Intussusception in pediatrics as a type of intestinal obstruction in childhood and neonatal period with its pathophysiology and management plan

1. Intussusception
In Pediatrics
A surgical emergency

2. By
Amr Abdellatif
Pediatric Surgery Registrar
Supervised by
Dr . Ahmed Al-Elewi
Pediatric Surgery Consultant

3. o Intussusception is the most frequent cause of bowel obstruction in infants
and toddlers.
It was first described in 1674 by Paul Barbette of
Amsterdam, defined by Treves in 1899, and operated on
successfully in 1873 by John Hutchinson(1)
o Defined as an acquired invagination of the proximal bowel (intussusceptum)
into the distal bowel (intussuscipiens)
(1). Hutchinson J. A successful case of abdominal section for intussusception. Proc R Med Chir Soc. 1873;7:195–198.

4. o Idiopathic intussusception can occur at any age.
o Two-thirds are boys.
o The highest incidence occurs in infants between ages
4 and 9 months and it is the most common cause of
small bowel obstruction in this age group.
o Intussusception is uncommon below 3 months and
after 3 years of age.
o The condition has been described in premature
infants and has been postulated as the cause of small
bowel atresia in some cases.
o Most affected patients are well-nourished, healthy
infants.
Incidence

5. Pathophysiology
o The intussusceptum telescopes into the
distal bowel ( intussuscepiens ) by peristaltic
activity.
o There may or may not be a lead point.
o The mesentery is compressed, resulting in
venous obstruction and bowel wall edema.
o Arterial insufficiency will ultimately lead
to ischemia and bowel wall necrosis.
o Although spontaneous reduction can occur,
the natural history of an intussusception is to
progress to bowel ischemia and necrosis.

6. Types of intussusception
PRIMARY INTUSSUSCEPTION SECONDARY INTUSSUSCEPTION
No lead points There is a lead point

7. PRIMARY INTUSSUSCEPTION ( idiopathic )
o A majority of cases, especially in infants.
o do not have a lead point.
o The cause is usually due to hypertrophied Peyer’s
patches within the bowel wall.
o Intussusception occurs frequently in the wake of an
upper respiratory tract infection or an episode of
gastroenteritis.
o Adenoviruses and to a lesser extent rotaviruses, have
been historically implicated in up to 50% of cases.

8. o There is an identifiable lesion that serves as a lead
point.
o The incidence of a lead point varies from 1.5–12%.
o Increases in proportion with age, so more common
after age of 2 years.
o The most common lead point is a Meckel
diverticulum followed by polyps and duplications.
o Other benign lead points include the appendix,
hemangiomas, carcinoid tumors, foreign bodies,
hamartomas from Peutz– Jeghers syndrome and
lipomas.
o Malignant causes are rare like lymphomas and small
bowel tumors.
SECONDARY INTUSSUSCEPTION

9. Clinical Presentation
o The classic presentation is an infant or a young child with
intermittent, cramping abdominal pain associated with “currant jelly”
stools and a palpable mass on physical examination.
o This triad is seen in less than a fourth of children.
 The abdominal pain
 sudden, intermittent and the child may stiffen
and pull the legs up to the abdomen.
 The pain also can be associated with
hyperextension, breath holding, and vomiting.
 The attack often ceases as suddenly as it
started.
 Between attacks the child may appear
comfortable but will become lethargic.

10.  Stools
may be blood tinged as ischemia causes mucosal sloughing and
compression of mucous glands leading to evacuation of dark red
mucoid clots or currant jelly stools.
This is often a late sign.
A pitfall is to wait for the
currant jelly stool,
leukocytosis, and electrolyte
abnormalities that are often
the hallmarks of ischemic
bowel.

11. Physical Examination
o Palpable Mass or even visualized.
o Flat or empty right lower abdominal quadrant (Dance sign).
o On rectal examination, blood-stained mucus or blood is a later sign.
o Cramping episodes occur every 15–30 minutes and during painless intervals,
the child may appear normal.

