Intussception

INTUSSUSCEPTIONINTUSSUSCEPTION

Dr. K.M. Abul Hasan, MS., M.Ch., F.I.C.S, FIAGES

Hon. Secretary, AMS IMA TNSBSecretary Elect, CGP IMA HqrsPast Secretary, NHB IMA TNSB

City Hospital87, RKV Road, Erode – 638 003Ph: 0424 – 2214000, 2217000

Age 6months to 1 Age 6months to 1 yearyear

Chubby male childChubby male child

6Kg6Kg

Intermittent ColicIntermittent Colic

Redcurrent jelly Redcurrent jelly stoolsstools

Preceeded by Preceeded by diarrhoeadiarrhoea

Mass per Mass per abdomenabdomen

INTUSSUSCEPTIONMake no mistake

INTUSSUSCEPTIONINTUSSUSCEPTIONDEFINITIONDEFINITION

Telescoping of a proximal segment of Telescoping of a proximal segment of the intestine (intussusceptum) into a the intestine (intussusceptum) into a distal segment (intussuscipiens)distal segment (intussuscipiens)

INTUSSUSCEPTIONINTUSSUSCEPTIONANATOMIC LOCATIONSANATOMIC LOCATIONS

ILEOCOLICILEOCOLIC

– MOST COMMON IN CHILDRENMOST COMMON IN CHILDREN

ILEO-ILEOCOLIC ILEO-ILEOCOLIC

– SECOND MOST COMMONSECOND MOST COMMON

ENTEROENTERICENTEROENTERIC

– ILEO-ILEAL, JEJUNO-JEJUNALILEO-ILEAL, JEJUNO-JEJUNAL

– MORE COMMON IN ADULTSMORE COMMON IN ADULTS

– MAY NOT BE SEEN ON BARIUM ENEMAMAY NOT BE SEEN ON BARIUM ENEMA

CAECOCOLIC, COLOCOLICCAECOCOLIC, COLOCOLIC

– MORE COMMON IN AFRICAN CHILDRENMORE COMMON IN AFRICAN CHILDREN

INTUSSUSCEPTION INTUSSUSCEPTION ETIOLOGIESETIOLOGIES

Majority of pediatric intussusceptions idiopathic Majority of pediatric intussusceptions idiopathic (85-90%)(85-90%)

– LYMPHOID HYPERPLASIA POSSIBLE ETIOLOGYLYMPHOID HYPERPLASIA POSSIBLE ETIOLOGY

Mechanical abnormalities may act as “lead Mechanical abnormalities may act as “lead points”points”

– CONGENITAL MALFORMATIONS CONGENITAL MALFORMATIONS (MECKEL’S DIVERTICULUM, DUPLICATIONS)(MECKEL’S DIVERTICULUM, DUPLICATIONS)

– NEOPLASMS (LYMPHOMA, LYMPHOSARCOMA)NEOPLASMS (LYMPHOMA, LYMPHOSARCOMA)

– POLYPOSIS (JUVENILE, FAMILIAL)POLYPOSIS (JUVENILE, FAMILIAL)

– TRAUMA (POST-SURGICAL, HEMATOMA)TRAUMA (POST-SURGICAL, HEMATOMA)

– MISCELLANEOUS (APPENDICITIS, PARASITES)MISCELLANEOUS (APPENDICITIS, PARASITES)

– ILLNESSES (HSP, HUS, CYSTIC FIBROSIS)ILLNESSES (HSP, HUS, CYSTIC FIBROSIS)

INTUSSUSCEPTION INTUSSUSCEPTION HYDROSTATIC REDUCTIONHYDROSTATIC REDUCTION

MethodMethod

– SEDATION VARIABLESEDATION VARIABLE

– DILUTE BARIUM NOT > 100 cm ABOVE PTDILUTE BARIUM NOT > 100 cm ABOVE PT

– AVOID COMPRESSION OF ABDOMENAVOID COMPRESSION OF ABDOMEN

Success Rate (65-85%)Success Rate (65-85%)

