INTUSSUSCEPTION

DR.TUMUSIIME GERALD. the trouble with doctors is not that they dont know enough but that they dont see enough

OUTLINE

Definition Epidemiology Aetiology / predisposing factors Types of intussusception Pathology and pathophysiology Diagnosis (history, physical examination, investigations-baseline and specific) Treatment-supportive and specific. Prognosis.

Definition

Intussusception is the invagination of a portion of bowel into another immediately adjacent to it (usually, proximal into distal and very rarely vise versa). Invagination of the proximal loop of gut into the adjacent distal loop of gut Telescoping of one segment of bowel into another. Intussusception is isoperistaltic and therefore, antegrade and self propelling.

Epidemiology

Exists worldwide. Its a relatively new disease- <300years. Common in Uganda. Less common in Europe Common in males than females- male to female ratio of 3 to 2. Age group affected is 3 months to 2 years. Common in age group of 6 months to 9 months (weaning period)

AETIOLOGY (causes)

Idiopathic or unknown in about 95% of children between sixth and ninth month of life and usually in some part of the last 50cms of small gut. Beyond nine months of age, usually there is an underlying cause. A change in diet (weaning) Aggregation of inflamed Payer's patches (maximum in the lower ileum) Annular pancreas Intra-luminal or para -luminal lesions (polyps, submucous lipoma or Meckels diverticulum) Infestation with Ascaris lumbricoides

Types of Intussusceptions

Ileo-ileal 5 percent Ileo -colic 77 ,, Ileo -ileocolic 12 ,, Colo-colic 2 ,, Multiple 1 ,, Retrograde 0.2 ,, Others 2.8 ,,

Pathology
An intussusception mass consists of three layers: Inner or entering tube Middle or returning tube Outer or the sheath (intussuscipiens) The inner and middle together form the intussusceptum The neck is the junction of the entering layer with the mass. The part which advances is known as Apex

Pathophysiology

The whole mass constitutes the Intussusception which increases as it moves. The majority involve the distal ileum telescoping into the caecum with propagation around the colon to varying levels. The blood supply of the inner layer may easily be impaired if invagination becomes tight and this may lead to gangrene. Intussusception results in intestinal obstruction with the threat of strangulation of involved bowel as its blood supply becomes compromised. An ileocolic intussusception is the most common due to high pressure at the ileocaecal junction.

Diagnosis..

The diagnosis is made clinically from history, observations and physical examination. This can be confirmed by doing relevant investigations.

History

Usually six to nine months old Abdominal pain occurs every 5 to 10 minutes (intestinal colic) during which the child cries and doubles up, followed by a period of disarming quietness. Colicky abdominal pain with drawing up of the legs and fists. Vomiting- usually bilious (vomiting bile. Bloody mucoid stools (red currant jelly stool) May be recent weaning.

General examination

Usually healthy baby screaming in pain with the legs drawn up. Pallor May have signs of dehydration (sunken eyes, sunken anterior fontanelle, dry lips and tongue)

ABDOMINAL EXAMINATION

Normal fullness or scaphoid or flat abdomen (because it is an incomplete obstruction and no gas accumulation) Distension may commence when there is complete bowel obstruction. Visible peristalsis Tender abdomen The intussuscepted bowel can often be palpated as a tubular mass across the upper abdomen when the child relaxes between episodes of intestinal colic. Palpable Sausage-like mass in left or right subcostal margins or around the umbilicus is felt Dances sign (a feeling of emptiness in the right iliac fossa) may be present Increased bowel sounds unless peritonitis has set in

Per rectal examination

Bloody mucoid stool may be visible A visible protruding mass in late stages A conical mass may be felt on digital examination of the rectum if the apex has moved far enough. Bloodstained mucoid stool on the gloved examining finger.

Baseline investigations.

Full haemogram and ESR Blood grouping and crossmatching Serum electrolyte

Specific investigations

Abdominal ultrasound shows a characteristic Doughnut sign and the state of other solid abdominal organs. Erect plain abdominal X-ray to rule out intestinal obstruction (air-fluid levels) and demonstrate any calcifications. Barium enema (claw sign)

Air-fluid levels.

Differential Diagnosis Acute enterocolitis Henochs purpura (characteristic rash) Rectal prolapse Other causes of small bowel obstruction.

Differentials

Treatment

Conservative treatment: Nasogastric tube and gastric aspiration Improve general condition Reduce by hydrostatic pressure Operative treatment: Signs of intestinal obstruction or peritonitis are related to bowel strangulation and mandate operative reduction. Operative reduction is done by milking Resection and anastomosis when gut is irreducible or gangrenous.

Pre operative management

Nasogastric tube for drainage Intravenous line for medicines and fluids Informed consent from parent(s) Ensure warmth to prevent hypothermia.

Intra operative

General anaesthesia with intubation Aseptic conditions are observed. Maintain the warmth Transverse abdominal incision. Adequate exposure ensured. Reduction by milking using a mop soaked in warm saline-do not pull. Resection and anastomosis in case of failed reduction or gangrenous gut. Handle tissues gently. Achieve haemostasis. Count mops and instruments before closure.

Post operative mgt.

Ensure patency of the airway Check wound for active bleeding and institute timely intervention Adequate analgesia Fluid balance Maintain warmth Decision to remove nasogastric tube and introduce oral feeds.

Prognosis depend on:

Complications before
arrival

Expertise of treating team

Aetiology

WORDS OF WISDOM
by Oliver Wendell Holmes (1867)

The most essential part of a students instruction is obtained, not in the lecture room, but at the bedside.

Nothing seen there is lost; the rhythms of disease are learned by frequent repetition; its unforeseen occurrences stamp themselves indelibly on the memory. Before the student is aware of what he has acquired, he has learned the aspects and causes and probably issues of the diseases he has seen with his teacher and the proper mode of dealing with them, so far as his master knows.