Intussusception - Dr Hasan Nugud

Intussusception
Dr Hasan Nugud
Intussusception
Intussuscetion is the most common abdominal
emergency in early childhood and the second
most common cause of intestinal obstruction
Decreasing early recurrence rate of acute
intussusception by the use of dexamethasone,
Premedication with intramuscular
dexamethasone may decrease the rate of early
recurrent intussusception by amelioration of
lymphoid hyperplasia
Intussusception



Definition :In a peculiar variant of normal peristalsis,
one segment of the alimentary canal passes
onwards to be engulfed by the adjacent distal
segment, i.e. the proximal bowel segment
folds, invaginates, prolapses or slips into the
distal adjacent bowel segment.
As a clinical entity this telescoping
phenomenon becomes established and
intestinal obstruction follows.
Intussusception
Intussusception




Pathophysiology :Intussusception most commonly occurs at the
terminal ileum, (i.e. ileocolic).
The telescoping proximal portion of the bowel (i.e
intussusceptum) invaginates into the adjacent distal
bowel (i.e.intussuscepiens), the outer bowel (sleeve).
The mesentery of the intussusceptum is compressed, and the ensuing swelling of the bowel wall
quickly leads to obstruction.
Intussusception
Intussceptum
Mass
Intussuscepiens
Intussusception



Pathophysiology :- (cont….)
Venous engorgement and ischemia of the
intestinal mucosa cause bleeding and outpouring of mucus, which results in the classic
description of red “currant jelly” stool.
Most cases (90%) are idiopathic, with no
identifiable lesion acting as the lead point or
pathological apex of the intussusceptum.
Intussusception



Pathophysiology :- (cont….)
The walls of the two “telescoped” sections
of intestine press on each other due to
increasing swelling, leading to “cut off” of
blood supply to this area and cause damage
to intestines.
Intussusception seems to be seasonal and
occur more often in spring and fall months.
Intussusception
 Incidence



:-
Occurs largely in the first year of life and most
commonly between 5th and 9th month,
Rarely occurs in newborns (about 0.3% of
cases occur in the first month of life),
Boys are affected 3 times more often than
girls, however, with advancing age, gender
difference becomes marked (>3yrs), the male
to female ratio is 8:1.
Intussusception
 Incidence




:- (cont…)
Two thirds of cases (60-65%) occur before
the patients first birthday.
Less common in infants (<3 months), and
older than 3 years.
Recurrence is observed in 3-11% of cases,
Overall incidence is 1-4 per 1000 live births.
Intussusception
 Incidence





:-
75% in kids < 2 years of age,
75% ileocolic,
15% ileo-ileocolic,
90% idiopathic
Regardless of the cause it is the most common
cause of intestinal obstruction in children.
Intussusception
 Why
Infants are the target of
intussusception?

In newborns and infants subsequent change
from breast milk to formula plays a major role.
Weaning may lead to a change in the bowel
flora which in turn may produce oedema of
Payer’s patches (the sub-mucosal plaques of
the mesenteric lymphoid tissue) and may
become the apex of intussusception.
Intussusception
 Other causes of intussusception : Meckel’s diverticulum, inflamed appendix,
 Intestinal polyp or submucosal enterogenic cyst ,
intestinal lymphoma, duplications, neoplasms,
 Ectopic pancreas, Intestinal haemangiomas,
 Henock-Shoeinlein purpura, hemophilia, leukemia,
 Blunt abdominal trauma (Intestinal haematoma) ,
 2nd to 4th day after abdominal operations,
 Ingested foreign body, URTI, cystic fibrosis, teething.
Intussusception
 Increased
incidence is seen in
children :






