Pediatric intussusception final

pediatric intususception

1. Pediatric Intussusception By Dr Biruk Ertiban (GSR III) Moderator Dr Wondimagegn ( GS,pediatric surgeon)

2. Introduction Types of intususception Clinical approach Investigations Management options Post op complications and recurrence Summery R eference Outline

3. Wilson (1831) reported the first successful operative reduction in an adult, Hutchinson reported it in an infant 40 years later (1871 ) But with high mortality rate As operative technique evolved, results improved. … cont

4. 1876 Hirschsprung published the first of a series of reports on hydrostatic reduction with much decreased mortality (23%) than operation … cont

5. In 1913 Ladd reported bismuth enemas and published the first photographs of roentgenologic pictures of an intussusception Fourteen years later (1927), Olsson and Pallin , Poulquien , and Retan used barium-guided fluoroscopy … cont

6. Till 1948 operation was the choise in USA till Ravitch and McCune reported a surgical mortality of 32% By 1958, nonoperative reduction rates of up to 75 % were achieved with a mortality rate close to zero. … cont

7. Burke and Clarke (1977) used only ultrasonography (US) for screening, diagnosis, and monitoring the reduction of intussusception Guo and colleagues (1986) successfully tried delayed repeat enema reduction attempts Today, operation is the accepted norm for failed radiologicguided reduction of intussusception. … cont

8. intussusception is derived from the Latin word intus (within) suscipere (to receive ) invagination of one part of the intestine into another … cont

9. Three cylinders of intestinal wall are involved. The inner and middle cylinders are the invaginated bowel ( intussusceptum ) the outer cylinder is the recipient of the invaginated bowel ( intussuscipiens ) … cont

10. It is the second cause of abdominal pain in pre school children after constipation diagnosis and treatment is a combined effort among the pediatrician, the pediatric radiologist, and the pediatric surgeon … cont

11. 1 to 4 in 2000 infants and children more males than females ( 2:1 or 3:2 ratio) (78% males) after 9 months of age than before (55 %) Incidence and Demographics

12. 75% of cases occur within the first 2 years of life 90 % in children within 3 years of age. More than 40% are seen between 3 and 9 months of age … cont

13. Intussusception has been reported in families and relatives viral cause rather than a genetic cause seasonal variation that usually correlates with viral infections ( respiratory,gastrointestinal ) incidence of a preceding viral illness has been reported as high as 20% … cont

14. Hirschsprung’s classic statement: “ I never saw a malnourished child with an intussusception.” … cont

15. prograde bowel peristalisis ( intussusceptum ) carries its mesentery in to( intussuscipiens ). The mesenteric vessels are angulated, squeezed, and compressed between the layers of the intussusceptum . This causes intense local edema of the intussusceptum Pathophysiology

16. four main types: general , specific , anatomic , and other Types

17. (1 ) The two general types are permanent (fixed, 80%) symptomatic (85%), and all require treatment transient ( spontaneous reduction , 20%); small and freq <2cm, reduces spontaneously, incidental findings most are small bowel,asymptomatic , 6% could have PLPs … cont

18. (2) the specific types can be described as idiopathic (no pathologic lead point [PLP], 95%), PLP (4%), postoperative (1%); … cont

19. ( Peyer patches) functions as a lead point Majority of all cases (95 %) Peyer patches are usually located in the antimesenteric area of the bowel wall. In the distal ileum, Peyer patches involve the entire circumference of the bowel Idiopathic (No Pathologic Lead Point)

20. distal ileal wall lymphoid tissues and the nearby mesenteric lymph nodes may enlarge and form a lead point useally 2ry to infection However , in a mouse model , the Peyer patches did not appear to act as the anatomic lead point for intussusception Rotavirus vaccine ( RRV-TV) … cont

21. Malnourished children have a lower risk of intussusception because of less prominent intestinal lymphoid tissue infants who consumed soy milk–based formula had a much lower risk, and infants who consumed cow’s milk formula had an increased risk for intussusception … cont

22. (3) when classified by anatomic types ileocolic (85%); ileoileocolic (10%); appendicocolic , cecocolic , or colocolic (2.5%) jejunojejunal , ileoileal (2.5%) occurring around indwelling tubes … cont

23. (4) the fourth type is “ other” recurrent (5%) neonatal (0.3 %) intussusception . … cont

24. 1.5% to 12% of all intuss . increases with age from about 5% in the first year to 44% within the first 5 years of life and 60% in 5- to 14-yearolds in 4% of infants and children who have one recurrence 19 % with multiple recurrences Pathologic Lead Point