– INTUSSUSCEPTUM MOVES BACKWARD INTUSSUSCEPTUM MOVES BACKWARD THROUGH ILEOCECAL VALVETHROUGH ILEOCECAL VALVE

– TERMINAL ILEUM MUST BE FILLEDTERMINAL ILEUM MUST BE FILLED

– PATIENTS SYMPTOMS RESOLVEPATIENTS SYMPTOMS RESOLVE

Complication RateComplication Rate

– PERFORATION IN 1-2%PERFORATION IN 1-2%

– RECURRENCE IN 8-20%RECURRENCE IN 8-20%

INTUSSUSCEPTION INTUSSUSCEPTION NON-OPERATIVE REDUCTION NON-OPERATIVE REDUCTION

CONTRAINDICATIONSCONTRAINDICATIONS Absolute ContraindicationsAbsolute Contraindications

– PERITONEAL SIGNSPERITONEAL SIGNS

– SUSPECTED PERFORATIONSUSPECTED PERFORATION

Relative ContraindicationsRelative Contraindications

– SYMPTOMS > 24-48 HRSSYMPTOMS > 24-48 HRS

– RECTAL BLEEDINGRECTAL BLEEDING

– POOR PROGNOSTIC INDICATORSPOOR PROGNOSTIC INDICATORS

IntussusceptionIntussusception

INTUSSUSCEPTIONINTUSSUSCEPTIONDEFINITIONDEFINITION

Telescoping of a proximal segment of Telescoping of a proximal segment of the intestine (intussusceptum) into a the intestine (intussusceptum) into a distal segment (intussuscipiens)distal segment (intussuscipiens)

INTUSSUSCEPTIONINTUSSUSCEPTIONANATOMIC LOCATIONSANATOMIC LOCATIONS

ILEOCOLICILEOCOLIC– MOST COMMON IN CHILDRENMOST COMMON IN CHILDREN

ILEO-ILEOCOLIC ILEO-ILEOCOLIC – SECOND MOST COMMONSECOND MOST COMMON

ENTEROENTERICENTEROENTERIC– ILEO-ILEAL, JEJUNO-JEJUNALILEO-ILEAL, JEJUNO-JEJUNAL

– MORE COMMON IN ADULTSMORE COMMON IN ADULTS

– MAY NOT BE SEEN ON BARIUM ENEMAMAY NOT BE SEEN ON BARIUM ENEMA

CAECOCOLIC, COLOCOLICCAECOCOLIC, COLOCOLIC– MORE COMMON IN AFRICAN CHILDRENMORE COMMON IN AFRICAN CHILDREN

INTUSSUSCEPTIONINTUSSUSCEPTIONPATHOPHYSIOLOGYPATHOPHYSIOLOGY

Precipitating mechanism unknownPrecipitating mechanism unknown

Obstruction of intussusceptum Obstruction of intussusceptum mesenterymesentery

Venous and lymphatic obstructionVenous and lymphatic obstruction

Third spacing of fluid into bowel wallThird spacing of fluid into bowel wall

Ischemic necrosis occurs in both Ischemic necrosis occurs in both intussusceptum and intussuscipiensintussusceptum and intussuscipiens

Pathologic bacterial translocationPathologic bacterial translocation

INTUSSUSCEPTIONINTUSSUSCEPTION PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Majority occur in the region of the Majority occur in the region of the ileocecal valve (80%)ileocecal valve (80%)

– DISPROPORTIONATE DIAMETERS OF ILEUM AND DISPROPORTIONATE DIAMETERS OF ILEUM AND CECUMCECUM

– ILEOCECAL VALVE PROTUDES INTO CECUMILEOCECAL VALVE PROTUDES INTO CECUM

– LYMPHOID AGGREGATES MORE NUMEROUS IN LYMPHOID AGGREGATES MORE NUMEROUS IN TERMINAL ILEUMTERMINAL ILEUM

– ILEOCECAL REGION ANATOMIC NEURAL TRANSITION ILEOCECAL REGION ANATOMIC NEURAL TRANSITION ZONEZONE

INTUSSUSCEPTION INTUSSUSCEPTION ETIOLOGIESETIOLOGIES

Majority of pediatric intussusceptions Majority of pediatric intussusceptions idiopathic (85-90%)idiopathic (85-90%)

– LYMPHOID HYPERPLASIA POSSIBLE ETIOLOGYLYMPHOID HYPERPLASIA POSSIBLE ETIOLOGY

Mechanical abnormalities may act as “lead Mechanical abnormalities may act as “lead points”points”

