Intussuscetion

I

INTUSSUSCEPTION

v Intussusception is one of the most frequent causes of bowel obstruction in infants and
toddlers.
PATHOGENESIS
v Telescoping of one portion of the intestine ( intussusceptum) into another
(intussusc ipiens ) by peristaltic activity .
1- Primary : - idiopathic, commonly 5-9 months, frequently occur in the wake of upper
respiratory tract infections or episodes of gastroenteritis , associated with
enlargement of Payer’s patches ,adeno virus and rota virus implicated .
2- Secondary: - a definite anatomic lead point is found in 2-12% of cases, e.g.
M eckel `s diverticulum "the commonest ", appendix, polyps, duplication of bowel,
Henoch -Schonlein purpura "due to sub mucosal hemorrhage ", and non -Hodgkin
lymphoma ,hemangiomas,foriegn bodies and cystic fibrosis.
Types :
1- Ileocolic (80 -95 % ).
2- Ileoileal .
3- Cecocolic.
4- Colocolic.
5- Jejunojejunal.
NATURAL HISTORY
• Intussusceptions > compressed bowel & mesentery > venous obstruction > bowel wall
oedema >venous insufficiency> arterial insufficiency > bowel wall necrosis > sepsis >
death, if not treated .
INCIDENCE
• Age : any age especially 4-9 months .
• Sex: 2/3 rd is boys, well -nourished healthy infants (plumpy child) .
• Peaks of R.T.I or epidemics of gastroenteritis.
PRESENTATIONS
• The classic presentation of intussusception is a young child with intermittent, crampy
abdominal pain associated with “currant jelly” stools and a palpable mass on physical
examination, although this triad is seen in less than a fourth of children.
• Abdominal pain : acute, cramping; stiffen & pull legs to the abdomen > free of pain
and the attack usually occure every 15 -30 minute ,the child between the attack health y
and later on become lethargic on recurrent attacks and the attack ceases as it started .
• Vomiting: almost universal, later on become bilious .
• Bowel motion: small & normal initially > stool tinged with blood > dark -red mucoid
clots ( currant -jelly stool).

II

EX AMINATION

• Flat or empty RLQ (Dance`s sign) .
• During relaxation, sausage shape or curved mass can b e felt anywhere in the abdomen ,
especially in the ri ght upper quadrant or epigastrium .
• PR > blood stained mucus or fresh blood & palpable mass.
• Delayed > signs of dehydration and bacteraemia with tachycardia and fever and signs of
peritonitis .
• Grave sign > intussusceptions through anus may mimic rectal prolapse : .
Blade can be passed more than 1 -2 cm throu gh the anus suggesting intussusception .
DIAGNOSTIC STUDIES
1- Plain AXR: -
• Abnormal distribution of gas & fecal content .
• Sparse large bowel gas and a bsence of caecal gas.
• Air fluid level .
• M ass .
2- U/S: - high sensitivity and specificity.
• Target lesion on transverse section: 2 rings of low echogenicity separated by hyper
echoic ring.
• Pseudo -kidney sign on longitudinal section.
• Lymph node enlargement.
• Free intra peritoneal fluid.
.
3- Barium enema:
• Claw sign.
• Coiled spring sign.
4- Colored Doppler:
• To assess the vascularity of intussusception .
5- CT s can or MRI .

III

NON -OPERATIVE MANAGEMENT:

1. Nothing per oral.
2. NG tube.
3. I.V fluid.
4. Antibiotics.
5. F.B.C & s.electroly tes.
6. Reduction .
Hydrostatic reduction.
By using barium enemaunder fluoroscopic monitor but due to risk of perforation and barium peritonitis(85%
fatality rate) for that reasoned recently use water soluble contrast under fluoroscopic guide with successful
rate 85% in uncomplicated case .
Pneumatic reduction.
By using air 80 -120mmHg ,the pneumatic reduction is used under fluoroscopic monitor and successful in 90%
of uncomplicated case s.
It is faster than hydrostatic and safer and decrease the time of radiation exposure
The dis advantage was perforation >pneumo peritoneum .
OPERATIVE MANAGEMENT :
• Indications:
1. Evidence of peritonism or perforation , sepsis or possible gangrenous bowel .
2. Evidence of lead points e.g. filling defect on contrast enema.
3. Delay ed presentation with persistent hypotension

4. Failure of non -operative management.

5. Perforation during non -operative reduction.
RECURRENT INTUSSUSCEPTION:
• The majority within 6 months.
• Usually have no lead points .
• Less with surgical reduction.
POSTOPERATIVE INTUSSUSCEPTION:
• Intussusception occurs after operations done for a variety of conditions e.g. , thoracic or
abdominal.
• Ma y not been diagnosed preoperatively (adhesion).
• Usually within a month .
• Most > ileoileal .