25. most common focal cause of a PLP is Meckel diverticulum (inverted) intestinal polyps duplications Others periappendicitis ; Appendiceal stump; inversion appendectomy appendiceal mucocele ; local suture line; … cont

26. massive local lymphoid hyperplasia; Ectopic pancreas ; abdominal trauma; benign tumors (adenoma, leiomyoma, carcinoid, neurofibroma , hemangioma ); and malignant tumors (lymphoma, sarcoma, leukemia) …Other PLPs

27. Henoch-Scho nlein purpura cystic fibrosis celiac disease, Disorderedcoagulation hemophilia, neutropeniccolitis , Hirschsprungenterocolitis , Peutz-Jeghers syndrome familial polyposis Other with multifocal bowel wall thickening

28. Most PLPs manifest as ileoileocolic intussusceptions(40%) jejunojejunal , ileoileal , ileocolic , appendicocolic , cecocolic , and colocolic intussusceptions Recurrence vs PLP 5 % of patients with one recurrence 19 % of children with multiple recurrent episodes … cont

29. manifests as a small bowel obstruction (SBO ) third most common intussusception (1%) found most often in the small bowel after prolonged laparotomy significant bowel handling Postoperative intussusception

30. no lead point present SBO after pediatric laparotomy is about 5% (with 80% occurring within the first 2 years after laparotomy). Three to ten percent of those are caused by postoperative intussusceptions SBO after pediatric laparotomy is about 5% (with 80 % in 1 st 2 yr ) … cont

31. gastrojejunostomy tubes with a reported incidence of 16 % Antegrade jejunal intussusceptions , Usually asymptomatic treatment may be clinical monitoring Removal or conversion to a gastrostomy or nasogastric tube will cure the problem Around Tubes Intussusception

32. 8% to 15%following barium enema reduction, 5.2 % to 20% following sonography -guided hydrostatic enema reduction, 5.4 % to15.4 % following fluoroscopy-guided air enema reduction, 6.25 % to 7% after sonography -guided air enema Recurrent intussusception

33. Recurrence rates are lower after manual operative reduction (3% to 4 %) operative resection and anastomosis of an intussusception(0%) occur within the first few days after the initial reduction, some within hours …recurrence

34. Reduciblity >>> 100% for initial recurrence and 95% for multiple recurrences pathologic lead point 4% in children with one recurrence 14 % withmultiple recurrences … cont

35. infrequent ( 0.3%of all cases) caused by a pathologic lead point NEC like manifestation abdominal distension (17/17 ), bilious gastric aspirates (13/17), bloody stools (10/17), and palpable abdominal mass (5/17) Neonatal Intussusception

36. suspected with any of the two classic symptoms and signs Abdominal pain(85%) sudden,colicky,intemittent Vomiting (45% of infants) signs abdominal mass or rectal bleeding Clinical Findings and PhysicalExamination ( Intussusc ..)

37. In USA Most cases are diagnosed within 24 hours of the onset of symptoms . recurrent intussusception diagnosed early crampy abdominal pain>>>>high index of suspicion … cont

38. All four classic signs and symptoms can only be found late (<30% of cases) diarrhea precedes and may mislead to incorrect diagnosis and triage(20%) absence of pain(15%), delays the diagnosis>>pale and listless and appear quite ill … cont

39. curved, sausage-shaped right upper quadrant(65%) usually extends to the left along the transversecolon Mass>> intus …..

40. Slightly tender Easily palpable and visiblemass in silent child Dance sign palpated on rectal examination (5 %) Rectal bleeding>>>last sign to occur …mass>>> intus …

41. Rectal bleeding mucus-like texture Dueto sloughing of the mucosa dueto congestion and subsequent ischemia currant jelly appearance

42. Delayed presentation Fever Tachycardia hypotension >>>>bacteremia and bowel perforation N.B>Rapid diagnosis and emergent operation are essential to prevent a fatal outcome … cont

43. Lab No lab investigation is diagnostic leucocytosis , Acidosis electrolyte diagnosis

44. Clinical diagnosis only is 50% sensitive radiologic imaging and US to either confirm or make the correct diagnosis(100%) Radiologic Diagnostic Evaluation

45. meniscus sign and target sign

46. Up to 100 % accuracy for the diagnosis of intussusception portable, noninvasive, and without radiation Characteristic finding>>>> 3- to 5-cm diameter mass, typical target or doughnut sign found just deep to the anterior abdominal wall on the right side ULTRASONOGRAPHY

47. can detect a possible pathologic lead point with higher frequency (66%) than contrast (40%) or air enema (11 %) Can also detect Other DDX that mimic intussuscepption …US