– CONGENITAL MALFORMATIONS CONGENITAL MALFORMATIONS (MECKEL’S (MECKEL’S DIVERTICULUM, DUPLICATIONS)DIVERTICULUM, DUPLICATIONS)

– NEOPLASMS (LYMPHOMA, LYMPHOSARCOMA)NEOPLASMS (LYMPHOMA, LYMPHOSARCOMA)

– POLYPOSIS (JUVENILE, FAMILIAL)POLYPOSIS (JUVENILE, FAMILIAL)

– TRAUMA (POST-SURGICAL, HEMATOMA)TRAUMA (POST-SURGICAL, HEMATOMA)

– MISCELLANEOUS (APPENDICITIS, PARASITES)MISCELLANEOUS (APPENDICITIS, PARASITES)

– ILLNESSES (HSP, HUS, CYSTIC FIBROSIS)ILLNESSES (HSP, HUS, CYSTIC FIBROSIS)

INTUSSUSCEPTION INTUSSUSCEPTION EPIDEMIOLOGYEPIDEMIOLOGY

Incidence 2 - 4 / 1000 live birthsIncidence 2 - 4 / 1000 live births

Usual age group 3 months - 3 yearsUsual age group 3 months - 3 years

Greatest incidence 6-12 monthsGreatest incidence 6-12 months

Male predominance (1.5-2 : 1)Male predominance (1.5-2 : 1)

No clear hereditary associationNo clear hereditary association

No seasonal distributionNo seasonal distribution

Frequently preceded by viral Frequently preceded by viral infectioninfection

– URI, ADENOVIRUSURI, ADENOVIRUS

INTUSSUSCEPTIONINTUSSUSCEPTIONCLINICAL CHARACTERISTICSCLINICAL CHARACTERISTICS Early SymptomsEarly Symptoms

– PAROXYSMAL ABDOMINAL PAINPAROXYSMAL ABDOMINAL PAIN

– SEPARATED BY PERIODS OF APATHYSEPARATED BY PERIODS OF APATHY

– POOR FEEDING AND VOMITINGPOOR FEEDING AND VOMITING

Late SymptomsLate Symptoms– WORSENING VOMITING, BECOMING BILIOUS WORSENING VOMITING, BECOMING BILIOUS

– ABDOMINAL DISTENTIONABDOMINAL DISTENTION

– HEME POSITIVE STOOLSHEME POSITIVE STOOLS

– FOLLOWED BY “CURRANT JELLY” STOOLFOLLOWED BY “CURRANT JELLY” STOOL

– DEHYDRATION (PROGRESSIVE)DEHYDRATION (PROGRESSIVE)

Unusual SymptomsUnusual Symptoms– DIARRHEADIARRHEA

INTUSSUSCEPTIONINTUSSUSCEPTION CLINICAL SYMPTOMS BY AGECLINICAL SYMPTOMS BY AGE

INTERMITTENTPAIN (85%)

VOMITING (78%)

BLOOD IN STOOL (36%)

0

23236 5

1515 3636 9


VOMITING (55%)

BLOOD IN STOOL (5%)

0

663 2

7979 8484 8

PATIENTS < 1 YRPATIENTS < 1 YR PATIENTS > 1 YRPATIENTS > 1 YR(n = 94)(n = 94) (n = 182)(n = 182)

INTUSSUSCEPTIONINTUSSUSCEPTION CLINICAL SYMPTOMS BY DURATIONCLINICAL SYMPTOMS BY DURATION


VOMITING (78%)

BLOOD IN STOOL (36%)

0

775 0

4545 5252 5


VOMITING (55%)

BLOOD IN STOOL (5%)

0

22224 7

4949 6868 12

SYMPTOMS SYMPTOMS 0-60-6 HRS HRS SYMPTOMS SYMPTOMS > 6> 6 HRS HRS(n = 114)(n = 114) (n = 162)(n = 162)

INTUSSUSCEPTIONINTUSSUSCEPTION PHYSICAL EVALUATIONPHYSICAL EVALUATION

Moderately to severely illModerately to severely ill

Irritable, limited movementIrritable, limited movement

Most are at least 5-10% dehydrated Most are at least 5-10% dehydrated

80% have palpable abdominal masses80% have palpable abdominal masses

Paucity of bowel soundsPaucity of bowel sounds

Rectal examination (blood, mass)Rectal examination (blood, mass)

