Intussusception

Intussusception is the most common acute abdominal disorder of early childhood. In this lecture, we describe the manifests of Intussusception, the diagnosis, and the treatment of this disease.

1. Intussusception Dr. Leen Doya Department of pediatric Tishreen university

2. The Anatomy of Intussusception Intussusception occurs when a segment of bowel , the Intussusceptum , telescopes into a more distant segment of bowel . The most common type is ileocolic , followed by ileoileocolic , and colocolic .

3. Demographics Most common acute abdominal disorder of early childhood (56 children from 100000 year in US). Boys 4× ‘s more frequently than girls. Majority of patients between 3 mon and 3 year. Pick incidence between 5 and 9 months. 75% under 2 years. Seasonal peaks in spring and autumn. 95%no pathologic lead point. 5-10% recognizable lead point.

4. Etiologies of Intussusception Idiopathic (<3): no defined lead point. - Association with viral illness( adenovirus). Hypertrophy of lymphoid tissue. Recognizable cause for lead point:( > 3) - Meckel ‘s diverticulum(the most common).. Intestinal polype . Enteric duplication. Lymphoma. Intramural hematoma. Henoch-Shonlein purpura .

5. Clinical Presentation : Variable Intermittent , colicky cramping , pain . Later development of lethargy and somnolence. Vomiting (may be bile-stained). Current jelly stool (blood and mucus). Sausage shaped mass. Distention and tenderness. Additional signs : irritability, nausea ,fever , and anorexia. Classic traid : abdominal pain , currant jelly stool, vomiting ( 50%)

6. PHYSICAL EXAM Lethargic with colicky pattern of abdominal pain Mass in the RUQ may be palpated (“RUQ sausage”) Absence of bowel contents in right lower quadrant ( Dance sign ) Abdominal distention Rectal exam: Blood-tinged mucous or currant jelly stool ; occasionally the intussusception can be felt Peritoneal signs if intestinal perforation has occurred .

7. Dance sign

8. DIFFERENTIAL DIAGNOSIS Infection : Gastroenteritis, enterocolitis ..... Immunologic : Henoch-Scho nlein purpura Miscellaneous : - Appendicitis - Meckel diverticulum: May act as a lead point in the absence of bleeding – Incarcerated hernia – Crohn disease – Celiac disease – Henoch Scho ¨ nlein purpura

9. Obstruction : Adhesions, hernia, volvulus, stricture, bezoar, foreign body, polyp, tumor Other causes of lethargy: – Hypoglycemia – Meningitis – Encephalitis – Sepsis – Seizure – Infantile botulism – Toxic ingestion – Metabolic disorder

10. DIAGNOSTIC TESTS & INTERPRETATION Lab: No lab testing is routinely necessary. Consider serum electrolytes, glucose, and CBC with appropriate symptoms Consider routine preoperative lab assays as per institutional protocol.

11. Imaging: Abdominal x-ray Not sensitive or specific . Normal in early stages 25%. later can have absence of gas in right lower quadrant (RLQ) and RUQ, as well as RUQ soft tissue mass; with obstruction, will have air-fluid levels , paucity of distal gas .

12. 2. The meniscus sign is a crescent of gas within the colonic lumen outlining the apex of the intussusception 1 . The target sign is a rounded soft tissue mass representing the intussusception, with concentric lucencies due to the presence of mesenteric fat within the mass

13. 4. Nonspecific signs of intussusception on AXR that may suggest or support the diagnosis include soft tissue density and absence of gas in the right lower quadrant 5. and signs of small bowel obstruction

14. Abdominal ultrasound Abdominal US has high sensitivity (98–100%) and Specificity (88–100%) for intussusception .

15. intussusceptions are usually quite superficial masses measuring 2.5–5 cm in diameter , and most are found in the right side of the abdomen . In transverse section concentric rings of tissue representing components of the bowel wall and mesenteric fat are seen, sometimes referred to as the doughnut or target sign . Doughnut sign : Hypoechoic outer rim with a central hyperechoic core on transverse view

16. In longitudinal section the mass is roughly ovoid in shape , with different tissues appearing layered longitudinally . This appearance is often likened to a sandwich or called the pseudokidney sign

17. Enlarged lymphoid tissue or lymph nodes may be seen within the mass in transverse or longitudinal section Other sonographic features such as trapped fluid between the layers of bowel

18. CT most useful in evaluating for a pathologic leadpoint .

19. Barium enema was the gold standard for diagnosis of intussusception until the mid-1980s. Diagnostic and therapeutic with reduction often achieved; air enema preferred because less perforation risk than barium; can miss a lead point

20. the coiled spring sign which is produced when small amounts of contrast material accumulate between the intussusceptum and intussuscipiens . The classic signs of intussusception on contrast enema are the meniscus sign where the apex of the intussusception projects into the contrast material intussusception

21. Air contrast or barium enema reduction is the standard nonoperative treatment for intussusception: – 70–85% success with barium enema – Up to 90% success with air enema Barium or air contrast enema exam is useful for both diagnosis and therapy.

22. Complication Typically do not occur within the first 24 hrs …. Bowel obstruction. Intestinal ischemia. GI bleeding Perforation. Shock. Sepsis. dehydration. Thus we have a window of opportunity in which to treat and avoid surgery.

23. Successful management of intussusception depends on early recognition and diagnosis, adequate fluid resuscitation and prompt reduction. the longer the duration of symptoms (particularly if .24 h) the lower the likelihood of successful nonoperative reduction. Decreased reduction rates are also reported when the intussusception is situated in the rectum, in children with small bowel obstruction and those under 3 months of age.

24. Treatment of Intussusception Conservative management: NG drainage , resuscitation with IV fluid ,antibiotics Non operative management: Air or barium enema performed if there are no signs of peritonitis perforation. Operative management: Reducible intussusception. Irreducible intussusception. Resection with primary anastomosis.

25. Non-surgical reduction of intussusception has a long history, with enema treatment for ileus described for centuries Non-operative reduction techniques using enemas may be hydrostatic (using barium, water soluble contrast , saline or Hartmann’s solution) or pneumatic (using either air, or medical gases )

26. SURGERY/OTHER PROCEDURES If perforation/peritonitis exists, patient is unstable, nonoperative reduction is unsuccessful, or lead point is identified, proceed to surgical reduction.

27. Thank you