Intussusception

Question 1

Key factors in history and exam

Answer 1

6-12 months

Intermittent pain, becomes more frequent, distress more obvious. Brings knees up. Male gender Abdominal pain Vomiting Lethargy PR blood Hypovolemic shock. Pale with crying

Question 2

Other diagnostic factors

Answer 2

Pallor Palpable abdominal mass Diarrhea Poor feeding Abdominal distention

Question 3

Definition

Answer 3

Telescoping of bowel into lumen of immediately distal bowel

Question 4

Typical location

Answer 4

Ileocecal valve–>ileocolonic

Question 5

Progression pathophysiology

Answer 5

Telescoping pulls mesentery into lumen->obstructing venous outflow->edema->decreased arterial supply->ischemia->necrosis->perforation->death

Question 6

Importance in older children and adults

Answer 6

Always a pathological lead point

Question 7

Pathological lead points

Answer 7

Polyps, malignancy, meckels diverticulum, HSP

Question 8

Incidence in infants

Answer 8

40-50/100 000

Question 9

Aetiology in infants (idiopathic)

Answer 9

Hyperplasia of MALT->becomes traction point

Question 10

Predisposing factors in idiopathic (4)

Answer 10

Well developed lymphoid tissue Thin intestinal wall Narrow intestinal lumen Poor fixation of ileocecal regiona Viral/bacterial infection Recent abdominal surgery

Question 11

Physical examination

Answer 11

Assess hemodynamic stability Abdominal exam- mass/distension Rectal examination unecessary if food history of intusussception, abdominal mass or PR bleeding- otherwise do. Stool->bloody

Question 12

Investigations

Answer 12

Imaging- AXR, U/S Air/barium enema

Question 13

Sign of AXR

Answer 13

Target sign Soft tissue mass lower quadrant Air is dislocated appendix Signs of intestinal obstruction Look for free air

Question 14

When should an US be done

Answer 14

If hemodynamically stable, it is initial diagnostic test

Question 15

Finding on US

Answer 15

Mass - 3-5 cm deep to abdominal wall Target sign Pseudokidney sign Doughnut Can also see pathological lead points

Question 16

Epidemiology

Answer 16

Peak incidence 7mo 70% under 1 year of age Boys

Question 17

Management

Answer 17

ABC- emergency resuscitation. Secure IV access, IVF boluses may be required. Adequate analgesia. Nil oral. NGT. IV antibiotics. Contrast enema if stable Saline enema decompressioin- may now be used Broad-spectrum antibiotics- clindamycin + gentamycin Second line- surgical reduction

Question 18

Absolute contraindications to contrast enema

Answer 18

Peritonitis Perforation Hypovolemic shock

Question 19

Alternative to barium enema when contraindication

Answer 19

Surgical reduction

Question 20

What to do post acute management when recurrent

Answer 20

Consider evaluation for pathological lead point

Question 21

Management post reduction

Answer 21

Admit for 24 hours Monitor for resolution of symptoms Look for complications / recurrence Liquid diet

Question 22

Average stay post surgical reduction and commencement of liquid diet

Answer 22

3-5 days Liquid diet post return of normal bowel function

Question 23

Patient instructions- when to return

Answer 23

Fever, vomiting, abdominal pain, rectal bleed, lethargy Features of recurrence Surgical reduction- look at wound for redness, discharge, fever

Question 24

Vaccination relevance

Answer 24

Rotavirus contraindicated in children with history of intususseption

Question 25

Early complications

Answer 25

Shock, sepsis Bowel perforation Need to repeat surgery General operative/anaesthetic risks Recurrence

Question 26

Late complictions

Answer 26

Adhesions Incisinal hernia

Question 27

Purpose of AXR

Answer 27

To exclude peforation or bowel obstruction