INTUSSUSCEPTION.pptx

ACUTE INTUSSUCEPTION

1. ACUTE INTUSSUSCEPTION

2. When one portion of the gut invaginates into the immediately adjacent loop, the condition is called intussusception .

3. Usually proximal loop is invaginated into the distal bowel. But rarely the distal loop may invaginate into the proximal loop and this condition is called retrograde intussusception (e.g. jejunogastric intussusception following gastrojejunostomy ).

4. COMPOUND OR DOUBLE INTUSSUSCEPTION. Sometimes the mass of intussusception may again invaginate into the distal bowel and this condition is called compound or double intussusception .

5. MULTIPLE INTUSSUSCEPTIONS. Intussusception is usually single but very occasionally one may find more than one intussusception at different levels. This is called multiple intussusceptions.

6. Intussusception is usually acute, but rarely chronic intussusception may persist for months or years. Intussusception may recur and this is called recurrent intussusception .

7. AETIOLOGY Broadly speaking there are two varieties of intussusception — I. Where there is definite cause of intussusception — Secondary intussusception and 2. Where there is no definite cause for intussusception — Primary or idiopathic intussusception .

8. 1. SECONDARY INTUSSUSCETION Polyp, papilliferous carcinoma, lymphoma, hamartoma , submucous lipoma , stump of appendix, an inverted Meckel’s diverticulum etc. may cause intussusception . This type of intussusception , which is caused by some pathology, is known as secondary intussusception . This type of intussusception may occur at any age. Secondary intussusception usually occurs in the ileum. Sometimes intussusception may occur in the early postoperative period due to inco-ordinale peristalsis in the small intestine.

9. 2. PRIMARY OR IDIOPATHIC INTUSSUSCEPTION The majority of the intussusceptions belong to this group. This type of intussusception usually occurs in children between 6 to 9 months of age.

10. PATHOLOGY An intussusception is composed of three parts ( i ) the entering or inner tube, (ii) the returning or the middle tube and (iii) the sheath or the outer tube.

11. PATHOLOGY The entering or inner tube and the returning tube are together called intussusceptum . The ensheathing tube or outer tube is called intussuscipiens . The starting point ofthe intussusception is called the apex. It is the junction of the entering and returning tubes. It is the fixed point of intussusception and intussusception progresses at the cost of the ensheathing tube or the outer tube. The site where the retuning layer and the ensheathing layer meet is called the neck and this point varies as the intussusception progresses.

12. PATHOLOGY Intussusception is a type of intestinal obstruction which often accompanies strangulation

13. As the intussusception progresses, the mesentery of the entering and returning tubes is dragged alongwith the gut through the neck of the intussusception . Gradually the mass of the intussusception by the pull of the mesentery becomes sausage-shaped with concavity towards the umbilicus (approximately the point of attachment of the mesentery). the mesentery becomes compressed between the entering and returning tubes. In the beginning the mesentery become constricted and severe venous engorgement and oedema of the wall of the intussusceptum oedematous intussusceptum may cause total intestinal obstruction.

14. SAUSAGE-SHAPED WITH CONCAVITY TOWARDS THE UMBILICUS

15. PATHOLOGY If the mesentery is quite long intussusception can even present through the rectum at the anal canal pull on the mesentery becomes sufficient enough to occlude the arteries. This causes onset of gangrene Gangrene is dependent upon the tightness of the invagination and it often occurs in ileocolic intussusception ileocaecal valve exerts pressure on the mesentery. The returning layer near the apex is the first site to gangrene. Gangrene may cause perforation and ultimately peritonitis. The ensheathing tube is hardly affected.

16. In rare instances gross adhesion may develop at the neck between intussusceptum and intussuscipiens , develops in such case, the whole mass of intussusceptum becomes necrosed and sloughs out. This brings cure.

17. CLINICAL FEATURES Healthy male children between 6 and 9 months of age are mostly affected.

18. CLINICAL FEATURES Onset is usually sudden. The child screams with abdominal pain, which is colicky in nature. Alongwith the pain the child draws up his legs. During the attack the child may vomit. But remember that vomiting is a late feature and usually does not appear before 24 hours of the onset of the disease.

19. CLINICAL FEATURES Such attacks are also accompained by facial pallor. The attacks usually last for a few minutes and recur every 15 minutes . In between the attacks the child lies motionless and looks very drawn. Patient may pass a few normal motions before current jelly stool is passed.

20. CLINICAL FEATURES In long continued and untreated cases pain becomes continuous. After 2 or 3 days, the abdomen gradually starts distending. Vomiting becomes copious . Absolute intestinal obstruction occurs and death is the ultimate result from intestinal obstruction alone or peritonitis following gangrene and perforation

21. PHYSICAL SIGNS The abdomen becomes voluntarily contracted during paroxysms of pain . In early cases distension is not noticed. Distension only appears after 2 or 3 days of the commencement of the disease . If the abdomen is carefully palpated between the attacks one may feel a lump under the right or left costal margin.

22. PHYSICAL SIGNS This lump is a sausage-shaped lump with concavity towards the umbilicus . Right iliac fossa is peculiarly empty on palpation. called Signe-de-Dance . This is due to the fact that the If terminal part of ileum and caecum do not remain m right iliac fossa , but arc involved in intussusception and arc tclcscopcd through the ascending colon, transverse colon and descending colon according to the various stages.

23. PHYSICAL SIGNS RECTAL EXAMINATION should always be performed One may feel the intussusceptum if it has reached the rectum . It will feel very much like cervix uteri in the vagina . In majority of cases the apex of the intussusception cannot be felt per rectum but the finger will be smeared by blood-stained mu cus. This will give a definite clue to the diagnosis.

24. PHYSICAL SIGNS In very occasional cases intussusception may actually protrude through the anus when the patient possesses an unusually long mesentery. In this case it looks like a prolapse .

25. SPECIAL INVESTIGATIONS X-ray of the abdomen shows absence of caecal gas shadow and increased gas shadows in the small intestine . Barium Enema Radiography is very diagnostic when the intussusception has passed distally through ileocaecal valve. When the intussusception has reached at least the ascending colon the barium will stop intussusceptum and there it will show a ‘pincer-shaped ’ or ‘ colied -spring ’ deformity or ‘pitch fork.

26. Barium enema has got a therapeutic value, in the sense that the pressure of the barium enema may cause spontaneous reduction of the intussusception .

27. ‘pincer-shaped ’ or ‘ colied -spring ’ deformity

28. TREATMENT PREOPERATIVE MANAGEMENT Intra- venous fluid administration should be started immediately and appropriate fluid resuscitation should be begun. Decompression of the small intestine through nasogastric suction is similarly important. Prophylactic antibiotics should be given if symptoms have been present for more than 24 hours.

29. HYDROSTATIC REDUCTION When infants present with less than 24 hours of symptoms . hydrostatic reduction is a successful treatment in 60 to 70% of patients Barium enema can be used for hydrostatic reduction of intussusception . OPERATIVE TREATMENT RESECTION

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