I0 to 20 per cent.

Improvements in diagnosis and treatment con-tinue, but there is still no general agreement as tothe place of hydrostatic methods of reduction, norof the best way to deal with the irreducible organgrenous intussusception. The purpose of thispaper is to discuss some of the clinical aspects ofacute intussusception in childhood, and thetreatment in particular of the irreducible intus-susception.

DiagnosisThe dramatic classical clinical picture of this

condition is too well known to need repetition.Morrison and Court (1948) emphasized certainpoints in which their Newcastle series differedfrom the usual textbook description. The fall inmortality in a later series (Spence and Court, I950)was attributed to earlier diagnosis by the familydoctor. Some of the clinical aspects of ioo con-secutive acute intussusceptions in childhoodtreated by operation at the Radcliffe Infirmary,Oxford, from I938 onwards will be considered ina similar way.

Importance of Early Diagnosis. Of these ioochildren, 23 were operated upon within I2 hoursof the onset of symptoms, and 29 more within 24

hours, without fatality. There were 2 deathsafter 20 operations within the next 24 hours, and5 deaths after the remaining 28 operations per-formed after this time.Age and Sex. Thirty per cent. of the present

series were female. Infants of three to six monthsaccounted for I5 per cent. of the total (Table i).

TABLE IAGE IN IOO CHILDREN WITH ACUTE INTUSSUSCEPTION

Months YearsAge: Under 3 3-5 6-8 9-I I I-2 3-6 7-12Number: I I5 26 I I 34 10 3

Cause of the Intussusception. Three of the caseswere due to a Meckel's diverticulum, one to anadenomatous polyp, and one to an appendix(Fig. i) turned completely inside out (Forshall,I953). Enlargement of the mesenteric glands isa very common finding in intussusception.

Clinical Picture in the First 24 Hours. Thecardinal symptoms of pain, vomiting and thepassage of blood were all present during the first24 hours in only 40 of the present series, and 39 ofthe Newcastle series (Table 2).

TABLE 2THE M\/AIN COMBINATION OF SYMPTOMS IN THE FIRST

24 HOURSNo. and per cent.

Clinical features of the casesPain, vomiting and blood.. .. 40Pain and vomiting .. .. 25Vomiting .. .. .. .. 9Vomiting, blood and minimal pain 7Pain and blood .. .. 7Pain . .. .. .. 7Vomiting and minimal pain ..

Spontaneous Passage of Blood. In less than halfthe cases was blood passed by rectum within I2hours of the onset, and no blood was passed atany time by 25 (although in 3 of these it was found

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Augutst 1953 ELLIOT-SMITH & WARD-McQUAID: Acute Intussusception in Childhood 415

FIG. i.-An appendix turned completely inside out.

on the examining finger), compared with 24 inthe Newcastle series (Table 3).

TABLE 3. TIME WHEN BLOOD WAS FIRST PASSEDTime No. andper cent.

At onset .. .. .. I IWithin 12 hours .. .. 38Within 24 hours .. .. IIAfter 48 hours .. .. 15Never .. .. .. 25

Fever. Although it is often stated that thetemperature is normal or subnormal, or that feveris a late sign, in the present series, before operation,43 had temperatures below gg°F., 33 between 990and 99.9gF. and 27 above ioo0F. These figuresare not so high as in the Newcastle series, wheresome rise of temperature was found the rule evenon the first day of the disease, and in half of themwas as high as IOO to Io4'F.Abdominal Tumour. An abdominal tumour was

felt in 73 patients.Anatomical Type of Intussusception. There was

a higher proportion of small bowel intussusceptionsthan is usual (Table 4).

TABLE 4. ANATOMICAL TYPEIleo-ileal Ileo-ileo-colic Boundary

No. of cases .. 6 i8 76Per cent. of deaths 27.6 4.6 4.5

- Of the 6 ileo-ileal intussuspeptions, 3, aged one,two and three years, involved Meckel's diverticula,2 requiring resection with i death; of the remain-ing 3, aged four months, four and twelve years,2 involved the middle third of the small intestine,

i requiring resection. The clinical picture ofthese 6 ileo-ileal intussusceptions was characterizedby pain and vomiting, but absence (4 cases) ordelayed passage of blood and difficulty in feelinga tumour (i felt by abdomen and i by bimanualexamination under anaesthetic). The conditionis said to be commoner in older children.