Who have cystic fibrosis and also dehydrated,
Who have celiac disease (gluten enteropathy),
Who have abdominal or intestinal tumors,
Who have viral gastroenteritis, Otitis media,
Who have an URTI , (including adenovirus ),
Who are taking chemotherapy for cancer,
Who had Rota virus vaccine, (? Link).
Intussusception
 Other


causes :-
Constipation and diarrhoea may play a part,
Occasionally a long indwelling G.I. tube
(jejunal feeding tube) may cause jejuno- /
ileo-ileal intussusception with a confusing
picture of cramps due to intermittent
intestinal obstruction.
Intussusception
It is postulated that swollen Peyers
patches (focal lymphoid hyperplasia)
adjacent to the ileum my stimulate
intestinal peristalsis, thus causing most
intussusceptions,
Several agents associated with enteric
infection may be the aetiology of
mesenteric lymphadenopathy in
intusssusception.
Intussusception
 Clinical




Features :-
Intussusception tends to occur in sturdy, well
nourished infants. It is relatively uncommon to see
in malnourished children,
Awakened from asleep with violent abdominal pain,
with lethargy usually later in the process,
Paroxysms of pain occur 10-20 minutes part, while
completely well between the episodes,
The classic triad of colicky abd.pain, vomiting and
red currant jelly stools occur in only 21% of cases.
Intussusception
Adenoviruses are the most frequently
isolated infectious agents in patients with
intussusception, although enterovirus,
echovirus and human herpes virus 6 also
have been implicated,
Hence, swollen mesenteric lymphnodes,
not only are responsible for idipathic
intussusceptions, but also for their
following ERI.
Intussusception
 Clinical



Features :- (cont…)
Initially loose watery stools are present concurrent with vomiting and within 12-24 hrs,
blood or mucus is passed rectally,
Most patients (75%) without obviously bloody
stools, have stools that test positive for occult
blood, (currant jelly stools in 50% of patients).
Fever is a late finding and suggestive of enteric
sepsis.
Intussusception
 Pain


:-
In 80% of patients, intermittent, extremely
severe, typically colic, lasts 2 t0 3 minutes,
during which the infant screams, draws up his
knees and clenches his fist to release as the
spasm eases,
Spasms occur at intervals of 15-20 minutes.
After an hour or more the infant becomes pale,
exhausted and drowsy between spasms.
Intussusception
 Vomitting



:-
Almost all infants vomit once or twice in the
first hour after the onset, but may not be
repeated once the stomach is emptied,
The vomiting of intestinal obstruction is a late
sign and should never be seen in a case of
intussusception that is been properly handled.
Only 80% of the older children vomit.
Intussusception
 Currant


Jelly Stools :-
It is formed by the diapesis of the red cells
through the mucosa of the intussusceptum to
become mixed with mucus,
This discharge may be more sanguineous and
appear at the anus as small hemorrhage, or it
may remain in the rectum to be discovered
after rectal examination.
Intussusception
 Signs


:-
There is much to learn by observing a spasm
of pain, and palpate the abdomen while
awaiting its arrival,
Usually, the abdomen is soft and non-tender
early, but eventually becomes distended and
tender.
Intussusception



Unfortunately this “test question” presentation
is rarely seen, particularly early in the disease
process making the diagnosis tricky at best.
Between the episodes of pain, the patient may
appear calm and content, and the physical
exam may be entirely normal as well.
It is generally a detailed history that will be the
most helpful.
Intussusception
 Signs



:-
A vertically oriented mass may be palpable in
the right upper quadrant, tubular, cylinderic or
sausage shaped lump in 66% of cases,
It may be palpable anywhere along the line of
the colon,
Prolapse of the head of intussusception
through the anus is observed in 10% of cases.
Intussusception
 Sites



of involvement :-
The commonest site involved is the ileo-caecal
junction ( Bauchin valve ) in 95% of cases,
Few in the small bowel with violent symptoms,
Occasionally may occur in the colon with less
striking symptoms.
 Rectal
examination is mandatory though
the findings are usually negative.
Intussusception
 General



