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![ (2) the specific types can be described as
idiopathic (no pathologic lead point [PLP],
95%),
PLP (4%),
postoperative (1%);](https://image.slidesharecdn.com/pediatricintussusceptionfinal-181217081903/75/Pediatric-intussusception-final-20-2048.jpg)
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Pediatric intussusception final
- 2. Introduction Typesof 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 publishedthe first of a series of reports on hydrostatic reduction with much decreased mortality (23%) than operation
- 5. In 1913Ladd 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 1948operation 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 andClarke (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 isderived from the Latin word intus (within) suscipere (to receive) invagination of one part of the intestine into another
- 9. Three cylindersof 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 isthe 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 to4 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% ofcases 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 hasbeen 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 classicstatement: “I never saw a malnourished child with an intussusception.”
- 17. prograde bowelperistalisis (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 maintypes: general, specific, anatomic, and other
- 19. (1) The twogeneral 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) thespecific 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 ilealwall 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 childrenhave 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 classifiedby anatomic types ileocolic (85%); ileoileocolic(10%); appendicocolic, cecocolic, or colocolic (2.5%) jejunojejunal, ileoileal (2.5%) occurring around indwelling tubes
- 25. (4) thefourth type is “other” recurrent (5%) neonatal (0.3%) intussusception.
- 26. 1.5% to12% 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 commonfocal cause of a PLP is Meckel diverticulum(inverted) intestinal polyps duplications Others periappendicitis; Appendiceal stump; inversion appendectomy appendiceal mucocele; local suture line;
- 28. massive locallymphoid 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 PLPsmanifest 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 asa small bowel obstruction (SBO) third most common intussusception (1%) found most often in the small bowel after prolonged laparotomy significant bowel handling
- 32. no leadpoint 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 tubeswith 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% to15%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 ratesare 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%ofall 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 anyof the two classic symptoms and signs Abdominal pain(85%)sudden,colicky,intemittent Vomiting (45% of infants) signs abdominal mass or rectal bleeding
- 39. In USAMost cases are diagnosed within 24 hours of the onset of symptoms. recurrent intussusception diagnosed early crampy abdominal pain>>>>high index of suspicion
- 40. All fourclassic 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 labinvestigation is diagnostic leucocytosis, Acidosis electrolyte
- 46. Clinical diagnosisonly is 50% sensitive radiologic imaging and US to either confirm or make the correct diagnosis(100%)
- 48. Up to100% 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 detecta 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 leadsto 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 absenceof 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 notroutinely 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 agold 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 bysurgeon 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 (underoccasional and specific situations), radiologic reduction or operative reduction, resection, closure of an enema perforation excision of a PLP by laparotomy or laparoscopy
- 57. differentiate suitablecandidates 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 managementremains 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 avoidsradiation 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 needfor 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 enematip 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 shouldflow 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 iseasy to perform can be done quickly less messy delivers less radiation exposure is more comfortable, results in smaller perforations Less peritoneal contamination
- 67. passage ofair into the terminal ileum without complete reduction of the ileocolic intussusception tension pneumoperitoneum (rare)
- 71. the liquidenema 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 perforationoccur 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 roundedbarium column suddenly becomes concave forms a meniscus around the head of the intussusception When the intussusception is displaced, the meniscus flattens out
- 75. barium seepsbetween 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 theenema 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 theirreduction rate with air enema from 58% to 76% this technique may be more widely used than reported in the literature
- 80. In thepast 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 surgicalintervention 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 cooperationbetween experienced pediatric radiologists and surgeons and careful clinical monitoring is a must
- 83. observed closelyfor 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 antibioticis 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 radiographicreduction 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 usedfor diagnostic purpose Currently used for therapeutic reason too Onset<36hr and no sign of peritonitis>>good ourcome(60%)
- 88. right-sided transverseincision 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 constantpinching 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 to50% 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 duringenema 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 youngerthan 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 upto 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 graduallydeclining 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 than20 years, nonwhite, Unmarried education level below grade 12
- 99. Pediatric intussusceptionoften 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 successrate 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 ischemicbowel 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,ArnoloG.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
Editor's Notes
- #12 Diagram of the most common (idiopathic, ileocolic) type of intussusception. As it develops in the terminal ileum with its prograde bowel peristalsis, the proximal invaginated bowel (intussusceptum) carries its mesentery into the recipient bowel (intussuscipiens) and the mesenteric vessels are angulated, squeezed, and compressed between the layers of the intussusceptum. This causes intense local edema of the intussusceptum, which produces venous compression, stasis, and congestion leading to an outpouring of mucus and blood from the engorged intussusceptum, often producing stool with the appearance of currant jelly. If this vicious cycle continues, ischemic changes will lead to bowel gangrene. The outermostlayer ofthe intussusceptum becomes devitalized first, the innermost layer of the intussusceptum becomes gangrenous much later, and the outermost layer of bowel (intussuscipiens) loses its viability last. Most perforations, however, are located in the colon near the intussusceptum.