Recurrent Intussusception. Two children hadalready been operated upon for intussusceptionon a previous admission.

Spontaneous Reduction. Two intussusceptionswere found reduced at operation, one followinga barium enema and the other after palpation ofthe tumour under anaesthesia. It seems likely thatseveral others, not proved by operation or radio-graphy and not included in this series, reducedspontaneously, and that at least two of these wererecurrent intussusceptions.

Chronic IntussusceptionDuring the period under review, 3 children

aged seven, seven and a half and eight years withchronic intussusceptions, were successfully treatedby operation; in 2 a resection was necessary.These cases are not included in this series andhave been discussed by Garvie and Kemp (1945).

Barium EnemaAlthough some half-dozen early cases, not in-

cluded in this series, were reduced without in-cident during the period under review, operationhas proved a satisfactory routine for these earlycases, and all the children so treated in the first

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4I6 POSTGRADUATE MEDICAL JOURNAL, August 1953

TABLE 5. ANALYSIS OF THE SEVEN DEATHS- _I Time of death

Age and sex Duration Type Treatment after operation Probable cause of death

4 years (M.) 2nd day Boundary Reduction (bowel) 2 hours Circulatory failure.gangrenous)

i6 months (M.) 4th day Boundary Exteriorization 72 hours Pneumonia terminal event.

6 months (M.) 5th day Boundary Reduction I4 hours Prolonged obstruction: hyperpyrexiaterminal event.

4 months (M.) 3rd day Ileo-ileal Reduction 7 hours Circulatory failure.

I 5 months (M.) 4th day Ileo-ileal Resection 6 hours Prolonged intestinal obstruction:(Meckel's) circulatory failure.

6 months (M.) 2nd day Boundary Resection 4 hours Circulatory failure.

2 1- years (F.) 4th day Ileo-ileo Reduction 40 hours Acute gastric dilatation final cause ofcolic death.

24 hours recovered. A barium enema has beenused as an aid to diagnosis in difficult cases, andby some to effect partial reduction in order tofacilitate the subsequent operation.

Excellent results have, of course, been obtainedby hydrostatic methods, either alone or combinedwith operation, by Hipsley (I948) and Nelson(I949) in Australia, Lindb-rg and Morales (I949)and Nordentoft (1950) in Scandinavia, and Ravitchand Morgan (I952) in the United States, amongstothers. In spite of these successes, as Teall (I95 I)says, opinion still remains sceptical in GreatBritain, where the majority of paediatriciansprefer surgical treatment. It is difficult to becertain that an ileo-ileal intussusception has beenreduced completely, nor is a gangrenous intussus-ception necessarily irreducible. The purpose ofof this paper is not to discuss in detail the treatmentof the early cases in which this method finds its use.

Irreducible or Gangrenous IntussusceptionsSix of the I22 acute intussusceptions in children

operated upon at the Radcliffe Infirmary from1938 to the early part of 1953 were found to beirreducible, and 4 others were gangrenous afterreduction. Two patients seen recently, both boysof five months, are of interest. Both recovered,the first uneventfully afterr 'a short-circuit, thesecond following a resection made unavoidable bydamage to the bowel in attempted reduction, andpost-operative paralytic ileus. Resections werealso performed on children aged three, four, fiveand twelve years of age with recovery, and inchildren aged six and fifteen months with a fataloutcome. An exteriorization operation was per-formed on a child of sixteen months who also died.Fatal CasesThere were 7 deaths in the I22 children (Table

5); 5 deaths occurred in the first and 2 in thesecond half of the series. In 3 children, bloodwas passed before the family doctor was called,but the child was not sent into hospital until afterthe next visit. In 2 others the diagnosis wasmissed in hospital for 36 hours, possibly owing torecurrent intussusception and lack of repeatedexamination and barium radiography. In 3 ofthe 7 fatal cases the bowel was not gangrenous,and 2 of these died within 24 hours of operation.In some cases what would now be consideredadequate resuscitative measures were clearlylacking.

