pediatric intususception

2.  Introduction
 Types of intususception
 Clinical approach
 Investigations
 Management options
 Post op complications and recurrence
 Summery
 Reference

3.  Wilson (1831) reported the first successful
operative reduction in an adult,
 Hutchinson reported it in an infant
40 years later (1871)
 But with high mortality rate
 As operative technique evolved, results
improved.

4.  1876 Hirschsprung
published the first of a series of reports on
hydrostatic reduction with much decreased
mortality (23%) than operation

5.  In 1913 Ladd reported bismuth enemas and
published the first photographs of
roentgenologic pictures of an intussusception
 Fourteen years later (1927), Olsson and
Pallin, Poulquien, and Retan used barium-
guided fluoroscopy

6.  Till 1948 operation was the choise in USA till
Ravitch and McCune reported a surgical
mortality of 32%
 By 1958, nonoperative reduction rates of up
to 75% were achieved with a mortality rate
close to zero.

7.  Burke and Clarke (1977) used only
ultrasonography (US) for screening, diagnosis,
and monitoring the reduction of intussusception
 Guo and colleagues (1986)
successfully tried delayed repeat enema
reduction attempts
 Today, operation is the accepted norm for failed
radiologicguided reduction of intussusception.

8.  intussusception is derived from the Latin
word
 intus (within)
 suscipere (to receive)
 invagination of one part of the intestine into
another

9.  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)

12.  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

13.  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%)

14.  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

15.  Intussusception has been reported in families
and relatives viral cause rather than a genetic
cause
 seasonal variation that usually correlates with
viral infections (respiratory,gastrointestinal)
 incidence of a preceding viral illness has
been reported as high as 20%

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

17.  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

18.  four main types:
 general,
 specific,
 anatomic, and
 other

19. (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

20.  (2) the specific types can be described as
 idiopathic (no pathologic lead point [PLP],
95%),
 PLP (4%),
 postoperative (1%);

21.  (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

22.  distal ileal wall lymphoid tissues and the
nearby mesenteric lymph nodes may enlarge
and form a lead point useally 2ry to infection
 However, in a mouse model, the Peyer
patches did not appear to act as the anatomic
lead point for intussusception
 Rotavirus vaccine (RRV-TV)

23.  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

24. (3) when classified by anatomic
types
 ileocolic (85%);
 ileoileocolic(10%);
 appendicocolic, cecocolic, or colocolic (2.5%)
 jejunojejunal, ileoileal (2.5%)
 occurring around indwelling tubes

25.  (4) the fourth type is “other”
 recurrent (5%)
 neonatal (0.3%) intussusception.

26.  1.5% to 12% of all intuss.
 increases with age from about 5% in the first
year to 44% within the first 5 years of life and
60% in 5- to 14-yearolds
 in 4% of infants and children who
have one recurrence
 19% with multiple recurrences

27.  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;

28.  massive local lymphoid hyperplasia;
 Ectopic pancreas;
 abdominal trauma;
 benign tumors (adenoma, leiomyoma,
carcinoid, neurofibroma, hemangioma); and
 malignant tumors (lymphoma, sarcoma,
leukemia)

29.  Henoch-Scho nlein
purpura
 cystic fibrosis
 celiac disease,
 Disorderedcoagulation
 hemophilia,
 neutropeniccolitis,
 Hirschsprungenterocolitis,
 Peutz-Jeghers syndrome
 familial polyposis

30.  Most PLPs manifest as ileoileocolic
intussusceptions(40%)
 jejunojejunal, ileoileal, ileocolic, appendicocolic,
cecocolic, and colocolic
intussusceptions
Recurrence vs PLP
 5% of patients with one recurrence
 19% of children with multiple recurrent episodes

31.  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

32.  no lead point present
 SBO after pediatric laparotomy is about 5%
(with 80% occurring within the first 2 years
after laparotomy).
 Three to ten percent of those are caused by
postoperative intussusceptions
 SBO after pediatric laparotomy is about 5%
(with 80% in 1st 2 yr)

33.  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

34.  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

35.  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

36.  Reduciblity>>> 100% for initial recurrence
and 95% for multiple recurrences
pathologic lead point
 4% in children with one recurrence
 14% withmultiple recurrences

37.  infrequent (0.3%of all cases)
 caused by a pathologic lead point
NEC like manifestation
 abdominal distension (17/17),
 bilious gastric aspirates (13/17),
 bloody stools (10/17), and
 palpable abdominal mass (5/17)

38. suspected with any of the two classic symptoms
and signs
 Abdominal
pain(85%)sudden,colicky,intemittent
 Vomiting (45% of infants)
signs
 abdominal mass or
 rectal bleeding

39.  In USA Most cases are diagnosed within 24
hours of the onset of symptoms.
 recurrent intussusception diagnosed early
 crampy abdominal pain>>>>high index of
suspicion

40.  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

41.  curved, sausage-shaped
 right upper quadrant(65%)
 usually extends to the left along the
transversecolon

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

43.  Rectal bleeding
 mucus-like texture
 Dueto sloughing of the mucosa dueto
congestion and subsequent ischemia

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

45. Lab
 No lab investigation is diagnostic
 leucocytosis,
 Acidosis
 electrolyte

46.  Clinical diagnosis only is 50% sensitive
 radiologic imaging and US to either confirm
or make the correct diagnosis(100%)