Examination :-
Early : Increased pulse rate,
: Pale,
: Tired infant, lethargic,
Followed by : Dehydration,
Later : Abdominal distension, bloody stools ,
(Diagnosis should be made before they
appear).
Intussusception
 Atypical




Features :-
No obvious colic in 20%,
Vomiting may be absent or may only appear after 6
to 12 hours. Fever is an inconsistent finding,
Rectal blood and mucus are absent in 30% of cases,
Abdominal mass not palpable in some series in up to
33% of cases. This can be explained when the mass
had passed into the hepatic flexure behind the right
costal margin under the right liver lobe.
Intussusception
 Differential




diagnosis :-
Wind colic,
Gastrointeritis,
Intestinal obstruction.
Laboratory studies are nonspecific, and
rarely helpful. They are usually done in the
process of searching for another diagnosis.
Intussusception
 Wind




Colic :-
Common in the first year of life,
Rarely lasts fore more than an hour or so,
Not accompanied by any of the other signs,
Persistent severe colic for more than 1 to 2
hours should arouse suspicion that an
intussusception is present.
Intussusception
 Gastroenteritis


:-
Colic and the passage of blood and mucus in
severe cases of gastroenteritis may well
mimic an intussusception or vice versa,
When any doubt arises in distinguishing
gastroenteritis from an intussusception, early
recourse to a diagnostic abdominal X-Ray,
abdominal USS or even barium enema is
essential.
Intussusception
 Intestinal



Obstruction :-
Intestinal obstruction due to other causes is
not common in infants 6 to 12 months of age,
Vomiting is likely to be more persistent and in
larger volumes,
And dehydration occurs more rapidly.
Intussusception
 Investigations





:-
Plain abdominal X-RAY,
Gasless right lower or upper quadrant,
Soft tissue mass shadow sometimes can be
identified,
Dilated bowel loops,
In the erect film, fluid levels appear late in
intussusception usually > 18 hours.
Intussusception

Obtaining supine, prone, supine horizontalbeam lateral views of the abdomen are useful
to diagnose or exclude intussusception and to
assess the safety of a potential radiographic
reduction. The prone film aids in distinguishing
small from large bowel and also distends the
terminal ileum, cecal pole and ascending colon
with air which is helpful in excluding ileocolic
intussusception, which may be identified as an
intraluminal mass on plain film.
Intussusception
Intussusception
Intussusception
Dilated
small
bowel
loops
Intussusception
 Investigations
:-

Abdominal Ultrasound Scan ;

Specific echogram of concentric circles or a target
shaped sign on transverse scan, and sleeve shaped
on longitudinal scan is seen in all intussusception
cases, (superimposed over the right kidney),
The accuracy rate is fascinating, with sensitivity and
specificity approaching 100%,
As screening tool in patients of low suspicion index.


Intussusception
Target Sign or “donut sign” on transverse us scan
Intussusception
S
O
F
T

T
I
S
S
U
E
M
A
S
S
<--
Intussusception
Soft tissue mass
Corresponding enema

--
Intussusception
The intussusception Head

Barium reduction progress

Intussusception

Progress (at the mobile caecum)
Reduced (post evacuation)
Intussusception
Pseudokidney sign
Target sign
Intussusception

Recurrence, same case

Plain abdominal x-ray
after 48 hrs (same
symptoms)
Vissible head of
intussusception (due to
remaining contrast)


Intussusception

US of Recurrence
Pseudokidney
Donut
Intussusception

Repeat Barium enema
for recurrence
M


plain
Head
Progress
Intussusception

Case 2 :

Typical history of several
hours,
PR “currant jelly” stools,
O/E palpable abdominal
mass at the right upper
quadrant,
Plain abdominal X-Ray
few bowel gases RLQ.



