Intussuception Flashcards
What is intussusception?
A condition where the proximal bowel invaginates or telescopes into the distal bowel.
At what age is intussusception most commonly seen?
Between 3 months and 3 years, with a peak incidence at 3 to 9 months.
What percentage of intussusception cases occur in children under 2 years of age?
Approximately 85%.
What is intussusception?
The invagination of one part of the bowel into another.
What is the term for the invaginated part of the bowel in intussusception?
Intussusceptum
What is the term for the receiving part of the bowel in intussusception?
Intussuscepiens
What is the most common cause of intussusception?
Idiopathic causes, which are usually related to viral infections or gastroenteritis.
When does intussusception most commonly occur in relation to respiratory infections or gastroenteritis?
About 10 days after the infection
What is the role of the transition from breast to bottle feeding in intussusception?
It may play a role in triggering intussusception.
Is there any seasonal variation in the incidence of intussusception?
Yes, it is higher in the spring and summer, often referred to as the “gastro-season.”
What happens to Peyer’s patches during a viral infection, and how is this related to intussusception?
Peyer’s patches in the terminal ileum enlarge during a viral infection and are dragged along by peristalsis, leading to ileocolic intussusception.
Is intussusception associated with rotavirus vaccination?
Yes, but only with some preparations, not the strain used in South Africa.
What are lead points in intussusception, and what are some examples?
Lead points are structural abnormalities that cause intussusception. Examples include Meckel’s diverticulum, enlarged lymph nodes (including lymphoma), or polyps.
When is lead point-associated intussusception most commonly seen?
In older children, and it is much less common than idiopathic cases.
What is the typical presentation of postoperative intussusception?
It usually occurs 2-5 days after surgery, is generally painless, and presents with signs of bowel obstruction.
What type of intussusception is most commonly seen after retroperitoneal surgery?
Small bowel intussusception, such as ileo-ileal intussusception.
What happens when one part of the bowel telescopes into another in intussusception?
Obstruction of venous and lymphatic return, leading to edema and increased intra-luminal pressure.
What effect does the telescoping bowel have on the proximal bowel?
It leads to dilation of the proximal bowel due to intestinal obstruction.
What is the cause of the blood-mucoid stool in intussusception?
The mucosa on the intussuscepted bowel produces mucus and bleeds due to capillary rupture, resulting in the classic “redcurrant jelly” stool.
What is the most common type of intussusception?
Ileocolic intussusception.
Can intussusception occur in other parts of the bowel?
Yes, it can also be colo-colic or ileo-ileal.
What happens during intussusception in terms of fluid loss?
There is massive third-space fluid loss.
What complications can arise from the increasing pressure and ischemia caused by intussusception?
Strangulation, bowel infarction, and eventual necrosis.
What is a common misdiagnosis for patients with intussusception?
They are often misdiagnosed as having gastroenteritis or dysentery.
What are the initial symptoms of intussusception?
Symptoms often progress from an upper respiratory tract infection (URTI) or gastroenteritis to signs of bowel obstruction and peritonism due to necrotic bowel.
What is the classic feature of abdominal pain in a child with intussusception?
Sudden onset of colicky abdominal pain that is severe enough to wake the child and is associated with pulling the legs up to the abdomen during pain.
How does the colicky pain in intussusception present?
The pain is intermittent, may go away and return every half hour, and lasts about 20-30 seconds. The child lies still between attacks.
What changes occur in vomiting as intussusception progresses?
Vomiting may start with milk feeds, then become bilious, and eventually faeculent.
What is the classic stool appearance in intussusception?
Passage of blood and mucus per rectum, referred to as “redcurrant jelly” stools.
What is a common physical finding in a child with intussusception?
Progressive abdominal distension.
How is the general condition of a child with intussusception between painful episodes?
The child appears apathetic and looks ill between painful episodes.
What is the typical response of a child during an intussusception pain episode?
The child cries severely and pulls their legs up to the abdomen during painful attacks.
What signs of dehydration or shock may be present in intussusception?
The child may be dehydrated and may show signs of shock.
What is a common physical finding on abdominal examination in intussusception?
A palpable mass in the right abdomen, typically shaped like a sausage or cylinder. The mass is usually non-tender unless ischaemia is present.
What may be found on rectal examination in a child with intussusception?
Bloody stool may be identified, and a mass may be palpated in the rectum.
Can the intussusceptum prolapse out of the rectum?
Yes, in some cases, the intussusceptum may prolapse out of the rectum.
What other signs may be present in advanced cases of intussusception?
