Intussusception differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sargun Singh Walia M.B.B.S.[2]


Intussusception must be differentiated from other diseases that cause abdominal pain,nausea/vomiting,and rectal bleeding.

Differential Diagnosis

  • Intussuception must be differentiated from other diseases that cause:
    • Abdominal pain
    • Nausea/vomiting
    • Rectal bleeding - occult/gross.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Intussusception Episodic ± - + - - - Positive if in shock Positive if intestine perforated Positive if intestine perforated Decreased or hypoactive
  • Ultrasound
    • Target Sign/Doughnut sign
    • Pseudo-kidney sign
  • X-Ray
    • Crescent sign
    • Absence of air in RLQ,RUQ
    • Distended loops of bowel
  • Non-operative reduction done in stable patients
  • Surgical reduction done if patient unstable/non-operative reduction completely unsuccessful
Peptic ulcer disease Diffuse ± + Positive if perforated Positive if perforated Positive if perforated N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Gastritis Epigastric ± + + N
Gastroesophageal reflux disease Epigastric ± N N
  • Gastric emptying studies
Gastric outlet obstruction Epigastric ± Hyperactive
  • Succussion splash
Gastroparesis Epigastric + ± Hyperactive/hypoactive
  • Scintigraphic gastric emptying
  • Succussion splash
  • Single photon emission computed tomography (SPECT)
  • Full thickness gastric and small intestinal biopsy
Gastrointestinal perforation Diffuse + ± - ± + + + ± Hyperactive/hypoactive
  • WBC> 10,000
Dumping syndrome Lower and then diffuse + + + Hyperactive
  • Postgastrectomy
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Acute appendicitis Starts in epigastrium, migrates to RLQ + Positive in pyogenic appendicitis + ± Positive in perforated appendicitis + + Hypoactive
  • Ct scan
  • Ultrasound
  • Positive Rovsing sign
  • Positive Obturator sign
  • Positive Iliopsoas sign
Acute diverticulitis LLQ + ± + + ± + Positive in perforated diverticulitis + + Hypoactive
  • CT scan
  • Ultrasound
Inflammatory bowel disease Diffuse ± ± + + Normal or hyperactive

Extra intestinal findings:

Irritable bowel syndrome Diffuse ± ± N Normal Normal Symptomatic treatment
Whipple's disease Diffuse ± ± + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Tropical sprue Diffuse + + N Barium studies:
  • Dilation and edema of mucosal folds
Celiac disease Diffuse + Hyperactive US:
  • Bull’s eye or target pattern
  • Pseudokidney sign
  • Gluten allergy
Infective colitis Diffuse + ± + + Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Colon carcinoma Diffuse/ RLQ/LLQ ± ± + ±
  • Normal or hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography 
  • PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Spontaneous bacterial peritonitis Diffuse + Positive in cirrhotic patients + ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
  • Ultrasound for evaluation of liver cirrhosis
Small bowel obstruction Diffuse + + + + + ± Hyperactive then absent Abdominal X ray
  • Dilated loops of bowel with air fluid levels
  • Gasless abdomen
  • "Target sign"– , indicative of intussusception
  • Venous cut-off sign" – suggests thrombosis
Volvulus Diffuse - + + Positive in perforated cases + + Hyperactive then absent CT scan and abdominal X ray
  • U shaped sigmoid colon
  • "Whirl sign"
<figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Right upper quadrant.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Epigastric quadrant pain.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Left upper quadrant.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline>
<figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Right flank quadrant.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Umbilical pain.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Left flank quadrant.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline>
<figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Right lower quadrant.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Hypogastric.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> <figure-inline class="mw-default-size"><figure-inline><figure-inline><figure-inline><figure-inline>Left lower quadrant.PNG</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline>


