Intussusceptionlecture by Amr Abdellatif.pptx
- 1. Intussusception In Pediatrics A surgical emergency
- 2. By Amr Abdellatif Pediatric Surgery Registrar Supervised by Dr . Ahmed Al-Elewi Pediatric Surgery Consultant
- 3. o Intussusception is the most frequent cause of bowel obstruction in infants and toddlers. It was first described in 1674 by Paul Barbette of Amsterdam, defined by Treves in 1899, and operated on successfully in 1873 by John Hutchinson(1) o Defined as an acquired invagination of the proximal bowel (intussusceptum) into the distal bowel (intussuscipiens) (1). Hutchinson J. A successful case of abdominal section for intussusception. Proc R Med Chir Soc. 1873;7:195–198.
- 4. o Idiopathic intussusception can occur at any age. o Two-thirds are boys. o The highest incidence occurs in infants between ages 4 and 9 months and it is the most common cause of small bowel obstruction in this age group. o Intussusception is uncommon below 3 months and after 3 years of age. o The condition has been described in premature infants and has been postulated as the cause of small bowel atresia in some cases. o Most affected patients are well-nourished, healthy infants. Incidence
- 5. Pathophysiology o The intussusceptum telescopes into the distal bowel ( intussuscepiens ) by peristaltic activity. o There may or may not be a lead point. o The mesentery is compressed, resulting in venous obstruction and bowel wall edema. o Arterial insufficiency will ultimately lead to ischemia and bowel wall necrosis. o Although spontaneous reduction can occur, the natural history of an intussusception is to progress to bowel ischemia and necrosis.
- 6. Types of intussusception PRIMARY INTUSSUSCEPTION SECONDARY INTUSSUSCEPTION No lead points There is a lead point
- 7. PRIMARY INTUSSUSCEPTION ( idiopathic ) o A majority of cases, especially in infants. o do not have a lead point. o The cause is usually due to hypertrophied Peyer’s patches within the bowel wall. o Intussusception occurs frequently in the wake of an upper respiratory tract infection or an episode of gastroenteritis. o Adenoviruses and to a lesser extent rotaviruses, have been historically implicated in up to 50% of cases.
- 8. o There is an identifiable lesion that serves as a lead point. o The incidence of a lead point varies from 1.5–12%. o Increases in proportion with age, so more common after age of 2 years. o The most common lead point is a Meckel diverticulum followed by polyps and duplications. o Other benign lead points include the appendix, hemangiomas, carcinoid tumors, foreign bodies, hamartomas from Peutz– Jeghers syndrome and lipomas. o Malignant causes are rare like lymphomas and small bowel tumors. SECONDARY INTUSSUSCEPTION
- 9. Clinical Presentation o The classic presentation is an infant or a young child with intermittent, cramping abdominal pain associated with “currant jelly” stools and a palpable mass on physical examination. o This triad is seen in less than a fourth of children. The abdominal pain sudden, intermittent and the child may stiffen and pull the legs up to the abdomen. The pain also can be associated with hyperextension, breath holding, and vomiting. The attack often ceases as suddenly as it started. Between attacks the child may appear comfortable but will become lethargic.
- 10. Stools may be blood tinged as ischemia causes mucosal sloughing and compression of mucous glands leading to evacuation of dark red mucoid clots or currant jelly stools. This is often a late sign. A pitfall is to wait for the currant jelly stool, leukocytosis, and electrolyte abnormalities that are often the hallmarks of ischemic bowel.
- 11. Physical Examination o Palpable Mass or even visualized. o Flat or empty right lower abdominal quadrant (Dance sign). o On rectal examination, blood-stained mucus or blood is a later sign. o Cramping episodes occur every 15–30 minutes and during painless intervals, the child may appear normal.