Signs of intestinal obstruction and peritonism may be present in advanced cases.
Is abdominal x-ray necessary for diagnosing intussusception?
Abdominal x-ray is not always necessary and is not diagnostic, but it is suggestive.
What are the signs of intestinal obstruction on an abdominal x-ray?
Tubular dilated loops of bowel, a gasless rectum, and air-fluid levels at different levels.
Can a mass be seen on an abdominal x-ray in intussusception?
Yes, a mass may be seen on the x-ray.
When might an abdominal x-ray be normal in intussusception?
It may be normal early in the presentation of intussusception.
What is the diagnostic investigation for intussusception?
Abdominal ultrasound is the diagnostic investigation.
What is the sensitivity of abdominal ultrasound for diagnosing intussusception?
Abdominal ultrasound has approximately 99% sensitivity for diagnosing intussusception.
What are the key ultrasound signs of intussusception?
A “target” lesion on transverse view or a “pseudo kidney” on longitudinal view.
What does the transverse view of intussusception show on ultrasound?
The transverse view shows a “swiss roll” appearance.
What does the longitudinal view of intussusception show on ultrasound?
The longitudinal view shows a “kidney bean” appearance.
What is the initial management approach for intussusception?
The initial management involves resuscitation and stabilization of the patient, including intravenous fluids, NGT drainage, intravenous antibiotics, and analgesia.
When is non-operative reduction attempted in intussusception?
Non-operative reduction is attempted once the child is stable and if there are no signs of perforation.
What is the success rate of non-operative reduction of intussusception?
Non-operative reduction is more than 80-90% successful worldwide and is preferred in early presentations.
What are the two methods for non-operative reduction of intussusception?
• Pneumatic (air enema) reduction under fluoroscopic guidance
• Hydrostatic (saline enema) reduction under ultrasound guidance
How does the column of air appear during air reduction of intussusception?
The column of air (dark) extends from the rectum to the transverse colon, with the reducing intussusceptum appearing as a rounded mass being displaced by the advancing air column.
What are the absolute contraindications to air reduction of intussusception?
Absolute contraindications include:
• Pure small bowel intussusception
• Shock or an incompletely resuscitated patient
• Signs of peritonitis or dead bowel (septicaemia or perforation, pneumoperitoneum on AXR or fluoroscopic scout film).
What are the relative contraindications to air reduction of intussusception?
Relative contraindications include:
• Long-standing history of a few days
• Grossly dilated or thickened loops of bowel on AXR
• Impaired blood flow on Doppler sonar.
What is required for a child during attempted air reduction of intussusception?
The child may be sedated and requires full vital sign monitoring
Who is present during the air reduction procedure?
Both the surgeon and radiologist are present during the procedure.
How is air introduced during the air reduction of intussusception?
Air is pumped into the rectum through a tube while monitoring the pressure used and observing the movement of the bowel fluoroscopically.
What indicates a successful air reduction of intussusception?
Air flow into the ileum is a sign of successful reduction.
What are the complications of air reduction in intussusception?
• Unsuccessful reduction in 20-50% of cases
• Perforation requiring urgent decompression of pneumoperitoneum with a needle followed by open surgery
• Repeat attempt after 2 to 4 hours may be made if no signs of perforation
• Recurrence after hydrostatic reduction: 5%, compared to 2% after surgical reduction
What are the indications for operative reduction of intussusception?
• Unsuccessful non-operative reduction
• Peritonitis
• Proven lead point intussusception
• Intussusception in a child above age 2
• Small bowel intussusception
What is the common surgical approach for operative reduction of intussusception?
The approach is usually via a right upper transverse laparotomy.
Can laparoscopy be used for operative reduction of intussusception?
Yes, laparoscopy may be utilized in selected cases without longstanding obstruction.
How is the intussusception reduced during surgery?
The intussusception is reduced manually. If reduction is not possible or necrotic bowel/perforation is present, the involved bowel is resected.
What should be done if a lead point is found during surgery for intussusception?
The lead point (e.g., lymphomatous lymph node, Meckel’s diverticulum) should be resected and sent for histology.
What is included in the post-operative care for intussusception?
• Intravenous fluids & analgesia
• Restart oral feeds once post-operative ileus has resolved
What is the risk of recurrence of intussusception after surgery?
About 2% risk of recurrence, usually during the first 10 days post-reduction.
How does the recurrence rate of intussusception after pneumatic reduction compare to surgery?
Recurrence rate is about 5% after pneumatic reduction.
What is the mortality rate for intussusception in the developing world?
The mortality rate is approximately 10% or more, often due to late presentation.
