Basic on intussusception Pediatrics note

Understanding the basics of intussusception in children

1. TOPIC : Intussusception By: Lecturer: ALIMAMY HASSAN KAMARA ID: 22035 Dr AMADU JALLOH & ANSUMANA KAPRI KAMARA ID: 11036 Senior

2. Outline Summary Epidemiology Etiology Pathophysiology Classification Clinical features Diagnostic approach procedures Differential diagnosis Treatment Complications Prognosis References

3. Summary Intussusception occurs when a  proximal  part of the bowel invaginates into a  distal  part, leading to a mechanical obstruction and  bowel ischemia .  Infants  aged 3–12 months are most affected, usually with no identifiable underlying cause. Some patients may have an  intraperitoneal  anomaly or abnormality which initiates the process of intussusception ( pathological lead point ). Affected  infants  are typically of a healthy weight, and present with acute cyclical abdominal  pain ,  knees drawn to the chest, and vomiting (initially nonbilious).  Pallor ,  lethargy , and other symptoms of  shock  or altered mental status may be present.

4. Summary contd. A late-onset symptom is “currant jelly" stool (stool with blood and mucus) passed from the  ischemic  bowel. A classic sign is a palpable  right upper quadrant  ( RUQ ) mass on  abdominal examination , seen as a target or  pseudo-kidney sign  on abdominal  ultrasound .  Contrast enema  (i.e.,  pneumatic insufflation  or hydrostatic enema with  normal saline  or barium), is the best confirmatory diagnostic test. Intussusception is considered a surgical emergency, as it may lead to bowel  necrosis  and perforation if left untreated. Open surgery is indicated when nonoperative measures fail, a  pathological lead point  is suspected, or  bowel perforation  is present. If treated before complications arise, patients generally have an excellent prognosis.

5. Intussusception

6. Epidemiology Sex :  ♂  >  ♀  (3:2) Age   Peak  incidence : 3–12-month-old  infants Otherwise commonly occurs in children 3 months to 5 years of age  Uncommon in adults

7. Etiology Mostly  idiopathic : ∼ 75% of cases have no identifiable  lead point ; more common in children 3 months to 5 years of age Pathological lead points Defined as  intraperitoneal  anomalies or abnormalities that obstruct or tether the bowel and act as  lead points  in the process of intussusception  Meckel diverticulum   (most common in children) Intestinal polyps  or other  benign tumors  (most common in adults and 2 nd  most common in general) Enlarged  Peyer patches : individuals with a history of a recent viral infection or  immunization  (e.g.,  rotavirus  or  adenovirus )  Bowel wall thickening in  Henoch-Schoenlein purpura Cystic fibrosis   Hematoma ,  hemangioma Enlarged lymph nodes ,  lymphomas Adhesions More likely the underlying cause in patients with recurrent episodes of intussusception; more common in children < 3 months or > 5 years of age

8. Pathophysiology Imbalance in the bowel wall ( idiopathic  or via a  pathological lead point ) → invagination or “ telescoping ” of a portion of intestinal bowel (intussusceptum) into the  distal  adjacent bowel loop (intussuscipiens) → impaired  lymphatic drainage  and increasing pressure in intussusceptum bowel wall → venous impairment →  mesenteric vessels  congestion →  ischemia  of intussusceptum bowel wall → sloughing of bowel  mucosa  (most sensitive to  bowel ischemia  since it is the furthest from the arterial supply) →  transmural   necrosis  and perforation with prolonged  ischemia The dysfunctional passage leads to  mechanical bowel obstruction  → vomiting

9. Intussusception A proximal part of the bowel invaginates into a distal part → congestion of mesenteric vessels → edema, ischemia → necrosis, perforation

10. Classification Ileocecal invagination (most common; accounts for 85–90% of cases)  Ileoileal invagination Ileocolic invagination Colosigmoidal invagination Appendicocecal invagination (very rare)

11. The intestines

12. Ileocolic invagination

13. Clinical features Child typically looks healthy. Acute  cyclical  colicky abdominal  pain  (sudden screaming or crying spells), often with legs drawn up, with asymptomatic intervals: Acute attacks occur approx. every 15–30 min.  Vomiting (initially nonbilious)  Abdominal tenderness, palpable  sausage-shaped mass  in the  RUQ   and an “emptiness” or  retraction  in the  RLQ  (Dance sign) during palpation High-pitched bowel sounds on  auscultation   “ Currant jelly stool ”: Dark red stool (resembling “currant jelly”) may be noticed in passed stool or during  digital rectal examination  (usually a late sign).  Lethargy, pallor , and other symptoms of  shock  or altered mental status may be present.

