Presentation on a very much common topic of Pediatric Surgery called Intussusceptions.

1. Intussusception
.

2. Introduction
 Intussusception was first described in 1674 by
Paul Barbette of Amsterdam and was defined
by Treves in 1899 as the prolapse of one part of
the intestine into the lumen of the immediately
adjoining part.
 John Hutchinson reported the first successful
operation for intussusception in 1873.

3. ….Cont
 IN 1876, HAROLD HIRSCHSPRUNG
DESCRIBED HYDROSTATIC REDUCTION,
WHICH LED TO A 23% REDUCTION IN
MORTALITY.
 RAVITCH POPULARIZED THE USE OF
CONTRAST ENEMA REDUCTION FOR
INTUSSUSCEPTION, WHICH GRADUALLY
BECAME THE ACCEPTED INITIAL
TREATMENT FOR PEDIATRIC
INTUSSUSCEPTION IN STABLE PATIENT.

4. Intussusception is derived from the
Latin word
Intus (within)
Suscipere (to receive)
Invagination of one part of the intestine
into another

5. Three cylinders of intestinal wall are
involved.
The inner and middle cylinders are
the invaginated bowel
(intussusceptum)
The outer cylinder is the recipient of
the invaginated bowel
(intussuscipiens)

8. It is the second cause of abdominal pain
in pre school children after constipation
Diagnosis and treatment is a combined
effort among the pediatrician, the
pediatric radiologist, and the pediatric
surgeon

9. 1 to 4 in 2000 infants and children
more males than females ( 2:1 or 3:2
ratio)
(78% males) after 9 months of age
than before (55%)

10. 75% of cases occur within the first 2 years
of life
90% in children within 3 years of age.
More than 40% are seen between 3 and
9 months of age

11. Hirschsprung’s classic statement: “I
never saw a malnourished child with an
intussusception.”

12. prograde bowel peristalisis
(intussusceptum) carries its mesentery
in to(intussuscipiens).
The mesenteric vessels are angulated,
squeezed, and compressed between
the layers of the intussusceptum.
This causes intense local edema of
the intussusceptum

13. four main
types:
1)General,
2)Specific,
3)Anatomic, and
4)Other

14. (1)The two general types are
Permanent (fixed, 80%)
symptomatic (85%), and all
require treatment
Transient (spontaneousreduction, 20%);
small and freq <2cm, reduces
spontaneously, incidental findings
Most are small bowel,asymptomatic, 6%
could have PLPs

15. The specific types can be described as
Idiopathic (no pathologic lead point
[PLP], 95%),
PLP (4%),
Postoperative (1%);

16. (Peyer patches) functions as a lead point
Majority of all cases (95%)
Peyer patches are usually located in
the antimesenteric area of the bowel
wall.
In the distal ileum, Peyer patches
involve the entire circumference of the
bowel

17. Malnourished children have a lower risk
of intussusception because of less
prominent intestinal lymphoid tissue
Infants who consumed soy milk–
based formula
had a much lower risk, and infants who
consumed cow’s milk
formula had an increased risk
for intussusception

18. (3)when classified by
anatomic types
Ileocolic (85%);
Ileoileocolic(10%);
Appendicocolic, cecocolic, or colocolic
(2.5%)
Jejunojejunal, ileoileal (2.5%)
occurring around indwelling tubes

19. (4) The fourth type is “other”
Recurrent (5%)
Neonatal (0.3%)
intussusception.

20. …Cont
 Most common focal cause of a PLP is
Meckel diverticulum(inverted)
Intestinal polyps
Duplications
 Others
 Periappendicitis;
 Appendiceal stump;
 Inversion appendectomy
 Appendiceal mucocele;
 Local suture line;

21. Massive local lymphoid hyperplasia;
Ectopic pancreas;
Abdominal trauma;
Benign tumors (adenoma, leiomyoma,
carcinoid, neurofibroma, hemangioma); and
Malignant tumors (lymphoma, sarcoma,
leukemia)

22. Henoch-Scho nlein
purpura
Cystic fibrosis
Celiac disease,
Disorderedcoagulation
Hemophilia,
Neutropeniccolitis,
Hirschsprungenterocolitis,
Peutz-Jeghers syndrome
Familial polyposis