TreatmentThe routine treatment has been by operative

reduction in the usual way, through a right para-median incision. A barium enema occasionallyhas been used as an aid to diagnosis. Generalanaesthesia after passage of a gastric tube is aroutine. The value of adequate preparation foroperation with special attention to electrolytebalance, the availability of blood, and careful post-operative care with nasogastric suction, anti-biotics and parenteral fluid where indicated, can-not be overstressed. We have no experience ofglycerine as an aid to reduction (Ireland, 1950)nor of injecting streptomycin into the bowel toreduce toxic absorption (Zintel, Wiley, Nicholsand Rhoads, 1947), nor of a transverse incisionfor this type of operation.Removal of the appendix was performed more

often than indicated solely on grounds of impairedviability of the organ, and any primary caus2 ofthe intussusception was dealt with. Wansboroughand Cram (I952) condemn routine appendi-cectomy, because of the danger of leakage fromthe stump, and Gross and Ware (1948) remove

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August I953 ELLIOT-SMITH & WARD-McQUAID: Aczute Intussusception in Childhood

any primary cause some two weeks later.No preventive operation has been attempted.

The Irreducible or Gangrenous IntussusceptionIt is fortunate that reduction is easily achieved

in most cases of acute intussusception. Onlysmall series of irreducible or gangrenous intussus-ceptions have been published even from the largercentres, and most individual surgeons encounterthis condition very occasionally. Case reportsbased on a single recovery still appear in theliterature. In spite of the striking fall in themortality of these cases in the last few years, it isprobable that at least a quarter of these childrendie. It is difficult to assess the merits of thevarious methods of treatment unless the age andcondition of the child, the type of intussusceptionand other details are considered. In the presentseries, for example, in which io of these caseswere treated over fifteen years, the only con-clusion one can draw in this respect is that nochild aged two years or less recovered until tha2 recent infants already mentioned.

Incidence of Irreducible IntussusceptionThe incidence of 8 to 9 per cent. in this series

is not unusual and the experience of Dennis(I947), who found that half his cases in Minnesotarequired resection, must be exceptional. Mc-Laughlin (1948) gave the incidence as 12.4 peircent. in a large collected series, White and Den-nison (1952) as 7.6 per cent., while Snyder, Krausand Chaffin (I949) give a figure as low as 4 percent.

Cause ofDeath in Untreated Cases ofIntussusceptionWarren Tay (Hutchinson, I874), from post-

mortem studies of 131 untreated cases of intus-susception, showed that there was rarely peri-tonitis even when gangrene of incarcerated in-testine had occurred; obstruction seemed to havebeen the main cause of death. Experimental workon dogs by Montgomery and Mussil (1930)supported this view, and lateral anastomosisaround the unresected mass has been performedsuccessfully on many occasions. Macnab (1948),however, implies that peritonitis is almost in-variable in untreated intussusceptions. Whiteand Dennison (1952) state that they have neverseen death from peritonitis in an unreducedintussusception, but the bowel may not recoverafter forcible reduction and the child die of ileusor peritonitis. Ravitch and McCune (1950) havecultured faecal bacteria from the outside of whatappeared after reduction to be only severelycongested bowel.

Spontaneous separation of an intussusceptionwith passage of the slough occurs from time to

time, and recent reports include those of Benson,Carpenter and Suredenburg (1953), Welsh (1952)and Poltegher (195I). Louw (I949) has alsogiven an interesting account of an African whodisdained orthodox methods of treatment of acuteintestinal obstruction and consulted his witchdoctor. A medicine was prescribed and takenand, after an uncomfortable night, the patientpassed the slough in the form of what he describedas' the father and mother of all snakes.' Recoverywas rapid and complete.

Operative Techiniques in the Irreducible orGangrenous IntutssusceptionMuch has been written on this subject lately

and other recent reviews not referred to elsewhereare those of Benson and Sharpe (1950), Kahle(195I), Laurence and Ufelder (1952) and Wareand Coffey (I950).There are now three main methods of dealing

with this problem, by resection and anastomosis,by exteriorization, and by short-circuiting. TheJesset procedure, in which the intussusception isexcised through an incision in its sheath, wouldnot seem to be popular today, although Barnesdescribed a modification in 1947.

