Intussusception

1. CASE OF THE WEEK

2. A young 30 years female patient presents with acute left sided abdominal pain With nausea and vomiting.

3. On examination Tachycardia Abdominal guarding with tenderness on the left side.

4. lab investigation Blood picture was normal with normal LFTS and RFTS.

5. On imaging , her CT abdomen reveals This specific appearance.

6. Intussusception

7. 58 y/o male with no significant past medical history has a 3 day history of intermittent cramping abdominal pain, vomiting, and diarrhea.

8. Abdominal Radiograph

9. Erect Abdominal Radiograph

10. Barium Study

11. The Invagination or telescoping of a proximal segment of bowel ( intussusceptum ) into the lumen of a distal segment ( intussuscipiens ) Intussusception

12. This can often result in an obstruction . The part that prolapses into the other is called the intussusceptum , and the part that receives it is called the intussuscipiens .

13. The invaginated segment is carried distally by peristalsis. Mesnetery and vessels become involved with the intraluminal loop and are squeezed within the engulfing segment causing venous congestion. Types : enteroenteric , enterocolic , and colocolic . Pathophysiology

14. Pathogenesis, aetiology and prevalence Intussusception can be classified according to location (small bowel or colon) or according to the underlying aetiology (neoplastic (benign or malignant), non-neoplastic or idiopathic). Intussusception arises in the small bowel in two-thirds of cases. The aetiology of intussusception in the small bowel and the colon is quite different.

15. Most common in infants and children Accounts for 95% of all cases of intussusception Ranks 2 nd to appendicitis as a cause of acute abdomen 90% of the cases in children are idiopathic Most common in children of 6 months to 2 years in age Epidemiology (Children)

16. Rare in adults: accounts for 0.003% to 0.02% of all hospital admissions Accounts for 1% of all bowel obstructions in adults 80-90% of cases have and underlying cause 65% are due to neoplasm Epidemiology (Adults)

17. Location Adults: ileoileal > ileocolic > colocolic Children: ileocolic > ileoileal > colocolic Epidemiology

18. Idiopathic (most common in children) Neoplasm Benign (more common in small bowel) Polyp, Leiomyoma, Lipoma, Lymphoma, Adenoma of appendix, Appendiceal stump granuloma Malignant Primary (more common in colon) Metastatic (more common in small bowel) Etiology

19. Postoperative (more common in small bowel) Meckel’s diverticulum Colitis Many cases thought to be related to viral gastroenteritis in children

20. Children : Well nourished infant Cramping abdominal pain Poor feeding / Vomiting Diarrhea A palpable, tender, sausage shaped mass in the abdomen Hx of abdominal surgery History and Physical Examination

21. Adults Intermittent pain Nausea and vomiting Often red blood per rectum Often nonspecific complaints

22. CT is the most accurate detecting 78% of the cases. Ultrasound is often used in children Barium studies are also very useful Imaging

23. Abdominal Plain X ray Abdominal films often show signs of small bowel obstruction

24. Erect films often show fluid levels in the small bowel Free intraperitoneal gas

25. Barium Studies Show a classic “ coiled spring ” appearance due to trapping of contrast between layers of bowel.

26. Ultrasound Ultrasound: transverse scan shows a target sign

27. Ultrasound i s today considered the imaging modality of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation. A target-like mass, usually around 3 cm in diameter, confirms the diagnosis

28. 53-year-old woman who had history of total gastrectomy due to advanced gastric cancer with retrograde jejunojejunal intussusception caused by adhesive band. Sonogram along longitudinal axis of intussusception shows typical “ pseudokidney ” sign

29. Intussusception can be confidently diagnosed on CT because of its virtually pathognomonic appearance. It appears as a complex soft tissue mass, consisting of the outer intussuscipiens and the central intussusceptum . There is often an eccentric area of fat density within the mass representing the intussuscepted mesenteric fat, and the mesenteric vessels are often visible within it CT appearance

30. A rim of orally administered contrast medium is sometimes seen encircling the intussusceptum , representing coating of the opposing walls of the intussusceptum and the intussuscipiens

31. The intussusception will appear as a sausage-shaped mass when the CT beam is parallel to its longitudinal axis but will appear as a “target” mass when the beam is perpendicular to the longitudinal axis of the intussusception

32. CT Target sign is also seen in CT. Can also see a sausage shaped mass

33. Small bowel intussusception in a 51-year-old man with recurrent left lower quadrant pain. Contrast material–enhanced CT scan of the abdomen demonstrates the typical multilayered appearance of a small bowel intussusception. The intussusceptum (black arrowhead), with an accompanying complex of mesenteric fat and blood vessels (arrow), is surrounded by the thick-walled intussuscipiens (white arrowhead).

34. Differential diagnosis Intussusception has three main differential diagnoses. These are acute gastroenteritis , Henoch – Schönlein purpura , and rectal prolapse. Abdominal pain, vomiting, and stool with mucus and blood are present in acute gastroenteritis, but diarrhea is the leading symptom.

35. Rectal prolapse can be differentiated by projecting mucosa that can be felt in continuity with the perianal skin, whereas in intussusception the finger may pass indefinitely into the depth of sulcus. Henoch – Schönlein purpura presents the characteristic rash.

36. Air reduction is the treatment of choice for children and is successful 75-90% of the time Contrast reduction was more frequently used a decade ago Treatment (children)

37. Adults require surgical exploration and resection of the intussuscepted bowel loops Reduction is not recommended in adults due to the risk of spreading/seeding malignant cells, potential perforation of the intussuscepted bowel, and venous embolization at the ulcerated mucosa area Treatment (Adults)

38. THANKS