23. Manifests as a small bowel obstruction (SBO)
Third most common intussusception (1%)
Found most often in the small bowel
After prolonged laparotomy
Significant bowel handling

24. No lead point present
SBO after pediatric laparotomy is about
5% (with 80% occurring within the first 2
years after laparotomy).
SBO after pediatric laparotomy is about
5% (with 80% in 1st 2 yr)

25. Gastrojejunostomy tubes with a
reported incidence of 16%
Antegrade jejunal intussusceptions,
Usually asymptomatic
Treatment may be clinical monitoring
Removal or conversion to a gastrostomy
or nasogastric tube will cure the
problem

26. 8% to 15%following barium enema
reduction,
5.2% to 20% following sonography-
guided hydrostatic enema reduction,
5.4% to15.4% following fluoroscopy-
guided air enema reduction,
6.25% to 7%after sonography-guided
air enema

27. Recurrence rates are lower after
manual operative reduction (3% to 4%)
Operative resection and anastomosis of
an intussusception(0%)
Occur within the first few days after
the initial reduction, some within
hours

28. Infrequent (0.3%of all cases)
Caused by a pathologic lead
point NEC like manifestation
Abdominal distension
Bilious gastric aspirates
Bloody stools
Palpable abdominal mass

29. Suspected with any of the two classic
symptoms and signs
Abdominal
pain(85%)sudden,colicky,intemitte
nt
Vomiting (45% of infants)
signs
Abdominal mass or
Rectal bleeding

30. All four classic signs and symptoms can
only be found late (<30% of cases)
Diarrhea precedes and may mislead
to incorrect diagnosis and
triage(20%)
Absence of pain(15%), delays the
diagnosis>>pale and listless and
appear quite ill

31. Curved, sausage-shaped
Right upper quadrant(65%)
Usually extends to the left along
the transversecolon

32. Slightly tender
Easily palpable and visiblemass in silent
child
Dance sign
Palpated on rectal examination (5%)
Rectal bleeding>>>last sign to occur

33. Rectal bleeding
Mucus-like texture
Dueto sloughing of the mucosa
dueto congestion and subsequent
ischemia

34. Delayed presentation
Fever
Tachycardia
Hypotension >>>>bacteremia and
bowel perforation
N.B>Rapid diagnosis and emergent
operation are essential to prevent a fatal
outcome

35. Lab
No lab investigation is
diagnostic
Leucocytosis,
Acidosis
Electrolyte

36. Clinical diagnosis only is 50% sensitive
Radiologic imaging and USto either
confirm or make the correct
diagnosis(100%)

38. Up to 100% accuracy for the
diagnosis of intussusception
Portable, noninvasive, and without radiation
Characteristic finding>>>>3- to 5-cm
diameter mass,
Typical target or doughnut sign
Found just deep to the anterior abdominal
wall on the right side

39. The absence of blood flow on Doppler
A thick peripheral hypoechoic rim,
Free intraperitoneal fluid,
Fluid trapped within the
intussusceptum,
Enlarged lymph nodes dragged with the
mesentery into the intussusception

40. Are not routinely used
Intussusception found incidentally on
imaging performed for another
suspected diagnosis
Target or doughnut
sign immediate CT
scanning
Target sign with a diameter 3 cm(US)
Atypical location in the (Lt Abd &
ublicus)

41. Evaluation by surgeon if there is
need for emergent operation
Fluid resuscitation
NG tube decompression
Broad-spectrum antibiotic
Cross-matched blood
Radiologic confirmation
N.B>>The operating room should be
notified

42. Medical (under occasional and
specific situations),
Radiologic reduction or operative
reduction,
Resection,
Closure of an enema perforation
Excision of a PLPby laparotomy
or laparoscopy

43. Differentiate suitable
candidates Contraindications
(BEand AE)
 Dehydration>>>corrected
Shock
Peritonitis, or
Radiographic evidence of perforation with
free air

44. Younger age (<6 months),
Rectal bleeding,
Radiographic signs of intestinal
obstruction, or
Longer duration of signs and symptoms
(>72 hours)
Hydrostatic or pneumatic enema should
be attempted in all children without
peritonitis

