INTUSSUSCEPTIONIN CHILDREN

ARIF KHAN4TH GROUP5TH COURSE

INTUSSUSCEPTION• Intussusception (in-tuh-suh-SEP-shun) is the most common

abdominal emergency affecting children under 2 years old. It happens when one portion of the bowel slides into the next, much like the pieces of a telescope.

• When this "telescoping" happens, the flow of fluids and food through the bowel can become blocked, the intestine can swell and bleed, and the blood supply to the affected part of the intestine can get cut off. Eventually, this can cause part of the bowel to die.

• Intussusception happens in 1 to 4 out of every 1,000 infants and is most common in babies 5 to 9 months old, though older children also can have it. Boys get intussusception more often than girls.

Epidemiology

• The male-to-female ratio is approximately 3:2.• Two thirds of patients are under one year old,

the peak age being between 5-10 months.• Intussusception is the most common cause of

intestinal obstruction in patients aged 5 months-3 years and accounts for up to 25% of abdominal emergencies in children up to age 5.

• It is rare preterm.• One large Swiss study found an overall incidence

of 38, 31 and 26 cases per 100,000 live births in the first, second and third year of life respectively.

Presentation

• It is usually of sudden onset, and may be more insidious in the older child.• There are paroxysms (about every 10-20 minutes) of colicky

abdominal pain (>80%) ± crying.• The child may appear well between paroxysms initially.• There is early vomiting - rapidly becoming bile-stained.• Neurological symptoms such as lethargy, hypotonia or sudden alterations

of consciousness can occur.[4]

• There may be a palpable 'sausage-shaped' mass (often in the right upper quadrant).

• There may be absence of bowel in the right lower quadrant (Dance's sign).• Dehydration, pallor, shock.• Irritability, sweating.• Later, mucoid and bloody 'redcurrant stools'.• Late pyrexia

Causes and associated conditions

• Non-pathological lead point (>90%)

• Viral 50% - rotavirus, adenovirus and human herpesvirus 6 (HHV6).

• Amoebomata, shigella, yersinia.

• Peyer's patch hypertrophy.

• Pathological lead point (<10%)• NB: older patients (may have longer history):• Meckel's diverticulum (75%).• Polyps and Peutz-Jeghers syndrome (16%).• Henoch-Schönlein purpura (3%).• Lymphoma and other tumours (3%).• Reduplication - a process by which the bowel

wall is duplicated (2%).• Cystic fibrosis.• An inflamed appendix.• Nephrotic syndrome.• Foreign body.• Postoperative - rarely, postoperative

intussusception following operative treatment of an intussusception has been reported.

• Hyperperistalsis.• Exclusive breast-feeding.• Weight above average.• Rotavirus vaccine.• Abdominal tuberculosis.

Investigations

• FBC - may show neutrophilia.• U&Es - may reflect dehydration.• Abdominal X-ray - may show dilated gas-filled proximal bowel,

paucity of gas distally, multiple fluid levels (but may be normal in the early stages).

• Ultrasound - may show doughnut or target sign, pseudokidney/sandwich appearance.[6] It is a very effective modality and many consider it the investigation of choice.[7]

• Bowel enema - barium has been gold standard (crescent sign, filling defect) but air and water-soluble double-contrast now available; each has pros and cons - the choice is left to the individual radiologist.[1]

• CT/MRI scanning - more often used in adults than in children.

Management

• The child will first be stabilized. A tube will be passed into the stomach through the nose (nasogastric tube). An intravenous (IV) line will be placed in the arm, and fluids will be given to prevent dehydration.

• Antibiotics may be needed to treat any infection.• Radiological:

– Reduction (three tries for three minutes each) if there is no sign of peritonitis, perforation or shock.

– Air enema <120 mm Hg of pressure or barium enema.– The choice of enema is usually left to the radiologist (many now favour air enema).[7]

[9]

• Laparotomy (reduction/resection) - indications:– Peritonitis– Perforation– Prolonged history (>24 hours)– High likelihood of pathological lead point– Failed enema

• Hospital admission is usually required but outpatient management may on occasions be an acceptable alternative.

Prognosis

• With treatment, prognosis is excellent.• Post-reduction recurrence:– Radiological: 5%– Surgical: 1-4%

• Mortality:– 1% with treatment– Fatal if untreated

• When a hole or tear in the bowel occurs, it must be treated promptly. If not treated, intussusception is almost always fatal for infants and young children.