Intussusception
Typical US findings


Sleeve sign
Target sign
Intussusception
Contrast enema
Crescent sign
Intussusception




Contrast enema took about only 2 mniutes with
the contrst rising negotiating the large bowel
and flowing into the small bowel without any
stoppage showing at mid transverese colon,
typical crescent sign.
Following the enema the child was
symptomless.
Was it an intussusception (colico-colic) ?
Did spontaneous reduction happened or was it
an easy quick reduction ?
Intussusception
Intussusception

Meniscus sign:

A crescent shaped area
of gas in the colon
which outlines the apex
of the intussusception.
Intussusception
 Advantages




of USS :
Allows rapid and confident diagnosis or
exclusion by noninvasive test with lack of
ionizing radiation,
Useful in making alternative diagnosis,
Useful in characterizing lead points,
The only disadvantage :- not therapeutic.
Intussusception
 Investigations
:

Barium Enema ; (water soluble contrast)

As a diagnostic and in the same time therapeutic
tool, (reasonable for classic presentations-triad),
(gold standard),
Obstruction of the contrast at the site of
intussusception,
A cup shaped filling defect at the site of obstruction,
Coiled spring appearance.



Intussusception


A bag of barium is hung three feet above the
table top with a single column of barium
flowing by gravity into the rectum and colon.
The method advocated is the rule of 3s :
- 3 attempts
- 3 minutes in duration for each attempt,
- 3 foot barium column above the table top
( approximately 1m).
Intussusception


Barium enema reduction is the treatment of
choice in all cases unless contraindicated,
It appears that failure to diagnose
intussusception in the first 24 hours will
decrease the successful rate of hydrostatic
reduction and increase the need for surgical
intervention and the period of hospitalization.
Intussusception

Preparation for contrast enema :-

Admission is indicated for all patients,
Patient must be fully resuscitated with i.v. line in situ
and naso-gastric tube inserted and kept open,
Antibiotics, sedation (of questionable value), but
consider antispasmodics (analgesia) as an alternative,
Informed and written consent must be obtained from
the parents or guardian,
Enema should be preceded by USS performed by
experienced ultra-sonogaphist,




Intussusception

Preparation for contrast enema:

Blood cross-matched,
Operating theatre should be called and informed and
operation scheduled in case,
Procedure should be done by an experienced
radiologist attended by well qualified paediatric surgeon
with paediatric resuscitation availability,
Parents can attend (mother not pregnant),
Anti-radiation protection for all attendants.




Intussusception





Hydrostatic Reduction :Large bore tube or Foley catheter (> 18 F ) to
be put in ano and buttocks and legs strapped,
Barium container should be at one meter (1m)
above the table top,
Fluoroscope intermittently,
Cautious reduction should be undertaken
(maximum three attempts).
Intussusception
Hydrostatic Reduction : Three attempts should be tried if ;
 1- good general patients condition,
 2- if no blood flow is seen at the intussusception
site on good quality doppler evaluation,
 3- if ultrasound reveals trapped intraluminal fluid
in the intussusception mass,
 4- Progress in reduction .

Intussusception




Hydrostatic Reduction :
Typical meniscus cup-shaped at the apex of
the intussusception followed by coiled spring
sign, as reduction progresses,
Continue enema for 3 attempts of 3 minutes
each (generally sufficient and safe),
Success defined as reflux of barium “flooding”
into the distal ileum.
Intussusception




Hydrostatic Reduction :Total fluoroscopy times should be around 3 to
15 minutes or less,
Over 90% of successful reductions are
performed with screening time of <10
minutes,,
Prolonged screening should be avoided.
Intussusception



Hydrostatic Reduction :Lead points can be difficult to diagnose with
fluoroscopy, but USS is more sensitive,
Despite identifying a lead point on USS, at
least partial reduction of the intussusception
may facilitate subsequent surgery in these
cases (less handling of bowel at surgery,
smaller abd. Incision and scar may result)
Intussusception






Hydrostatic reduction :Response of a child- immediate fall asleep
after successful reduction,
If no progress in reduction (stationary), failed,
Peritonitis , shock,
Perforation, lead points,
Then surgery is required.
Intussusception
 Hydrostatic