46. Currently used options
Pneumatic or hydrostatic pressure enemas
under fluoroscopy or US
USAand Europe management of
intussusception varied greatly with a trend to
pneumatic reduction techniques with greater
use of ultrasound

47. The enema tip should be placed within the
child’s rectum and taped securely in place
Child is placed in a prone position to
squeeze the buttocks closed and prevent
air from leaking
Air is insufilated into the colon
under fluoroscopic observation
Reduction is followed fluoroscopically
until it is completely reduced

48. Air should flow freely from the cecum into the
distal small bowel loops to signify complete
reduction
Keep air pressure below a maximum limit
of 120 mm Hg to avoid the risk of
perforation

49. It is easy to perform
Can be done quickly
Less messy
Delivers less radiation
exposure
Is more comfortable,
Results in smaller
perforations
Less peritoneal contamination

50. Passage of air into the terminal ileum
without complete reduction of the ileocolic
intussusception
Tension pneumoperitoneum (rare)

54. The liquid enema is simple, safe,
and effective, and most
radiologists have experience with
its use than AE
US is relatively easy to use and the
imaging modality of choice in many
centers

55. Messy
Perforation occur with larger colonic
tears,
Increased peritoneal contamination
Rapid fluid shifts with hypertonic
water- soluble agents
Barium is no longer the liquid
contrast medium of
choice (peritonitis, infection, and
adhesions when perforates)

56. Three attempts
Each of 3 minutes duration
Enema bags 3 feet above the table
Reduction may occur rapidly or
stubbornly slowly
Pause when the barium column meets
the intussusception

57. The rounded barium column
suddenly becomes concave
Forms a meniscus around the head of
the intussusception
When the intussusception is displaced,
the meniscus flattens out

58. Barium seeps between the two and produces
the characteristic radiologic appearance of a
coiled spring
Filling of the cecum is often slow, the sudden
rush of barium into the distal ileum indicative
of reduction

60. If the enema is not freely filling in to the
ileum>>>incomplete reduction
Once the reduction is successful, the infant or
child is relieved of the pain and usually falls
asleep

61. Medications>>
GA,
Smooth muscle relaxants such as glucagon
Sedation(controversial)

62. Observed closely for at least a few hours
Discharge If parents are reliabe,pt is
aymptomatic and tolerated post
reduction fluid
Still most of the Pts need admission
for followup and further Tx
If NGT was needed initially for SBO, better
to keep it insitu overnight ,keep NPO and
put on MF

63. IV antibiotic is continued if the child is febrile
or the reduction is difficult (48hr)
10% recurrence rate is expected
Place of repeat Abd USstudy??>>the
edematous part at ieocecal area mimic
recurrence

64. Indication
Radiographic reduction is contraindicated,
has failed or is incomplete,
Peritonitis
Pneumoperitoneum is detected
Pathologic lead point is found

65. Fluid resuscitation
NGT decompression
IV antibiotic(for all minmum of 48hr)
Take to OR,keep in supine position
GA will be given
The mass is felt
The place of incision depends on the site
of the mass

66. Previously used for diagnostic purpose
Currently used for therapeutic reason
too
Onset<36hr and no sign of
peritonitis>>good
ourcome(60%)

67. Right-sided transverse incision above or
below the umbilicus is the standard
incision
If the incision is lower on the right
side>>appendectomy should be
done
serosanguineous peritoneal fluid
is encountered on entering the
abdomen>>suspect necrosis

68. slow constant pinching and squeezing of
the most distal part of the
intussusceptum, just like squeezing a
tube of toothpaste

69. Ileoileocolic intussusception, the
ileocolic component is reduced first
and then the remaining ileoileal
leading edge of the intussusceptum may
look particularly ischemic>>become pink
and vital after application of warm saline
towels for less than 10 minutes

70. Up to 50% of all nonviable
intussusceptions can be reduced
manually>>gives chance to save as long
bowel as possible saved
A primary end-to-end anastomosis can
be fashioned after the ischemic bowel is
resected
The ischemic bowel can be quickly
resected and both bowel ends
exteriorized as temporary stomas in
critical child

71. wound infection
Fascial dehiscence
SBO. Reported complications rates > >
(4%) when no enterotomy or bowel
resection had to be performed (26%)
Post OPcomplication after perforation of
Ba enema reduction>>50%