S.No. Disease Symptoms Signs Diagnosis Comments
Abdominal Pain Hematuria Headache Abdominal mass Abdominal tenderness Ultrasonography CT scan Histology
1. Wilms tumor + + - + +
  • Wilms tumor has a triphasic appearance.
  • It is comprised of 3 types of cells:
  • All the 3 types are not required for the diagnosis of Wilms tumor.
  • Primitive tubules and glomeruli are often seen comprised of neoplastic cells.
  • Beckwith and Palmer reported in NWTS the different histopathologic types of Wilms tumor to categorize them based on prognosis.[4]
2. Renal cell carcinoma + + +/- + -
  • Ultrasound (US) may be helpful when CT scan results are equivocal. It is noteworthy to mention that not all renal cell carcinomas are detectable on ultrasound.
Both CT and MRI may be used to detect neoplastic masses that may define renal cell carcinoma or metastasis of the primary cancer. CT scan and use of intravenous (IV) contrast is generally used for work-up and follow-up of patients with renal cell carcinoma. The histological pattern of renal cell carcinoma depends whether it is papillary, chromophobe or collecting duct renal cell carcinoma.
3. Rhabdoid kidney disease + + - + -
  • CT scan may be diagnostic of malignant rhabdoid tumor. Findings on CT scan suggestive of malignant rhabdoid tumor include a large, heterogenous, centrally located mass, which is lobulated with individual lobules separated by intervening areas of decreased attenuation, relating to either previous hemorrhage or necrosis. Enhancement is similarly heterogeneous. Calcification is relatively common, observed in 20-50% of cases and is typically linear and tends to outline tumor lobules.
  • Malignant rhabdoid tumor is characterized by the round blue tumor cells of high cellularity composed of atypical cells with eccentric nuclei, small nucleoli, and abundant amounts of eosinophilic cytoplasm with frequent mitotic figures.
4. Polycystic kidney disease + + + (from hypertension) + -

Ultrasound may be helpful in the diagnosis of polycystic kidney disease. Findings on an ultrasound diagnostic of polycystic kidney disease include:[5][6]

  • At least three unilateral or bilateral cysts in patients 15 - 39 years old
  • Atleast two cysts in each kidney in patients 40 - 59 years old
  • Atleast four cysts in each kidney in patients 60 years of age or older

Renal CT scan may be helpful in the diagnosis of polycystic kidney disease. Findings on CT scan diagnostic of ADPKD include:

  • Numerous renal cysts of varying size and shape with little intervening parenchyma with water attenuation and very thin wall.
  • Reduction in sinus fat due to expansion of the cortex
  • Occasional complex cysts with hyperdense appearance, with possible septations or calcifications
  • Multiple homogeneous and hypoattenuating cystic lesions in the liver in patients with liver involvement
  • On microscopic histopathological analysis, interstitial fibrosis, tubular atrophy, thickening and lamellation of tubular basement membranes, microcysts and negative immunofluorescence for complement and immunoglobulin are characteristic findings of ADPKD.[7][8][9][10]
5. Pheochromocytoma - - + (as a part of the hypertension paroxysm) - -
  • CT is the preferred imaging modality for the diagnosis of pheochromocytoma.
The following findings may be observed on CT scan:[11]
  • On microscopic pathology, Pheochromocytoma typically demonstrates a nesting (Zellballen) pattern on microscopy. This pattern is composed of well-defined clusters of tumor cells containing eosinophilic cytoplasm separated by fibrovascular stroma.
6. Burkitt lymphoma +/- (in non-endemic or sporadic form of the disease) - - - -
  • Chest, abdomen, and pelvis CT scan may be helpful in the diagnosis of Burkitt's lymphoma but it is not done routinely.[15]
  • On microscopic histopathological analysis, characteristic findings of Burkitt's lymphoma include:[16]
  • Medium-sized (~1.5-2x the size of a RBC) with uniform size ("monotonous") -- key feature (i.e. tumor nuclei size similar to that of histiocytes or endothelial cells)
  • Round nucleus
  • Small nucleoli
  • Relatively abundant cytoplasm (basophilic)
  • Brisk mitotic rate and apoptotic activity
  • Cellular outline usually appears squared off
  • "Starry-sky pattern":
  • The stars in the pattern are tingible-body macrophages (macrophages containing apoptotic tumor cells.
  • The tumour cells are the sky
7. Intussusception + - - +/- +
  • Ultrasound is the gold standard imaging modality used to diagnose intussusception[17]
    • Target or doughnut sign[18]
      • Edematous intussuscipien forms an external ring around the centrally located intussusceptum
      • Target sign is usually seen in right lower quadrant
    • Layers of intussusception forms pseudo-kidney appearance on the transverse view
  • CT scan may be helpful in the diagnosis of intussusception. CT scan maybe used when other image modalities like x-ray and ultrasound have not given positive results but suspicion of intussusception is high.
  • Intussusception occurs if there is an imbalance between the longitudinal and radial smooth muscle forces of intestine that maintain its normal structure. This imbalance leads to a segment of intestine to invaginate into another segment and cause entero-enteral intussusception. Etiology of intussusception is either idiopathic or pathologic (lead point). 
8. Hydronephrosis + +/- - - + (CVA tenderness in case of pyelonephritis)
  • In the case of renal colic (one sided loin pain usually accompanied by a trace of blood in the urine) the initial investigation is usually an intravenous urogram. This has the advantage of showing whether there is any obstruction of flow of urine causing hydronephrosis as well as demonstrating the function of the other kidney. Many stones are not visible on plain x ray or IVU but 99% of stones are visible on CT and therefore CT is becoming a common choice of initial investigation.
  • The kidney undergoes extensive dilation with atrophy and thinning of the renal cortex.
9. Dysplastic kidney N/A N/A N/A N/A N/A