(i) Resection and Anastomosis. The first suc-cessful resection in a child is credited to Clubbe(1907). This procedure once had an extremelyhigh mortality, and Tedesco (I95I) consideredthat it was worth publishing a single recoveryafter resection in an infant, while McLaughlin(I948), reviewing the literature up to 1947, couldfind only I3 successful resections below ayear. Dennis (I947) has had 8 consecutivesuccesses using a one-layer aseptic silk anas-tomosis technique; his resection rate was 50 percent. The resection mortality in Edinburgh wasreduced from ioo per cent. to io per cent. bynot persisting with attempts at reduction, butresecting before the child became shocked, andAird (1952) reports a consecutive series of 17resections with 13 recoveries. The 5 resectionsperformed by Forshall and Rickham (1953) outof io6 children in Liverpool were all successful.A very long segment of proximal dilated gut wasremoved, and the bowel anastomosed end to endwith silk mattress stitches.

(2) Exteriorization Resection. Gross and Ware(I948) advocate their modification of the PaulMikulicz procedure and had ii successes in 14operations. They excise the extruded mass overclamps, and perform a proximal enterostomy toreduce distension. Exteriorization proceduresused to carry an even higher mortality thanresection and anastomosis, but the problemsassociated with the fistula are now better under-stood and more easily managed. Nevertheless,

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418 POSTORADUJATE MEDICAL JOURNAL August 1053

convalescence may be protracted (Conway andDawson, I949). Macnab (I948) advises theWoodhall method, in which an entero-anastomosisis made at the time of resection, and subsequentcrushing of the spur thus obviated. Recently,Jones (1953) and his colleagues in Newcastle havelost only i of 9 children on whom they performedtheir modification of the two-stage exteriorizationprocedure.

(3) Lateral Anastomosis. Lateral anastomosisleaving the irreducible mass untouched was firstreported in I909 by Parry and by Rutherford.More recently it has been recommended byHamilton Bailey (i944) and by the late ProfessorGrey Turner (I943).

Elliot-Smith (I935) reported three successfulcases. No toxic effects were noted in these, nor intwo subsequent cases. In one, after commencingreduction, it was clear that a resection would benecessary if reduction was completed; the intus-susception was reformed, the entering and en-sheathing layers were stitched together and anileo-transverse colostomy performed. In another,a successful short circuit was performed for anileo-ileal intussusception. Stuppel (I939), how-ever, after a similar operation, had to reopen theabdomen for peritonitis, and this operation isprobably inadvisable in pure small bowel intus-susceptions, where the tight ensheathing layermay become gangrenous. McLaughlin (I948), inhis review, traced 3I short-circuit operations ofthis type with a mortality rate of 26.6 per cent.White and Dennison (I952) reported from

Glasgow a series of i6 infants with irreducibleintussusceptions treated by ileocolostomy with I2recoveries. If the bowel is gangrenous, theyrecommend exteriorization in addition, and thiswas done in 6 of their cases, with resection as soonas the infant was fit. They regard symptoms fromtoxic absorption as inevitable.

CommentWhichever method is used, it is clear that the

best results will be achieved by the experiencedsurgeon associated with a paediatric unit and,second, that prolonged attempts at reduction mustbe avoided, or the child will be too shocked tobenefit from other measures. It is difficult to sayhow long attempts at reduction should continue.White and Dennison (1952) consider that, withexperience, a very few minutes will suffice to knowwhether reduction will occur, while Hamman(I952) suggests ten minutes' gentle pressure.Much depends on the condition of the child.Damage to the bowel from excessive pressure willpreclude a simple lateral anastomosis.From the evidence available at the present time,

while it is difficult to dogmatise as to the treatment

of the individual child with an irreducible organgrenous intussusception, certain conclusionsemerge. Resection is the most difficult and severeprocedure, and probably more likely to be followedby ileus, but it gives good results in skilled hands.Exteriorization is an easier and a less shockingprocedure, but convalescence is often complicatedby electrolyte and nutritional disturbances. How-ever, in recent years, transfusion during operationand a better understanding of post-operativemetabolism have lessened the dangers of boththese operations. Lateral anastomosis is simpleand straightforward and there is little shock; it ispossible that convalescence may be impeded bythe effects of toxic absorption.The infant, especially if really sick, will not

stand resection as well as the simpler lateralanastomosis. There may be older children, too,in whom a resection will be fatal but a shortcircuit life-saving. If the outer sheath of theintussusception does not appear viable-an un-usual event-then a two-stage exteriorizationresection operation with ileocolostomy is lessshocking than resection and obviates the loss ofintestinal juices inherent in a Mikulicz-typeoperation.

