Careful analysis of how to prevent a potentially fatal catastrophe

1. Intussusception
will test the doctor, will cost the patient
Dr Mohan Samarasinghe
Consultant Surgeon in Gastroenterology
Provincial General Hospital - Badulla

2. Paul Barbette
(Amsterdam1620 – 1666)
In 1674
Intussusception was first
mentioned in his writings
as intestinal invagination
and suggested operative
reduction

3. John Hunter
(London 1728 – 1793)
In 1793
Accurately described
intussusception in a
postmortem specimen

4. The causes of intussusception are not fully known
Mostly seen in 1-5y of age. Most cases in young
children are ‘idiopathic’
Some viral and bacterial infections of the intestine
may possibly contribute to intussusception in infancy
(? payer’s patches hypertrophy / lymphadenopathy)
Intussusception is very rare in older children and
adults. If, often will have "lead points"

5. Pathological lead point
Pathologic lead points are seen in 10% of intussusception
and responsible for 14% to 19% of cases with recurrence.
Most cases are irreducible
• Meckel’s diverticulum
• Duplication cyst
• B-cell lymphoma
• Carcinoid
• Leiomyoma
• Henoch- Schonlein purpurn
• Celiac disease
• Neutropenic colitis
• Cystic fibrosis
• Puetz-Jehgers syndrome

6. Dr William Ladd
(Boston 1880 – 1967)
In 1940
“One rarely finds
intussusception in a child
who is thin,
undernourished, and
poorly developed.”

7. This healthy appearance can mislead the
doctor in the early hours of the illness.
At the first visit may leave the doctor with the
impression that the parent is overanxious?
Return visit the next day shows that the child
is desperately ill and can die

9. Intermittent severe cramping or colicky abdominal
pain, occurring every 5-30 mins
During an episode, the infant suddenly appears
startled, screams and flexes at the waist, draws the
legs up to the abdomen, and may appear pale
Episodes may last for few seconds and are
separated by periods of calm and normal
appearance and activity
As the disease progress, infants become quite
lethargic and somnolent between attacks

10. Early on, may vomit undigested food
As attacks continue, emesis may turn bilious
Stool that appear normal in character early in the
course of the illness eventually become dark red and
mucoid (red currant jelly)
This is a sign of intestinal ischemia and mucosal
sloughing which occurs late
Hence, classic triad of vomiting, abdominal pain, and
passage of blood per rectum ? outdated

11. Lethargy is a relatively common presenting
symptom with intussusception unlike in other
forms of intestinal obstruction
Lethargy can be the sole presenting symptom
Some, often have no classic symptoms, which
can lead to an unfortunate delay in diagnosis

12. Early intussusception will have the
differentials including gastroenteritis and
appendicitis
and
later including malrotation with midgut
volvulus, or incarcerated hernia

13. With early diagnosis, appropriate fluid
resuscitation, and therapy, the mortality rate
from intussusception in children is < 1%.
If left untreated, however, this condition is
uniformly fatal in 2-5 days

14. How can you save a life?

15. Examination!

16. Abdominal Examination
Careful palpation after an attack has subsided may
reveal an ill-defined or sausage-shaped mass
If you palpate thoroughly, may precipitate an
attack which suggests the diagnosis
Early ileocolic intussusception, the mass is in the
RUQ. The right lower quadrant (RLQ) may feel
empty - the Dance sign (French Pathologist Jean
Baptiste Hippolyte Dance 1797-1832 )

17. Rectal Examination
Inspection of faecal material in the diaper
‘Normal’ stool? - test for occult blood
Blood tinged mucoid or frankly bloody stool
supports the diagnosis
Digital rectal exam may feel the prolapsed
tip of the intussusception

18. New Developments
In view of concerns about rotavirus vaccine–
associated intussusception, the Brighton
Collaboration Intussusception Working Group
established a clinical diagnosis using a mix of major
and minor criteria

19. Major criteria
• Evidence of intestinal obstruction - History of bile-
stained emesis, with abdominal distention or
abnormal or absent bowel sounds
• Features of intestinal invagination - abdominal
mass, rectal mass, or rectal prolapse, Xray, USS, or
CT scan showing intussusceptus
• Evidence of intestinal vascular compromise or
venous congestion - Rectal bleeding or “red currant
jelly” stool or blood on DRE