48.  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

49.  can detect a possible pathologic lead
point with higher frequency (66%) than
contrast (40%) or air enema (11%)
 Can also detect Other DDX that mimic
intussuscepption

50.  it leads to a second study, increased health
care costs since the US could have been
avoided??
 Ultrasound cannot predict well if the
intussusception is already necrotic or
amendable to nonoperative reduction and
should therefore not preclude reduction by
enema

51.  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

52.  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)

53.  Was a gold standard Before ultrasound
became widely available
 In some institutions it is still the preferred
diagnostic modality
 accuracy of 100%
 Is both dignostic and therapeutic

54.  invasive (radiation)
 More than 50% of diagnostic BE suspected
intussusception turn out to be negative

55.  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

56.  medical (under occasional and specific
situations),
 radiologic reduction or operative reduction,
 resection,
 closure of an enema perforation
 excision of a PLP by laparotomy or
laparoscopy

57.  differentiate suitable candidates
Contraindications (BE and AE)
 Dehydration>>>corrected
 shock
 peritonitis, or
 radiographic evidence of perforation with free
air

58.  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

59.  operative management remains the usual
primary treatment in much of the developing
world(Nigeria and Kenya)
 mortality rate up to 20%
 AE reduction in developing world success rate
was 60% without mortality

61. Currently used options
 pneumatic or hydrostatic pressure enemas
under fluoroscopy or US
 USA and Europe management of
intussusception varied greatly with a trend to
pneumatic reduction techniques with greater
use of ultrasound

62.  it avoids radiation exposure
 provides more information than fluoroscopic
techniques do
 high accuracy and reliability for monitoring
the reduction process,
 visualizes all components of the
intussusception
 easily recognize pathologic lead points

63.  the need for a radiologist who is comfortable
using US for reduction guidance.
 less experience with pneumatic reduction
under US guidance,
 Difficulty of early identification of perforation

64.  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

65.  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

66.  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

67.  passage of air into the terminal ileum without
complete reduction of the ileocolic
intussusception
 tension pneumoperitoneum (rare)

71.  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

72.  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)

73.  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

74.  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

75.  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

77.  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

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

79.  improved their reduction rate with air enema
from 58% to 76%
 this technique may be more widely used than
reported in the literature

80.  In the past it was standard practice that
immediate operative intervention was
required for all patients, if intussusception
was irreducible by enema techniques
 10% of intussusceptions were found to be
already reduced, and another 40% were easily
reduced manually in the OR

81.  i.e surgical intervention could possibly have been
avoided in half the cases if radiologists used a
different or more aggressive approach to their
enema technique
 Interval>>>ranged between minutes and days
 Success rates between 50% and 84%
 Usually done under GA
 No. of attempt should be tailored to the
individual patient and experience of radiologist

82.  Close cooperation between experienced
pediatric radiologists and surgeons and
careful clinical monitoring is a must

83.  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

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

85.  Indication
 radiographic reduction is contraindicated, has
failed or is incomplete,
 peritonitis
 pneumoperitoneum is detected
 pathologic lead point is found

86.  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

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

88.  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

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

90.  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

91.  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

92.  Perforations during enema reduction usually
occur early during the procedure
 Still 50% can be reduced manually
 If the reduction is not possible, the
intussusception should be resected en mass

93.  Radiologic reduction
 bowel perforation(less than 1%)
 occur in the outer intussuscipiens and in
the absence of necrosis

94.  infants younger than 6 months
 longer duration of symptoms (>36 hours)
 High pressure(>120mmHg)
 Rapid increasment in pressure

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

96.  in up to 20% of the cases (average in published
series 5%)
 Recur within 6 months of the original episode
with 3rd within the first 24 hours
 Enema reduction for recurrence is as successful
as for the initial episode
 If multiple recurrences can occur in the same
child>>search for a pathologic lead point(tumor)

97.  Is gradually declining even in developing
world
 But still as high as 20%
 Is <1% for both non operative and operative
reduction
 The interval between onset of symptoms and
institution of treatment is of paramount
importance
 Near zero if presentation is within 24hr

98. mothers
 younger than 20 years,
 nonwhite,
 Unmarried
 education level below grade 12

99.  Pediatric intussusception often presents with
a wide range of nonspecific symptoms
 The four classic symptoms of pain, emesis,
and bloody stools +-mass are together
present in less than 25% of children
 Clinical dx is 50%sensitive
 US and contrast enema makes accuracy reach
100%

100.  The success rate of non operative reduction is
reaching >90%
 This days in westerns setup most are
managed non operaatively
 Duration of the complaint is the key for
successful reduction
 Delayed repeat enemas are up to 82%
successful

101.  suspected ischemic bowel and peritonitis,
unsuccessful enema reduction, suspected
pathologic lead point, or, rarely, perforation
after pressure enema (<1%) are indications
for operation
 Recurrence after BE and AE reduction is up to
20%(average 5%)

102.  Pediatric surgery,Arnolo G.coran,7th edition
 Aschcraft’s pediatric surgery,6th edition
 Schwartz principles of surgery,10th edition
 Sabiston text book of surgery,20th edition
 Uptodate 20.1