Summary(i) The clinical features of acute intussusception

in childhood have been considered.(2) The 7 deaths in 122 children treated by

operation between I938 and 1953 have beenanalyzed.

(3) The problem of the irreducible or gan-grenous intussusception, especially in the sickinfant, has been discussed; the short-circuitoperation is recommended.

BIBLIOGRAPHYAIRD, I. (1952), 'British Surgical Practice: Surgical Practice

1952,' London, Butterworth Med. Publns., p. i85.BAILEY, HAMILTON (i944), 'Emergency Surgery,' 5th Edn.,

Bristol, John Wright & Sons, p. 299.BARNES, J. P. (1947), Surg. Gynec. Obstet., 85, 747.BENSON, C. D., and SHARPE, H. R. (1950), Arch. Surg., 6I, 822.BENSON, C. D., CARPENTER, W. S., and SWEDENBURG,

R. D. (I953), Ann. Surg., 137, 26i.CONWAY, D. J., and DAWSON, R. C. G. (X949), Brit. med. Y.,

ii, 1153.DENNIS, C. (1947), Ann. Surg., 126, 788.ELLIOT-SMITH, A. (x935), Lancet, ii, 992.FORSHALL, I. (1953), Brit. J. Surg., 40, 305.GARVIE, J. M., and KEMP, F. H. (X945), Arch. Dis. Child., 20, 73.GREY TURNER, G. (943), 'Modern Operative Surgery,' 3rd

Edn., London, Cassell & Co., Ltd., p. 90I.GROSS, R. E., and WARE, P. F. (X948), New Eng. J. Med., 239, 45JONES, J. 0. T., HINDMARSH, O., COURT, S. 0. M., and

JACKSON, R. H. (1953), Brit. med.J7., i, 391.HIPSLEY, P. L. (1948), Ibid., ii, 312.HUTCHINSON, J. (i874), Med. Chir. Trans., 58, 3I.IRELAND, J. (I 94), Arch. Surg., 43, 4t8.KAHLE, H. R. (i95x), Surgery, 29, i82.LINDBERG, G., and MORALES, 0. (1949), Amer. J. Child., 77,

303.LOUW, J. H. (1949), Practitioner, I63, 223.

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August 1953 Manufacturers' Notes 419

McLAUGHLIN, C. W. (I948), Amer. J. Surg., 76, 306.McLAUGHLIN, C. W. (I948), Arch. Surg., 56, 48.MACNAB, G. H. (1948), 'British Surgical Practice,' London,

Butterworth's Med. Pubins., Vol. 5, p. I6o.MONTGOMERY, A. H., and MUSSIL, J. J. (1930), Surg. Gynec.

Obstet., 51, 415.MORRISON, B., and COURT, D. (1948), Brit. med. _., L, 746.NELSON, T. Y. (I949), Med. _. Aust., I, 825.NORDENTOFT, J. M. (1950), POSTGRADUATE MEDICAL JOURNAL,

26, 335.POLTEGHER, A. C. (i9sx), Arch. Ital. mal. app. dig., 17, 348.RAVITCH, M. M., and McCUNE, R. M. (1950), Y. Paediat., 37,

153.RAVITCH, M. M., and MORGAN, R. H. (1952), Ann. Surg.,

135, 596.SNYDER, W. H., KRUAS, A. R., and CHAFFIN, L. C. (1949),

Ann. Surg., 130, 200.SPENCE, J., and COURT, D. (i950), Brit. med. Y., 2, 920.STUPPEL, R. (I939), Ibid., ii, 722.TEALL, C. G. (1951), 'Modem Trends in Paediatrics,' London,

Butterworth & Co., p. 365.TEDESCO, V. E. (I95I), Amer. J7. Surg., 82, 526.WANSBOROUGH, R. M., and CRAM, R. W. (1952), Canad.

M.A.j., 67, 307.WARE, G. W., and COFFEY, R. J. (i950), Surg. Gynec. Obstet.

9!, 173.WELSH, F. (1952), Lancet, ii, SI8.WHITE, M., and DENNISON, W. (1952), Brit. Y. Surg., 40, 137.ZINTEL, H. A., WILEY, M., NICHOLS, A., and RHOADS,

J. E. (1947), Surgery, 21 ,I75-

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