Reduction :-
If manual pressure is avoided during
reduction (fluoroscopy),
If the barium cannister is not > 1m above the
x-ray table gangrenous bowel will not be
reduced and or perforated,
Success rate is > 70%
The method is not a substitute for operation
or an escape from operation.
Intussusception



Pneumatic Reduction :Initial attempt should be at a pressure of (60- 80
mmHg and a maximum pressure of 120 mmHg
is recommended, and should be monitored ( a
pressure monitoring devise is highly desirable),
or pressure release valve with a cut-off at 120
mmHg as an alternative ,
3 attempts x 3 minutes are sufficient and safe.
Intussusception



Pneumatic Reduction :The catheter used balloon or other (>18 F),
Successful reduction is defined as free flow
of air into the distal ileum, if no retrograde
flow from caecum, in a combined maximum
of 15 minutes attempt, the patient may be
observed and management decisions
delayed dependent on the child’s condition.
Intussusception

Pneumatic Reduction :-

In the event of bowel perforation, a large pneumoperitoneum can be relieved by quick abdominal
needle puncture,
Pneumatic reduction is generally considered the
optimal technique, but a well performed hydrostatic
reduction is a satisfactory and safe alternative,
Use Shiels Intussusception air reduction system
with junior flexi enema tip and pressure relief valve.


Intussusception
Air contrast enema
 (head)


Plain film (empty RU & LQ’s)
(cup-shaped apex)
Intussusception
air contrast reduction

Before
After
Intussusception
Complications : Intestinal haemorrhage,
 Necrosis and bowel perforation,
 Peritonitis, shock and sepsis,
 Recurrence,
 Prognosis is excellent if diagnosed and
treated early, otherwise, severe complications
and death may occur.

Intussusception






The indications for operative reduction :Moderate to marked abdominal distension,
Multiple fluid levels on plain abd. X-Ray,
Shock and collapse,
Failure of hydrostatic reduction,
Or doubtful viability of bowel after reduction
Intussusception



Surgery :At the level of the umbilicus , right transverse
abdominal incision, locate the
intussusception and push the “telescoped”
intestines to deliver. ( do not pull to tear the
fragile bowel),
If any of the affected intestines is damaged
and viability is doubtful resection and primary
end to end anastamosis is performed.
Intussusception
(
Intussusception

Medical / Legal Pitfalls :-

Failure to consider a mechanical lead point,
Failure to consider the diagnosis in any infant
with altered mental status,
Over-reliance on the typical age or typical
presentation with currant jelly stool.


Intussusception


A case of 5 days old infant with ileo-cecotransverse colic intussusception (11/03/03) :
After birth discharged home and was normally
breast fed. On the third day of age was
readmitted to the same hospital with history of
vomiting. Was put on I.V. fluids and observed.
Next day had abdominal distension and blood
per rectum. Abdominal x-ray and US were
done and intussusception was suspected. On
the 5th day of age referred to us.
Intussusception





Admitted,
Plain abdominal x-ray showed soft tissue mass,
Abdominal US showed typical donut and target
signs,
Contrast enema confirmed the diagnosis but was
not successful to reduce the intussusception,
Operative reduction was done. Caecum opened
to look for any pathology which was not found.
Biopsy taken found to be only haemorrhagic
mucosal changes at the Bauchin valve area.
Intussusception

Plain abdominal x-ray
showing soft tissue
mass at the right
subhepatic region
where exactly the haed
of the intussusception
was located.
Intussusception
USS
Donut sign by Doppler
Both intussuscepiens and
Intussusceptum seen
Intussusception
I
III
II
Unsuccessful trial
of contrast reduction
of intussusception
in a 5 days old
neonate.
IV
Intussusception
Operative reduction of intussusception and findings.
Intussusception