20. Minor criteria
• Male infants younger than 1 year
• Abdominal pain
• Vomiting
• Lethargy
• Pallor
• Hypovolemic shock
• Abdominal radiograph showing nonspecific
abnormality

21. How to use the Major and Minor criteria
Either of the following ~70% probability:
• Two major criteria
• One major criterion and three minor criteria
Following ~ 40% possibility:
• Four or more minor criteria

22. If its intussusception,
you are counting the minutes
First 12 hours are golden
Transfer to a hospital with
facilities to operate
Minimise the delay

23. In the hospital
Examine Again !
X-ray? low sensitivity and specificity
(can detect perforation)
Lab investigations not very helpful
USS Abdomen !!!

24. Richard A Bowerman in 1982

25. USS Abdomen
Target and pseudo-kidney
Sensitivity and specificity ~98%
Slight ascites and long intussusceptus
predicts failure of nonoperative management
Significant ascites, air, and absence of blood
flow in bowel wall suggests gangrene

27. Treatment

28. Sir Jonathan
Hutchinson
(London 1828 – 1913)
In 1871
First surgeon to
successfully manually
reduce an ileocolic
intussusception
(in a 2-year old girl)

29. Harald
Hirschsprung
(Copenhagen 1830 – 1916)
In 1876
Successful* nonoperative
Mx of intussusception
with hydrostatic enemas
(water)
No X-rays, (Roentgen’s x-ray -
1895), without methods to
confirm diagnostic accuracy and
reduction assessment

30. Harald
Hirschsprung
(Copenhagen 1830 – 1916)
In 1905
107 cases, treated during a
30y with an overall survival
of 70% in infants < 6/12 old
when treated in first 24 h
Remarkable in an era when the
mortality rate was often 75% after
attempted surgical treatment

31. Dr J M Elder
(Ontario 1880 – 1967)
In 1910
Elder noted: with early
diagnosis and prompt operation
within 12 hours of onset of
illness, 75% survival rate can
be achieved.
The importance of gentle
handling of the bowel
emphasizing that the bowel
should be milked out, never
pulled out.

32. Dr William Ladd
(Boston 1880 – 1967)
In 1913
First illustration of a
diagnostic contrast
enema (Bismuth) in a
child with intussusception

33. Dr P L Hipsley
(Sydney 1892 – 1973)
In 1926
Treatment by hydrostatic
saline pressure based on
an analysis of 100
consecutive cases

34. Wang and Liu in 1988

35. Modern Treatment Options
Hydrostatic reduction with or without USG
Barium enema reduction under fluoroscopy
Air enema reduction under fluoroscopy
Operative reduction

36. General Measures
Start intravenous fluid resuscitation
Intravenous antibiotics
Check Lactate levels: if high (>2) - Operate
Check for peritonitis or perforation

37. Saline Hydrostatic Reduction
• 14Fr Foley catheter in rectum
• 10cc saline to balloon
• Buttocks taped together or held together to stop
leakage
• Graduated bottle attached to catheter
• Moderate flow rate with monitoring for change of the
flow rate
• If flow became too slow for >10 min - failure
• If flow slows but becomes faster - Reducing
• If flow continues to be faster - Reduced
• Baby become comfortable / falls a sleep - Reduced

38. Saline Hydrostatic Reduction with US Guidance

39. Predictors for Operative Treatment
• Delayed diagnosis
• Age younger than 1 year
• Long intussusceptus
• Absence of blood flow in bowel wall
• Significant ascites / air
• Failure of initial enema reduction

41. Complications
• Necrosis of a significant length of bowel can lead to
complications seen in short bowel syndrome
• Whether treated by operative or radiographic
reduction, late stricture (4-8 weeks) may occur
within the length of intestine involved (if not
resected)
• Recurrence 10%

42. Take Home Message
If you see a young child with abdominal pain,
don't forget to examine the abdomen or it may cost
the child his/her bowel if not his/her life!

43. Thank you