MCDK is usually diagnosed by ultrasound examination before birth.

  • Mass of non-communicating cysts of variable size.
  • Unlike severe hydronephrosis, in which the largest cystic structure (the renal pelvis) lies in a central location and is surrounded by dilated calices, in multicystic dysplastic kidney the cyst distribution shows no recognizable pattern.
  • Dysplastic, echogenic parenchyma may be visible between the cysts, but no normal renal parenchyma is seen.
  • MCKD can be discovered accidentally on CT scan.
  • CT scan shows myltiple cysts with absence of renal parenchyma.
  • MCKD is the result of abnormal differentiation of the renal parenchyma.
10. Pediatric Neuroblastoma + - - +/- +/-
  • CT scan is the investigation of choice for the diagnosis of neuroblastoma.[20]
  • On CT scan, neuroblastoma is characterized by:[21]
  • On microscopic histopathological analysis the presence of round blue cells separated by thin fibrous septa are characteristic findings of neuroblastoma.
  • Other findings of neuroblastoma on light microscopy may include:[22]
  • Homer-Wright rosettes (rosettes with a small meshwork of fibers at the center)
  • Neuropil-like stroma (paucicellular stroma with a cotton candy-like appearance)
11. Pediatric Rhabdomyosarcoma + +/- +/- - +/- On CT scan, rhabdomyosarocma is characterized by:
  • Soft tissue density
  • Some enhancement with contrast
  • Adjacent bony destruction (over 20% of cases)
12. Mesoblastic nephroma + + - + -
  • Ultrasound may be helpful in the diagnosis of mesoblastic nephroma.
  • Mesoblastic nephroma may presents as a well-defined mass with low-level homogeneous echoes.[23]
  • The presence of concentric echogenic and hypoechoic rings can be a helpful diagnostic feature of mesoblastic nephroma.
  • CT scan may be helpful in the diagnosis of mesoblastic nephroma.
  • Findings on CT scan suggestive of mesoblastic nephroma include:
  • Solid hypoattenuating renal lesion
  • Variable contrast enhancement
  • No calcification

Classic mesoblastic nephroma

Cellular mesoblastic nephroma

  • Plump cells with vesicular nuclei
  • Well-defined border
  • Mitotically active

Mixed mesoblastic nephroma

  • Both classic pattern and cellular pattern areas are present
Most common renal tumor that occurs in 1st month of life


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