48. it leads to a second study, increased health care costs since the US could have been avoided?? Ultrasound cannot predict well if the intussusception is already necrotic or amendable to nonoperative reduction and should therefore not preclude reduction by enema Weaknesses of US

49. the absence of blood flow on Doppler a thick peripheral hypoechoic rim, free intraperitoneal fluid, fluid trapped within the intussusceptum , enlarged lymph nodes dragged with the mesentery into the intussusception Warning signs of necrosis on US

50. Are not routinely used Intussusception found incidentally on imaging performed for another suspected diagnosis target or doughnut sign immediate CT scanning target sign with a diameter 3 cm(US) atypical location in the ( L t Abd & ublicus ) CT and MRI

51. Was a gold standard Before ultrasound became widely available In some institutions it is still the preferred diagnostic modality accuracy of 100 % Is both dignostic and therapeutic CONTRAST ENEMA

52. invasive ( radiation) More than 50% of diagnostic BE suspected intussusception turn out to be negative disadvantages of contrast enema

53. Evaluation by surgeon if there is need for emergent operation Fluid resuscitation NG tube decompression B road-spectrum antibiotic cross-matched blood radiologic confirmation N.B>>The operating room should be notified M anagement

54. medical (under occasional and specific situations), radiologic reduction or operative reduction, resection , closure of an enema perforation excision of a PLP by laparotomy or laparoscopy T reatment options

55. differentiate suitable candidates Contraindications (BE and AE) Dehydration>>>corrected shock peritonitis , or radiographic evidence of perforation with free air RADIOLOGIC REDUCTION

56. younger age (<6 months), Rectal bleeding , radiographic signs of intestinal obstruction, or longer duration of signs and symptoms (>72 hours ) hydrostatic or pneumatic enema should be attempted in all children without peritonitis Factors that can decrease success of enema reduction

57. operative management remains the usual primary treatment in much of the developing world(Nigeria and Kenya) mortality rate up to 20 % AE reduction in developing world success rate was 60% without mortality … cont

58. Currently used options pneumatic or hydrostatic pressure enemas under fluoroscopy or US USA and Europe management of intussusception varied greatly with a trend to pneumatic reduction techniques with greater use of ultrasound … cont

59. it avoids radiation exposure provides more information than fluoroscopic techniques do high accuracy and reliability for monitoring the reduction process, visualizes all components of the intussusception easily recognize pathologic lead points Advantage of US

60. the need for a radiologist who is comfortable using US for reduction guidance. less experience with pneumatic reduction under US guidance, Difficulty of early identification of perforation disadvantage of US

61. The enema tip should be placed within the child’s rectum and taped securely in place child is placed in a prone position to squeeze the buttocks closed and prevent air from leaking Air is insufilated into the colon under fluoroscopic observation reduction is followed fluoroscopically until it is completely reduced Pneumatic Air Enema

62. Air should flow freely from the cecum into the distal small bowel loops to signify complete reduction keep air pressure below a maximum limit of 120 mm Hg to avoid the risk of perforation … cont

63. it is easy to perform can be done quickly less messy delivers less radiation exposure is more comfortable , results in smaller perforations Less peritoneal contamination Advantages of pneumatic reduction

64. passage of air into the terminal ileum without complete reduction of the ileocolic intussusception tension pneumoperitoneum ( rare ) Disadvantages

65. the liquid enema is simple, safe, and effective, and most radiologists have experience with its use than AE US is relatively easy to use and the imaging modality of choice in many centers Hydrostatic Barium Enema

66. messy perforation occur with larger colonic tears, increased peritoneal contamination rapid fluid shifts with hypertonic water-soluble agents Barium is no longer the liquid contrast medium of choice ( peritonitis , infection, and adhesions when perforates) Disadvantages Of BE

67. three attempts each of 3 minutes duration enema bags 3 feet above the table reduction may occur rapidly or stubbornly slowly pause when the barium column meets the intussusception R ule of threes

68. the rounded barium column suddenly becomes concave forms a meniscus around the head of the intussusception When the intussusception is displaced, the meniscus flattens out …BE

69. barium seeps between the two and produces the characteristic radiologic appearance of a coiled spring Filling of the cecum is often slow, the sudden rush of barium into the distal ileum indicative of reduction …BE

70. If the enema is not freely filling in to the ileum>>>incomplete reduction Once the reduction is successful, the infant or child is relieved of the pain and usually falls asleep …BE

71. Medications>> GA, Smooth muscle relaxants such as glucagon Sedation(controversial) Methods to Improve Reduction Rates

72. improved their reduction rate with air enema from 58% to 76 % this technique may be more widely used than reported in the literature Transabdominal Manipulation

