INTUSSUSCEPTION Read by : Krisna (KNA)

INTRODUCTION
The word intussusception is derived
from the Latin words,
 intus (within) and suscipere (to
receive).
Intussusception is the invagination of
one part of the intestine into another

Inner and middle intestinal wall

(invaginated bowel) :
intussusceptum
Outer intestinal wall (recipient) :
intussuscipiens
INTRODUCTION
Intussusception is one of the most frequent
causes of acute bowel obstruction in infants
and toddlers
INCIDENCE
 Intussusception occurs throughout the world with an incidence of
approximately 1 to 4 in 2000 infants and children. Most series report more
males than females with intussusception
 75% of cases occur within the first 2 years of life and 90% in children within
3 years of age. More than 40% are seen between 3 and 9 months of age
 In utero, intussusception may lead to intestinal atresia, most commonly ileal
atresia
 The frequency of intussusception displays a seasonal variation that usually
correlates with viral infections (respiratory, gastrointestinal, or both) – 20%
PATHOPHYSIOLOGY
The proximal invaginated bowel (intussusceptum) carries its mesentery into
the distal recipient bowel (intussuscipiens)
The mesenteric vessels are angulated, squeezed, and compressed
between the layers of the intussusceptum
Local edema of the intussusceptum
Venous compression, congestion, and stasis leading to an outpouring of
mucus and blood (the classic red currant jelly stool)
Ischemic changes leading to bowel necrosis in the intussusceptum (72 hours
to develop)
If the ischemic process goes undiagnosed, bowel obstruction, perforation,
or sepsis leads to death within 5 days
(In rare cases, the intussusceptum can become gangrenous, and slough and
the bowel may fuse)
 • General :
• Permanent : they are mostly symptomatic

PATHOGENESIS
(85%), and all require treatment
• Transient : <2 cm can spontaneously reduce

• Specific :
• Idiopathic (non-PLP) : thickened bowel wall
lymphoid tissue (Peyer patches) in distal ileum
(respiratory and gastrointestinal viral infection-
Adenovirus/rotavirus) - the majority of all
cases (95%)
• PLP : Meckel diverticulum, intestinal polyps,
other less common (periappendicitis,
appendiceal stump, inversion appendectomy,
appendiceal mucocele, local suture line,
massive local lymphoid hyperplasia, ectopic
pancreas, abdominal trauma, benign and
malignant tumor)
• Postoperative : manifests as a small bowel
obstruction – after prolonged laparotomy with
significant bowel handling
• Anatomic :
• The most common type is ileocolic (85%)
• Other :
• Recurrent : barium enema reduction (5,2-
20%), manual operative reduction (3-4%),
operative resection and anastomosis (0%)
CLINICAL FINDINGS
DIAGNOSIS
 LABORATORY STUDIES
No specific laboratory studies aid in the diagnosis of intussusception. As the
intussuscepted bowel becomes ischemic, associated leucocytosis, acidosis, and electrolyte
abnormalities worsen
 RADIOLOGIC
The correct diagnosis of intussusception can only be made clinically about 50% of the
time. The diagnostic evaluation relies on radiologic imaging to either confirm or make the
correct diagnosis
1. Plain radiograph of the abdomen
2. Ultrasonography
3. CT scan and MRI
4. Contrast enema
PLAIN RADIOGRAPH OF THE ABDOMEN ULTRASONOGRAPHY
TREATMENT
1. Nonoperative management
2. Radiologic reduction
3. Operative management
1. NONOPERATIVE MANAGEMENT
Medical : steroid (stable patient) – before, along with, and/or after radiologic
reduction attempts
(If steroid treatment is initiated with the intussusception still unreduced, the patient must be observed closely)
2. RADIOLOGIC REDUCTION

 Contraindication :
• Dehydration
• Shock (unstable patient)
• Peritonitis, or radiographic evidence
of perforation with free air –
(immediate operative management)
3. OPERATIVE MANAGEMENT
(LAPAROSCOPY/LAPAROTOMY)
COMPLICATION

 Radiologic : bowel perforation is the major complication

during enema reduction – risk factors for perforation are
infants younger than 6 months and a longer duration of
symptoms (>36 hours)
 Surgical : wound infection, fascial dehiscence, and SBO
(small bowel obstruction)
 Recurrence : can occur in up to 20% (average 5%)
 The recurrence rate for nonoperative reduction is reported to be up to 20%
 The recurrence rate following operative reduction is 1% to 3%
 A recent structured literature review and meta-analysis found an overall
recurrence rate of 12.7%
 A large survey found that almost 50% of the instances of recurrent
intussusception (RI) occurred within the first week of nonoperative reduction

The aim of this current study was to explore the risk

factors associated with recurrence of intussusception
after operative or nonoperative reduction in children
METHODS
 Retrospective cohort study - Between January 2004 and December 2012,
patients with intussusception treated with nonoperative and operative
reduction were retrospectively analyzed inWest China Hospital of Sichuan
University
 Recurrence of intussusception (RI) was defined as intussusception that
recurred after the first successful reduction with operative or nonoperative
reduction. The time of follow-up was five years. We included The patients who
were diagnosed with intussusception from the age of 0 year to 18 years who
received nonoperative and operative reduction as an initial treatment
METHODS
 The diagnosis of intussusception was determined by ultrasound
 Pneumatic reduction under fluoroscopy and hydrostatic reduction under ultrasound
 The success of reduction was determined by the disappearance of intussusception
and the visualization of the normal saline or air from the cecum to the ileum through
the ileocecal valve
 Operative procedures will be performed when nonoperative treatment is
contraindicated or has failed
 The data collected included demographic data, symptoms, signs, investigations
(ultrasound findings) and method of reduction
 The patients were divided into two groups: the recurrence group and the
nonrecurrence group
RESULTS
DISCUSSION
 This study was set to identify the risk factors that lead to recurrence of
intussusception
 Identification of risk factors for recurrence of intussusception in pediatric patients is
important to decrease delays and improve salvage of the intussuscepted bowel
 Some of the reviewed literature mentioned about the patient's age as a risk factor
for recurrence of intussusception :
• Niramis et al  68% (younger than 1 year)
• Wang Z et al  older than 1 year
• Kim et al  2 years or older

•We found that age ≥ 2 years was one of the risk factors for recurrence of idiopathic
intussusception in pediatric patients
DISCUSSION
 Reijnen et al  duration of symptoms > 48 h was a significant
predictor of failure of hydrostatic reduction
 Simon et al  suggested that delay in presentation to the
hospital may be because of the parents but mostly from the
peripheral hospitals
 Rectal bleeding and abdominal mass are the two classic signs
of intussusception
CONCLUSION

Our study found that age ≥ 2 years, duration of

symptoms≥48 h, rectal bleeding, location of mass (left
over right side) and pathological lead point were risk
factors for recurrence of intussusception