Advantages and disadvantages of barium
enema therapy :Advantages ;
Maximum experience with this method,
Good results with optimized method (55-90%),
Good evaluation of ileoeleal residual
intussusceptions,
Low perforation rate (0.39-0.7%)
Intussusception





Advantages and disadvantages of barium
enema therapy :Disadvantages ;
X-ray exposure required, thus limiting
procedure time,
Perforation causes chemical peritonitis,
Visualization of only intra-luminal contents.
Intussusception



Air Enema Therapy :While there is agreement that hydrostatic
reduction (HR) is the ideal first treatment for
childhood intussusception, there is controversy
about which technique is best, namely, barium,
air, or saline,
Air enema is a safe, rapid, efficient, clean
diagnostic and therapeutic procedure and if
guided by US is practical and reliable and can
achieve a high reduction rate comparable to
that of barium enema.
Intussusception




Air Enema Therapy :Prior to the procedure all patients can be sedated with
meperidine hydrochloride (0.5 mg/kg) or morphine (0.1
mg/kg),
In the case of failure of first attempt, two additional trials
at an interval of 45-60 min. can successfully reduce
more cases,
Persistence at air reduction must be successful and the
success rate increases with delayed attempts but the
risk of increasing radiation must be weighed against the
risks of emergency surgery and anaesthesia.
Intussusception





Advantages and disadvantages of air
enema therapy :Advantages ;
Excellent results (70-95.6%) of cases,
Less X-ray exposure than with barium
enema,
Easy, quick, clean technique
Intussusception






Advantages and disadvantages of air enema
therapy :Disadvantages ;
X-ray exposure required, thus limiting procedure
time,
Higher perforation rate (0.14-2.8%) with risk of
tension pneumo-peritoneum,
Visualization of only intra-luminal content,
Less control of residual ileoileal intussusceptions
Intussusception




US-guided Normal Saline, or Hartman’s Hydrostatic
Enema Reduction or Therapy :With this technique there is no risk of radiation to the
patient nor to the staff,
Clear echogram is shown during reduction and the
ileo-ileo colic intussusception can be diagnosed,
This technique is believed to be one of the most
promising methods in non-operative treatment of
paediatric intussusception and preferred because it is
safe accurate and hihger success rate.
Intussusception




US-guided Normal Saline, or Hartman’s
Hydrostatic Enema Reduction or Therapy :100% accuracy of diagnosing complete
reduction,
No complication reported,
Additional, delayed attempt after 30 minutes of
rest in those cases in which only partial
reduction had been achieved, increases the
rate of reductions,
Intussusception




US-guided Normal Saline, or Hartman’s
Hydrostatic Enema Reduction or Therapy :The height of the normal saline container 3
feet above the US examining table,
Examination time unlimited,
Patients in shock, patients with peritonitis and
with gross abdominal distension as well as
those with recurrent intussusception are
excluded from usage of this technique.
Intussusception
Before and after manual reduction
Intussusception
Intussusception





Advantages and disadvantages of USguided Saline Enema Therapy :Advantages ;
No X-ray exposure, thus procedure time not
limited,
Excellent results (76-95.5%) of cases,
Visualization of all components of the
intussusception,
Intussusception

Advantages and disadvantages of USguided Saline Enema Therapy :-

Advantages ; (continue---)
Easier recognition of lead points and residual
intussusception,
Low perforation rate (0.26%).
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
Intussusception

Advantages and disadvantages of USguided Saline Enema Therapy :-

Disadvantages ;

Sonographer or sonologist needed.
Intussusception
The recurrence rate of nonsurgical
reduction is reported to be approximately 5
to 10%,
Almost 50% of the instances of recurrent
intussusception occurred within the first
week of life, and is define as early
recurrent intussuscetion (ERI)
Intussusception
Corticosteroides would reduce the swelling
and oedema of the inflammatory
mesenteric lymphnodes, resulting in a
diminishing of the triggering factor
(lymphoid hyperplasia) of ERI and thus
would decrease the total recurrence rate of
intussusception