![DIAGNOSTIC APPROACH PROCEDURES
• Abdominal ultrasound (best initial test): often sufficient to confirm diagnosis
• Target sign (transverse view): The invaginated portion of bowel appears as rings on a target in
transverse view on ultrasound.
• Pseudo-kidney sign (longitudinal view): The lead point of the invagination in the distal loop of
bowel resembles a kidney. This “pseudo-kidney” is made up of longitudinal layers of bowel wall. [7]
• Possible pendulous peristalsis
• Can help rule out other causes of an acute abdomen
• Contrast or pneumatic enema using ultrasound or fluoroscopy (best confirmatory test)
• Interruption of contrast or air at the site of invagination.
• Pneumatic insufflation (air enema): air is injected into the intestines to create pressure.](https://image.slidesharecdn.com/intussusceptionbysmart-250228094303-c3c38050/85/Basic-on-intussusception-Pediatrics-note-14-320.jpg)
Basic on intussusception Pediatrics note
- 1. TOPIC: INTUSSUSCEPTION By: Lecturer: ALIMAMY HASSAN KAMARA ID: 22035 Dr AMADU JALLOH & ANSUMANA KAPRI KAMARA ID: 11036 Senior
- 2. OUTLINE • Summary • Epidemiology • Etiology • Pathophysiology • Classification • Clinical features • Diagnostic approach procedures • Differential diagnosis • Treatment • Complications • Prognosis • References
- 3. SUMMARY • Intussusception occurs when a proximal part of the bowel invaginates into a distal part, leading to a mechanical obstruction and bowel ischemia. Infants aged 3–12 months are most affected, usually with no identifiable underlying cause. Some patients may have an intraperitoneal anomaly or abnormality which initiates the process of intussusception (pathological lead point). Affected infants are typically of a healthy weight, and present with acute cyclical abdominal pain, knees drawn to the chest, and vomiting (initially nonbilious). Pallor, lethargy, and other symptoms of shock or altered mental status may be present.
- 4. SUMMARY CONTD. • A late-onset symptom is “currant jelly" stool (stool with blood and mucus) passed from the ischemic bowel. A classic sign is a palpable right upper quadrant (RUQ) mass on abdominal examination, seen as a target or pseudo-kidney sign on abdominal ultrasound. Contrast enema (i.e., pneumatic insufflation or hydrostatic enema with normal saline or barium), is the best confirmatory diagnostic test. Intussusception is considered a surgical emergency, as it may lead to bowel necrosis and perforation if left untreated. Open surgery is indicated when nonoperative measures fail, a pathological lead point is suspected, or bowel perforation is present. If treated before complications arise, patients generally have an excellent prognosis.
- 6. EPIDEMIOLOGY • Sex: ♂ > ♀ (3:2) • Age • Peak incidence: 3–12-month-old infants • Otherwise commonly occurs in children 3 months to 5 years of age • Uncommon in adults
- 7. ETIOLOGY • Mostly idiopathic: 75% of cases have no identifiable lead point; more common in children 3 months to 5 years of ∼ age • Pathological lead points • Defined as intraperitoneal anomalies or abnormalities that obstruct or tether the bowel and act as lead points in the process of intussusception • Meckel diverticulum (most common in children) • Intestinal polyps or other benign tumors (most common in adults and 2nd most common in general) • Enlarged Peyer patches: individuals with a history of a recent viral infection or immunization (e.g., rotavirus or adenovirus) • Bowel wall thickening in Henoch-Schoenlein purpura • Cystic fibrosis • Hematoma, hemangioma • Enlarged lymph nodes, lymphomas • Adhesions • More likely the underlying cause in patients with recurrent episodes of intussusception; more common in children < 3 months or > 5 years of age
- 8. PATHOPHYSIOLOGY • Imbalance in the bowel wall (idiopathic or via a pathological lead point) → invagination or “telescoping” of a portion of intestinal bowel (intussusceptum) into the distal adjacent bowel loop (intussuscipiens) → impaired lymphatic drainage and increasing pressure in intussusceptum bowel wall → venous impairment → mesenteric vessels congestion → ischemia of intussusceptum bowel wall → sloughing of bowel mucosa (most sensitive to bowel ischemia since it is the furthest from the arterial supply) → transmural necrosis and perforation with prolonged ischemia • The dysfunctional passage leads to mechanical bowel obstruction → vomiting
- 9. Intussusception • A proximal part of the bowel invaginates into a distal part → congestion of mesenteric vessels edema, ischemia → → necrosis, perforation
- 10. CLASSIFICATION • Ileocecal invagination (most common; accounts for 85–90% of cases) • Ileoileal invagination • Ileocolic invagination • Colosigmoidal invagination • Appendicocecal invagination (very rare)
- 11. THE INTESTINES
- 13. CLINICAL FEATURES • Child typically looks healthy. • Acute cyclical colicky abdominal pain (sudden screaming or crying spells), often with legs drawn up, with asymptomatic intervals: Acute attacks occur approx. every 15–30 min. • Vomiting (initially nonbilious) • Abdominal tenderness, palpable sausage-shaped mass in the RUQ and an “emptiness” or retraction in the RLQ (Dance sign) during palpation • High-pitched bowel sounds on auscultation • “Currant jelly stool”: Dark red stool (resembling “currant jelly”) may be noticed in passed stool or during digital rectal examination (usually a late sign). • Lethargy, pallor, and other symptoms of shock or altered mental status may be present.