- 12. o Prolapse of the intussusceptum through the anus is a grave sign, especially when the intussusceptum is ischemic. This may be missed and diagnosed as rectal prolapse ( how to differ ? ) If the obstructive process worsens and bowel ischemia occurs, dehydration, fever, tachycardia, and hypotension may develop { signs of shock }
- 13. Investigations and diagnosis 1. ABDOMINAL RADIOGRAPHY Suggestive radiographic abnormalities include : abdominal mass. abnormal distribution of gas and fecal contents. sparse large bowel gas. air-fluid levels in the presence of bowel obstruction
- 14. 2. ULTRASONOGRAPHY o Used now as a screening tool. {why??} o The characteristic finding on US has been referred to as a “target” or “doughnut” lesion in transverse plane. o And The “pseudokidney” sign in longitudinal plane. o Both are pathognomonic for intussusception along with the clinical picture
- 15. 3. COMPUTEDTOMOGRAPHY AND MAGNETIC RESONANCE IMAGING o Not routinely used in the evaluation of intussusception. o May confirm the diagnosis and/or pathologic causes for intussusception, such as a malignancy (i.e., lymphoma) o The characteristic CT finding is a target or doughnut sign
- 16. Management
- 17. Non operative management HYDROSTATIC REDUCTION PNEUMATIC REDUCTION Operative management LAPAROSCOPIC APPROACH OPEN APPROACH Options for treatment
- 18. Non operative management HYDROSTATIC REDUCTION PNEUMATIC REDUCTION Options for treatment Initial option of treatment with mean successful reduction rate in uncomplicated patients 85%. Could be repeated according rule of 3 for three times . Could be repeated once with improved success .
- 19. Operative management LAPAROSCOPIC APPROACH OPEN APPROACH Options for treatment Indications : 1. when nonoperative reduction is unsuccessful or incomplet. 2. For signs of peritonitis. 3. In the presence of a lead point. 4. With radiographic evidence of pneumoperitoneum.
- 20. PNEUMATIC REDUCTION o Fluoroscopically monitored. o air is insufflated into the rectum. o The maximum safe air pressure is 80 mmHg for younger infants and 110– 120 mmHg for older infants. o Disadvantages : 1. Possibility of developing tension pneumoperitoneum. 2. Poor visualization of lead points and/or the intussusception reduction process, resulting in false- positive reductions. 3. Perforation which ranges from 0.4–2.5%, with the most recent publications citing an average rate of 0.8%.
- 21. Video from fluoroscopy showing pneumatic reduction of ileocaecal intussusception
- 22. o Using water soluble contrast introduced through a rectal catheter under fluoroscopic guidance. o Using saline introduced through a rectal catheter under ultrasonographic guidance. o the rule of 3’s is followed keeping the can at a height at 3 ft, for 3 minutes, and for maximum three attempts. o Complications ??? HYDROSTATIC REDUCTION
- 23. LAPAROSCOPIC APPROACH o Initially, laparoscopy was strictly diagnostic. o Now has become the initial operation of choice : (improved postoperative pain and shorter time to full feeds and length of stay ). o Contraindications to laparoscopy include : 1. hemodynamic instability. 2. peritonitis or evidence of pneumoperitoneum. 3. severe bowel distention that limits visualization.
- 24. o Risk factors for increased conversion rates to an open procedure include : 1. An intussusceptum extending beyond the ascending colon. 2. Presence of known pathologic lead points. o Reduction is done by applying gentle pressure distal to the intussusceptum using atraumatic graspers. o Excessive force should be discouraged. o Appendectomy is not routinely performed unless it is felt to be the lead point. o If resection is required, exteriorizing the bowel through an enlarged periumbilical incision is done and If this is not possible, the operation is usually converted to a laparotomy.
- 26. OPEN APPROACH o By identification of the sausage-shaped mass,. o Starting squeezing from the apex ( milking ). o Avoiding pulling as it can cause rupture. o Compression with warm saline pack reduces edema, thus helping in reduction. o In difficult cases pressure squeeze to reduce edema of the ileocecal valve (Copes method) may be attempted. o Bowel resection is required for irreducible and gangrenous intussusception. o If a lead point is found like Meckel’s diverticulum or polyp then resection is recommended.