- #15 In utero, intussusception may lead to intestinal atresia, most commonly ileal atresia.32–35 Perinatal intussusception in newborns (0.3% of all intussusceptions) is more likely caused by a pathologic lead point like in older patients.
- #16 Intussusception has been reported in families and relatives (identical twins, sibling cases, as well as in fathers and sons), viral cause rather than a genetic cause
- #20 Transient intussusception may also be seen with gastroenteritis, probably because of hyperactivity of the inflamed bowel. Eighty-six percent of these transient intussusceptions involve only the small bowel and are noted in the central and left abdominal regions
- #23 , RotaShield) has a strong association between vaccination with RotaShield and intussusception WHO’s Global Advisory Committee the benefits of rotavirus vaccination exceed the possibly increased risk of intussusception
- #30 Intussusception caused by a PLP remains a diagnostic challenge US sensitivity>>>Diagnosis 74% of all focal PLPs, 40% of diffuse PLPs, 32% has been reported(diagnosis of the exact type of PLP) Less sensitive for a Meckel diverticulum >>>>repeat US increases the yield
- #31 In 35% of all PLP cases the intussusception is caused by thickened bowel wall, abnormal motility, impaction of secretions, or the presence of multiple polyps. Other important risk factors are ileoileocolic intussusception, an older child, the association of a long duration of symptoms with weight loss, and recurrent intussusception
- #37 The time between onset of symptoms and arrival in the hospital is shorter because of the awareness of the parents. The earlier the diagnosis, the greater is the chance for successful reduction. Recurrent intussusceptions may be looser and easier to reduce but also have a greater chance of repeat recurrence.
- #39 sudden onset of severe, colicky, intermittent abdominal pain, which makes infants pull up their legs, is the most common classic symptom of pediatric intussusception in about 85% of patients. This pain episode typically lasts only a few minutes The two classic signs, abdominal mass and rectal bleeding, can be found with about the same frequency
- #41 se children are often pale and listless and appear quite ill. Infants present more often with vomiting than older children do (up to 45%). Bilious vomiting tends to be found in delayed cases of intussusception with SBO
- #64 Several series have achieved equally high reduction rates using hydrostatic or pneumatic reduction under sonographic guidance igh as 95%.108,137,162 In conclusion, successful reductions can be achieved whether one chooses to use the hydrostatic or pneumatic reduction technique under fluoroscopic or sonographic guidance. The choice of technique used will depend largely on the experience, personal preference, and expertise of the radiologist involved, as well as on the local conditions in a particular institution and the type of patient population seen
- #84 Recurrence rates did not differ between children observed as inpatients and those discharged home, and there were no missed pathologic lead points
- #85 ficult. The presence of fever usually indicates bacteremia, endotoxemia, cytokine (tumor necrosis factor, interleukin) and lysozyme release, and even the production of reactive lymphocytes, in which case antibiotics may be continued for 48 hours A repeat abdominal US study should be performed if any doubt remains about the success of the enema reduction or the abdominal pain recurs the ileocecal valve often remains edematous and thickened for a day or more.108 This appearance can easily be differentiated from a recurrence because it lacks the typical concentric rings. The invaginated mesentery is smaller than the typical target sign of a true intussusception and will disappear with time.193 The ileocecal thickening can also be appreciated as a filling defect or narrowing if a contrast enema is performed
- #97 r the initial episode. Multiple recurrences can occur in the same child and should prompt a search for a pathologic lead point such as an occult malignancy. The recommended imaging modality is US.108 Operative exploration is indicated when the ultrasound suggests a pathologic lead point, the reduction enema was unsuccessful, or clinical symptoms persist postreduction