14. Diagnostic approach procedures Abdominal  ultrasound  (best initial test): often sufficient to confirm diagnosis  Target sign  (transverse view): The invaginated portion of bowel appears as rings on a target in transverse view on  ultrasound .  Pseudo-kidney sign (longitudinal view): The  lead point  of the invagination in the  distal  loop of bowel resembles a  kidney . This “pseudo-kidney” is made up of longitudinal layers of bowel wall.  [7] Possible  pendulous peristalsis   Can help rule out other causes of an  acute abdomen Contrast or  pneumatic enema  using  ultrasound  or  fluoroscopy  (best  confirmatory test )  Interruption of contrast or air at the site of invagination. Pneumatic insufflation  ( air enema ): air is injected into the intestines to create pressure. 

15. Diagnosis Contd. Abdominal  x-ray   Inhomogeneous distribution of gas with absence of air at the site of invagination (usually right upper and lower quadrants) may be visible. In cases of advanced-stage intussusception, other features of  mechanical bowel obstruction  will be detected. Abdominal CT: Perform if  ultrasound  and abdominal  x-ray  are inconclusive. May show  target sign Helps to identify  pathological lead points Laboratory tests:  leukocytosis  (suggests  peritonitis )

16. Target sign in intussusception Ultrasound abdomen (transverse view) Two concentric, alternating rings of hyperechoic and hypoechoic bowel are visible in the center-right of the image. The bowel mucosal layers form the hyperechoic bands, and the submucosa forms the hypoechoic bands. Together, they produce the target-like appearance.

17. Colosigmoidal intussusception in a 4-year-old girl Contrast enema; lateral view Rectum and lower sigmoid are filled with contrast (dark); sudden interruption of contrast in the upper sigmoid (green area). S = spine LE = lower extremity

18. Differential diagnosis of lower gastrointestinal bleeding in children Age group Condition Findings First month of life ( neonate ) Anal fissures Visualized during clinical exam of perianal area Necrotizing enterocolitis X-ray  and  ultrasound :  pneumatosis intestinalis Malrotation with  volvulus Abdominal  x-ray :  bird-beak sign Upper gastrointestinal series : malpositioned  ligament of Treitz 1 month to 1 year ( infant ) Intussusception Ultrasound : target and  pseudo-kidney sign Air enema : interrupted contrast Milk protein  allergy Cow's milk protein-specific  IgE Anal fissures Visualized during clinical exam of perianal area 1 year to 2 years Meckel diverticulum Technetium-99m pertechnetate scintiscan : gastric  mucosa > 2 years Juvenile polyps Visualized during  colonoscopy Inflammatory bowel disease  ( ulcerative colitis ) Endoscopy and  biopsy : inflamed  mucosa  extending from the  rectum Bacterial gastroenteritis  ( E. coli ,  Shigella ) Stool cultures

19. Treatment Initial steps : nasogastric decompression and  fluid resuscitation Nonsurgical management  (performed under continuous  ultrasound  or  fluoroscopic  guidance)  Air enema : treatment of choice Hydrostatic reduction:  normal saline  (or water-soluble  contrast enema ) Observe for 24 hours post-reduction, as there is a small risk of perforation and recurrence is common during this period.  Surgical reduction Indications  When a  pathological lead point  is suspected Failed  conservative management   Suspected gangrenous or perforated bowel Critically ill patient (e.g.,  shock ) Open or laparoscopic method Hutchinson maneuver: manual  proximal  bowel compression and reduction of intussusception For  necrotic  bowel segments: resection and end-to-end  anastomosis

20. Complications: small bowel obstruction bowel  gangrene , perforation, and  peritonitis PROGNOSIS The prognosis of intussusception depends on how quickly it is treated. Most cases may be treated successfully with conservative  pneumatic insufflation  or  hydrostatic reduction . The absence of  ischemia  or  necrotic  bowel is associated with a good prognosis. Success rates for non-surgical reduction: 45–95%  Rate of relapse in patients with non-surgical reduction: 4.5–10% 

21. What condition is this?

22. Hirschsprung’s disease

23. Reference 1.Kitagawa S, Miqdady M. Intussusception in children. In: Post TW, ed.  UpToDate  .Waltham, MA: UpToDate. https://www.uptodate.com/contents/intussusception-in-children?source=search_result&search=intussusception%20in%20children&selectedTitle=1~112 . Last updated March 30, 2016. Accessed January 24, 2017. 2.Ong NT, Beasley SW. The leadpoint in intussusception.  J Pediatr Surg  .1990; 25(6): p.640-643. pmid: 2359000.  | Open in Read by QxMD 3.Holmes M, Murphy V, Taylor M, Denham B. Intussusception in cystic fibrosis.  Arch Dis Child  .1991; 66(6): p.726-727. url:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793149/ . 4.Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B. Intussusception: clinical presentations and imaging characteristics.  Pediatr Emerg Care  .2012; 28(9): p.842-844. doi:  10.1097/PEC.0b013e318267a75e . | Open in Read by QxMD