Abdominal rigidity, poor perfusionAbdominal rigidity, poor perfusion

““Knocked Out” syndromeKnocked Out” syndrome

INTUSSUSCEPTION INTUSSUSCEPTION RADIOGRAPHIC EVALUATIONRADIOGRAPHIC EVALUATION

Plain radiographs (acute abdominal series)Plain radiographs (acute abdominal series)

Plain films suggestive in majority, but Plain films suggestive in majority, but cannot rule out diagnosiscannot rule out diagnosis

– PAUCITY OF LUMINAL AIR IN RLQPAUCITY OF LUMINAL AIR IN RLQ

– SMALL BOWEL DISTENTION, AIR FLUID LEVELSSMALL BOWEL DISTENTION, AIR FLUID LEVELS

– LUMINAL AIR CUTOFFS (CECUM, TRANSVERSE COLON)LUMINAL AIR CUTOFFS (CECUM, TRANSVERSE COLON)

– SOFT TISSUE MASS IN RUQ OR MIDABDOMENSOFT TISSUE MASS IN RUQ OR MIDABDOMEN

Suggestive clinical symptoms and Suggestive clinical symptoms and compatible or nonspecific plain films should compatible or nonspecific plain films should undergo evaluation with air or barium undergo evaluation with air or barium enemaenema

INTUSSUSCEPTIONINTUSSUSCEPTION TREATMENTTREATMENT

Obstructive surgical emergencyObstructive surgical emergency

Pediatric surgeon notified immediatelyPediatric surgeon notified immediately

Supportive TherapySupportive Therapy– INITIATE IV ACCESSINITIATE IV ACCESS

– AGGRESSIVE FLUID RESUSCITATIONAGGRESSIVE FLUID RESUSCITATION

– CBC, ELECTROLYTES, COAGS+ TYPE & CROSSCBC, ELECTROLYTES, COAGS+ TYPE & CROSS

– NASOGASTRIC TUBE PLACEMENT AND DRAINAGENASOGASTRIC TUBE PLACEMENT AND DRAINAGE

– ANTIBIOTICS IF ISCHEMIC BOWEL SUSPECTEDANTIBIOTICS IF ISCHEMIC BOWEL SUSPECTED

Arrange radiographic evaluationArrange radiographic evaluation

Physician should accompany patientPhysician should accompany patient– FREQUENT MONITORING OF FLUID STATUSFREQUENT MONITORING OF FLUID STATUS

INTUSSUSCEPTIONINTUSSUSCEPTION REDUCTIONREDUCTION

RadiographicRadiographic– HYDROSTATIC HYDROSTATIC

(BARIUM, WATER SOLUBLE CONTRAST)(BARIUM, WATER SOLUBLE CONTRAST)

OperativeOperative– MANUALMANUAL

– RESECTION AND REANASTAMOSISRESECTION AND REANASTAMOSIS

INTUSSUSCEPTIONINTUSSUSCEPTION HYDROSTATIC REDUCTIONHYDROSTATIC REDUCTION

MethodMethod– SEDATION VARIABLESEDATION VARIABLE

– DILUTE BARIUM NOT > 100 cm ABOVE PTDILUTE BARIUM NOT > 100 cm ABOVE PT

– AVOID COMPRESSION OF ABDOMENAVOID COMPRESSION OF ABDOMEN

Success Rate (65-85%)Success Rate (65-85%)– INTUSSUSCEPTUM MOVES BACKWARD THROUGH INTUSSUSCEPTUM MOVES BACKWARD THROUGH

ILEOCECAL VALVEILEOCECAL VALVE

– TERMINAL ILEUM MUST BE FILLEDTERMINAL ILEUM MUST BE FILLED

– PATIENTS SYMPTOMS RESOLVEPATIENTS SYMPTOMS RESOLVE

Complication RateComplication Rate– PERFORATION IN 1-2%PERFORATION IN 1-2%

– RECURRENCE IN 8-20%RECURRENCE IN 8-20%

INTUSSUSCEPTIONINTUSSUSCEPTIONPNEUMATIC REDUCTIONPNEUMATIC REDUCTION

Theoretical AdvantagesTheoretical Advantages– LESS INFLAMMATION IF PERFORATION OCCURSLESS INFLAMMATION IF PERFORATION OCCURS