12. o Prolapse of the intussusceptum through the anus is a
grave sign, especially when the intussusceptum is
ischemic. This may be missed and diagnosed as rectal
prolapse ( how to differ ? )
If the obstructive process worsens and bowel ischemia occurs,
dehydration, fever, tachycardia, and hypotension may develop
{ signs of shock }

13. Investigations and diagnosis
1. ABDOMINAL RADIOGRAPHY
Suggestive radiographic abnormalities include :
abdominal mass.
abnormal distribution of gas and fecal contents.
sparse large bowel gas.
air-fluid levels in the presence of bowel obstruction

14. 2. ULTRASONOGRAPHY
o Used now as a screening tool. {why??}
o The characteristic finding on US has been referred
to as a “target” or “doughnut” lesion in transverse
plane.
o And The “pseudokidney” sign in longitudinal
plane.
o Both are pathognomonic for intussusception along
with the clinical picture

15. 3. COMPUTEDTOMOGRAPHY AND MAGNETIC
RESONANCE IMAGING
o Not routinely used in the evaluation of intussusception.
o May confirm the diagnosis and/or pathologic causes for intussusception,
such as a malignancy (i.e., lymphoma)
o The characteristic CT finding is a target or doughnut sign

16. Management

17. Non
operative
management
HYDROSTATIC REDUCTION
PNEUMATIC REDUCTION
Operative
management
LAPAROSCOPIC APPROACH
OPEN APPROACH
Options for treatment

18. Non
operative
management
HYDROSTATIC REDUCTION
PNEUMATIC REDUCTION
Options for treatment
Initial option of treatment with mean successful
reduction rate in uncomplicated patients 85%.
Could be repeated according rule of 3 for
three times .
Could be repeated once with improved
success .

19. Operative
management
LAPAROSCOPIC APPROACH
OPEN APPROACH
Options for treatment
Indications :
1. when nonoperative reduction is
unsuccessful or incomplet.
2. For signs of peritonitis.
3. In the presence of a lead point.
4. With radiographic evidence of
pneumoperitoneum.

20. PNEUMATIC REDUCTION
o Fluoroscopically monitored.
o air is insufflated into the rectum.
o The maximum safe air pressure is 80 mmHg for younger infants and 110–
120 mmHg for older infants.
o Disadvantages :
1. Possibility of developing tension pneumoperitoneum.
2. Poor visualization of lead points and/or the intussusception reduction
process, resulting in false- positive reductions.
3. Perforation which ranges from 0.4–2.5%, with the most recent
publications citing an average rate of 0.8%.

21. Video from fluoroscopy
showing pneumatic
reduction of ileocaecal
intussusception

22. o Using water soluble contrast introduced through a
rectal catheter under fluoroscopic guidance.
o Using saline introduced through a rectal catheter under
ultrasonographic guidance.
o the rule of 3’s is followed keeping the can at a height at 3
ft, for 3 minutes, and for maximum three attempts.
o Complications ???
HYDROSTATIC REDUCTION

23. LAPAROSCOPIC APPROACH
o Initially, laparoscopy was strictly diagnostic.
o Now has become the initial operation of choice : (improved postoperative
pain and shorter time to full feeds and length of stay ).
o Contraindications to laparoscopy include :
1. hemodynamic instability.
2. peritonitis or evidence of pneumoperitoneum.
3. severe bowel distention that limits
visualization.

24. o Risk factors for increased conversion rates to an open procedure include :
1. An intussusceptum extending beyond the ascending colon.
2. Presence of known pathologic lead points.
o Reduction is done by applying gentle pressure distal
to the intussusceptum using atraumatic graspers.
o Excessive force should be discouraged.
o Appendectomy is not routinely performed unless it
is felt to be the lead point.
o If resection is required, exteriorizing the bowel
through an enlarged periumbilical incision is done
and If this is not possible, the operation is usually
converted to a laparotomy.

26. OPEN APPROACH
o By identification of the sausage-shaped mass,.
o Starting squeezing from the apex ( milking ).
o Avoiding pulling as it can cause rupture.
o Compression with warm saline pack reduces edema, thus helping in
reduction.
o In difficult cases pressure squeeze to reduce edema of the ileocecal valve
(Copes method) may be attempted.
o Bowel resection is required for irreducible and gangrenous
intussusception.
o If a lead point is found like Meckel’s diverticulum or polyp then resection
is recommended.

29. Pediatric surgery team