- 14. DIAGNOSTIC APPROACH PROCEDURES • Abdominal ultrasound (best initial test): often sufficient to confirm diagnosis • Target sign (transverse view): The invaginated portion of bowel appears as rings on a target in transverse view on ultrasound. • Pseudo-kidney sign (longitudinal view): The lead point of the invagination in the distal loop of bowel resembles a kidney. This “pseudo-kidney” is made up of longitudinal layers of bowel wall. [7] • Possible pendulous peristalsis • Can help rule out other causes of an acute abdomen • Contrast or pneumatic enema using ultrasound or fluoroscopy (best confirmatory test) • Interruption of contrast or air at the site of invagination. • Pneumatic insufflation (air enema): air is injected into the intestines to create pressure.
- 15. DIAGNOSIS CONTD. • Abdominal x-ray • Inhomogeneous distribution of gas with absence of air at the site of invagination (usually right upper and lower quadrants) may be visible. • In cases of advanced-stage intussusception, other features of mechanical bowel obstruction will be detected. • Abdominal CT: Perform if ultrasound and abdominal x-ray are inconclusive. • May show target sign • Helps to identify pathological lead points • Laboratory tests: leukocytosis (suggests peritonitis)
- 16. TARGET SIGN IN INTUSSUSCEPTION ULTRASOUND ABDOMEN (TRANSVERSE VIEW) • Two concentric, alternating rings of hyperechoic and hypoechoic bowel are visible in the center-right of the image. The bowel mucosal layers form the hyperechoic bands, and the submucosa forms the hypoechoic bands. Together, they produce the target-like appearance.
- 17. COLOSIGMOIDAL INTUSSUSCEPTION IN A 4-YEAR-OLD GIRL • Contrast enema; lateral view Rectum and lower sigmoid are filled with contrast (dark); sudden interruption of contrast in the upper sigmoid (green area). S = spine LE = lower extremity
- 18. Differential diagnosis of lower gastrointestinal bleeding in children Age group Condition Findings First month of life ( neonate) •Anal fissures •Visualized during clinical exam of perianal area •Necrotizing enterocolitis •X-ray and ultrasound: pneumatosis intestinalis •Malrotation with volvulus •Abdominal x-ray: bird-beak sign •Upper gastrointestinal series: malpositioned ligament of Treitz 1 month to 1 year (infant) •Intussusception •Ultrasound: target and pseudo-kidney sign •Air enema: interrupted contrast •Milk protein allergy •Cow's milk protein-specific IgE •Anal fissures •Visualized during clinical exam of perianal area 1 year to 2 years •Meckel diverticulum •Technetium-99m pertechnetate scintiscan: gastric mucosa > 2 years •Juvenile polyps •Visualized during colonoscopy •Inflammatory bowel disease (ulcerative colitis) •Endoscopy and biopsy: inflamed mucosa extending from the rectum
- 19. TREATMENT • Initial steps: nasogastric decompression and fluid resuscitation • Nonsurgical management (performed under continuous ultrasound or fluoroscopic guidance) • Air enema: treatment of choice • Hydrostatic reduction: normal saline (or water-soluble contrast enema) • Observe for 24 hours post-reduction, as there is a small risk of perforation and recurrence is common during this period. • Surgical reduction • Indications • When a pathological lead point is suspected • Failed conservative management • Suspected gangrenous or perforated bowel • Critically ill patient (e.g., shock) • Open or laparoscopic method • Hutchinson maneuver: manual proximal bowel compression and reduction of intussusception • For necrotic bowel segments: resection and end-to-end anastomosis
- 20. COMPLICATIONS: small bowel obstruction bowel gangrene, perforation, and peritonitis PROGNOSIS • The prognosis of intussusception depends on how quickly it is treated. Most cases may be treated successfully with conservative pneumatic insufflation or hydrostatic reduction. The absence of ischemia or necrotic bowel is associated with a good prognosis. • Success rates for non-surgical reduction: 45–95% • Rate of relapse in patients with non-surgical reduction: 4.5–10%
- 21. WHAT CONDITION IS THIS?
- 23. REFERENCE • 1.Kitagawa S, Miqdady M. Intussusception in children. In: Post TW, ed. UpToDate .Waltham, MA: UpToDate. https://www.uptodate.com/contents/intussusception-in-children?source=search_result&search=int ussusception%20in%20children&selectedTitle=1~112 . Last updated March 30, 2016. Accessed January 24, 2017. • 2.Ong NT, Beasley SW. The leadpoint in intussusception. J Pediatr Surg .1990; 25(6): p.640- 643. pmid: 2359000. | Open in Read by QxMD • 3.Holmes M, Murphy V, Taylor M, Denham B. Intussusception in cystic fibrosis. Arch Dis Child .1991; 66(6): p.726-727. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793149/. • 4.Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B. Intussusception: clinical presentations and imaging characteristics. Pediatr Emerg Care .2012; 28(9): p.842-844. doi: 10.1097/PEC.0b013e318267a75e.| Open in Read by QxMD