MethodMethod– TIGHT ANAL SEALTIGHT ANAL SEAL

– AIR INSUFFLATION LIMITED TO MAXIMUM “RESTING “ AIR INSUFFLATION LIMITED TO MAXIMUM “RESTING “ PRESSURE OF 120 mmHgPRESSURE OF 120 mmHg

– MAXIMUM PRESSURE MAINTAINED FOR 3 MINMAXIMUM PRESSURE MAINTAINED FOR 3 MIN

– USUALLY 3 ATTEMPTS AT REDUCTIONUSUALLY 3 ATTEMPTS AT REDUCTION

Success Rate (75-90%)Success Rate (75-90%)– MUST OBSERVE AIR IN THE TERMINAL ILEUMMUST OBSERVE AIR IN THE TERMINAL ILEUM

– LESS RECURRENCES (5-10%)LESS RECURRENCES (5-10%)

– LOW PERFORATION RATE (1%)LOW PERFORATION RATE (1%)

INTUSSUSCEPTION INTUSSUSCEPTION NON-OPERATIVE REDUCTION NON-OPERATIVE REDUCTION

CONTRAINDICATIONSCONTRAINDICATIONS

Absolute ContraindicationsAbsolute Contraindications– PERITONEAL SIGNSPERITONEAL SIGNS

– SUSPECTED PERFORATIONSUSPECTED PERFORATION

Relative ContraindicationsRelative Contraindications– SYMPTOMS > 24-48 HRSSYMPTOMS > 24-48 HRS


– POOR PROGNOSTIC INDICATORSPOOR PROGNOSTIC INDICATORS

INTUSSUSCEPTION INTUSSUSCEPTION FAILURE OF NON-OPERATIVE FAILURE OF NON-OPERATIVE

REDUCTIONREDUCTION

Factors associated with failureFactors associated with failure– SYMPTOMS > 48 HRSSYMPTOMS > 48 HRS


– SMALL BOWEL OBSTRUCTION SMALL BOWEL OBSTRUCTION RADIOGRAPHICALLYRADIOGRAPHICALLY

– ILEOILEOCOLIC OR SMALL BOWEL TYPESILEOILEOCOLIC OR SMALL BOWEL TYPES

– PRESENCE OF MECHANICAL LEAD POINTPRESENCE OF MECHANICAL LEAD POINT

– AGE < 3 MONTHSAGE < 3 MONTHS

Operative ReductionOperative Reduction

INTUSSUSCEPTIONINTUSSUSCEPTION POST-REDUCTION TREATMENTPOST-REDUCTION TREATMENT

Admit patient for 24 hoursAdmit patient for 24 hours

May attempt feeding within 12 hrsMay attempt feeding within 12 hrs

Return to fluoroscopy for suspected Return to fluoroscopy for suspected recurrence (occurs in ~ 4%)recurrence (occurs in ~ 4%)

– CONSIDER PATHOLOGIC LEAD POINTCONSIDER PATHOLOGIC LEAD POINT

– SCHEDULE MECKEL’S SCAN, ? ABDOMINAL CTSCHEDULE MECKEL’S SCAN, ? ABDOMINAL CT

May also recur up to one yearMay also recur up to one year

Need to follow as outpatientNeed to follow as outpatient

11%

4%0% 0%

50%

0%5%

10%15%20%25%30%35%40%45%50%

AGE AT TIME OF DIAGNOSISAGE AT TIME OF DIAGNOSIS

0-12 mo0-12 mo 1-2 yrs1-2 yrs 2-3 yrs2-3 yrs 3-6 yrs3-6 yrs > 6 yrs> 6 yrs(n = 12)(n = 12)(n = 36)(n = 36)(n = 36)(n = 36)(n = 96)(n = 96)(n = 198)(n = 198)

Meckel’s (21)Meckel’s (21)Ileal Polyp (1)Ileal Polyp (1)

Granuloma (1)Granuloma (1)

Lymphosarcoma (6)Lymphosarcoma (6)

INTUSSUSCEPTIONINTUSSUSCEPTIONAGE vs. INTESTINAL LESIONSAGE vs. INTESTINAL LESIONS

Thank YouThank You

Intussception

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