73. In the past it was standard practice that immediate operative intervention was required for all patients, if intussusception was irreducible by enema techniques 10% of intussusceptions were found to be already reduced, and another 40% were easily reduced manually in the OR Delayed Repeat Enema

74. i.e surgical intervention could possibly have been avoided in half the cases if radiologists used a different or more aggressive approach to their enema technique Interval>>> ranged between minutes and days Success rates between 50% and 84 % Usually done under GA No. of attempt should be tailored to the individual patient and experience of radiologist ….repeat enema

75. Close cooperation between experienced pediatric radiologists and surgeons and careful clinical monitoring is a must …. r epeat enema

76. observed closely for at least a few hours Discharge If parents are reliabe,pt is aymptomatic and tolerated post reduction fluid Still most of the Pts need admission for followup and further Tx If NGT was needed initially for SBO, better to keep it insitu overnight ,keep NPO and put on MF Postreduction Care

77. IV antibiotic is continued if the child is febrile or the reduction is difficult (48hr) 10% recurrence rate is expected Place of repeat Abd US study??>>the edematous part at ieocecal area mimic recurrence Post reduction care

78. Indication radiographic reduction is contraindicated , has failed or is incomplete, peritonitis pneumoperitoneum is detected pathologic lead point is found OPERATIVE MANAGEMENT

79. Fluid resuscitation NGT decompression IV antibiotic(for all minmum of 48hr) Take to OR,keep in supine position GA will be given The mass is felt The place of incision depends on the site of the mass …operative MGT

80. Previously used for diagnostic purpose Currently used for therapeutic reason too Onset<36hr and no sign of peritonitis>>good ourcome (60%) laparoscopy

81. right-sided transverse incision above or below the umbilicus is the standard incision If the incision is lower on the right side>>appendectomy should be done serosanguineous peritoneal fluid is encountered on entering the abdomen>>suspect necrosis Laparotomy

82. slow constant pinching and squeezing of the most distal part of the intussusceptum , just like squeezing a tube of toothpaste key to successful manual reduction

83. ileoileocolic intussusception, the ileocolic component is reduced first and then the remaining ileoileal leading edge of the intussusceptum may look particularly ischemic>> become pink and vital after application of warm saline towels for less than 10 minutes … cont

84. Up to 50% of all nonviable intussusceptions can be reduced manually>>gives chance to save as long bowel as possible saved a primary end-to-end anastomosis can be fashioned after the ischemic bowel is resected the ischemic bowel can be quickly resected and both bowel ends exteriorized as temporary stomas in critical child … cont

85. Perforations during enema reduction usually occur early during the procedure Still 50% can be reduced manually If the reduction is not possible, the intussusception should be resected en mass … cont

86. Radiologic reduction bowel perforation(less than 1 %) occur in the outer intussuscipiens and in the absence of necrosis Complications

87. infants younger than 6 months longer duration of symptoms (>36 hours ) High pressure(>120mmHg) Rapid increasment in pressure Risk factors for perforation

88. wound infection fascial dehiscence SBO . Reported complications rates >> (4%) when no enterotomy or bowel resection had to be performed (26 %) Post OP complication after perforation of Ba enema reduction>>50% post surgery complications

89. in up to 20% of the cases (average in published series 5 %) Recur within 6 months of the original episode with 3 rd within the first 24 hours Enema reduction for recurrence is as successful as for the initial episode If multiple recurrences can occur in the same child>>search for a pathologic lead point(tumor) RECURRENCE

90. Is gradually declining even in developing world But still as high as 20% Is <1% for both non operative and operative reduction The interval between onset of symptoms and institution of treatment is of paramount importance Near zero if presentation is within 24hr MORTALITY

91. mothers younger than 20 years, nonwhite , Unmarried education level below grade 12 Intussusception associated death

92. Pediatric intussusception often presents with a wide range of nonspecific symptoms The four classic symptoms of pain, emesis, and bloody stools +-mass are together present in less than 25% of children Clinical dx is 50%sensitive US and contrast enema makes accuracy reach 100% Summary

93. The success rate of non operative reduction is reaching >90% This days in westerns setup most are managed non operaatively Duration of the complaint is the key for successful reduction Delayed repeat enemas are up to 82% successful …summary

94. suspected ischemic bowel and peritonitis, unsuccessful enema reduction, suspected pathologic lead point, or, rarely, perforation after pressure enema (<1 %) are indications for operation Recurrence after BE and AE reduction is up to 20%(average 5%) …summary

95. Pediatric surgery,Arnolo G.coran,7 th edition Aschcraft’s pediatric surgery,6 th edition Schwartz principles of surgery,10 th edition Sabiston text book of surgery,20 th edition Uptodate 20.1 R eference

96. Thankyou