Intussusception Flashcards
Define intussusception
Invagination of the proximal bowel into a distal segment (prolapse of one part into the lumen of the adjoining distal part)
Most commonly involves the ileum passing into the caecum through the ileocaecal valve
What is the aetiology of intussusception
The intussusceptum telescopes INTO the lumen of the intussuscipiens
The lead point of the intussusception is most often an enlarged mesenteric lymph node (Peyer’s patch) in the terminal ileum
Viral infection → hyperplasia of the Peyer’s patches and lymphoid tissue in the intestinal wall
Idiopathic
Why can intussusception lead to ischaemia
The mesentery is dragged alongside the proximal bowel wall into the distal lumen → obstruction of venous return → oedema, muscosal bleeding, increased pressure
Arterial compromise → ischaemia, necrosis, perforation
What may act as the pathological lead point for intussusception
Luminal polyps
Malignant tumours
Benign mass lesions e.g. lipomata
Meckel’s diverticulum
Henoch-Schonlein purpura (intestinal wall haematoma)
Enteric duplication cysts
Appendix
Hypertrophies mucosal glands (cystic fibrosis)
What are the risk factors for intussusception
6-12 months
Male sex
Antecedent viral illness
First-generation rotavirus vaccination (RRV-TV)
What are the symptoms of intussusception
Abdominal pain
- Paroxysmal, severe colicky pain
- 1-3- minutes
- Episodes of pain: child becomes pale, draws up legs, pain around the mouth
- Infant is normal between episodes
- >3 months (rule out colic)
Lethargic
Poor feeding
Vomiting (may be bile-stained depending on the site of intussusception)
Redcurrant jelly-like stools (blood-stained mucous) - represents mucosal oedema/ulceration
Abdominal distension
What are the differentials for intussusception
Gastroenteritis
incarcerated inguinal hernia
Appendicitis
Mesenteric adenitis
Meckel’s diverticulum
Colic
Pyloric stenosis
Urinary tract infection
What are the signs of intussusception on examination
Obs: shock (from intestinal ischaemia, gangrene, perforation)
General
Pale, draws legs up
Lethargic
abdominal
Sausage-shaped mass in the RUQ or epigastrum
Abdominal distension
Dance’s sign (emptiness on palpation of RUQ)
DRE
Blood on gloves
What investigations should be done for intussusception
Urine dip
Blood glucose
FBC, CRP, LFTs, blood gas
Abdo US: Target/doughnut sign (single hypoechoic ring with hypoechoic centre)
AXR: distended small bowel, absent gas in distal colon or rectum, assess for perforation/obstruction
Diagnostic enema: meniscus sign
What is the management for intussusception in a patient who is stable
- IV fluid resuscitation
- Contrast (barium/Gastrograffin) or air enema reduction
Second line: Surgical reduction + Abx (clindamycin, gentamycin)
What is the management for intussusception in a patient who is unstable
- A-E assessment
- Contact paed surgeons
- IV fluid resuscitation
- NBM + NG feeds
- Rectal air insufflation by the radiologist - CI in peritonitis, perforation, shock
Second line: surgical reduction
What is the management for recurrent intussusception
Assess for a potential pathological lead point → CT abdomen
What are the complications of intussusception
Bowel perforation
Peritonitis
Gut necrosis
What is the prognosis for intussusception
Success rate of rectal air insufflation is about 75%
Recurrence of the intussusception occurs in less than 5% but is more frequent after hydrostatic/contrast enema reduction (10%)
Mortality in intussusception is related to delay in presentation, septic shock, and inadequate fluid resuscitation