What!!!
Sausages and donuts!!!
Hmm...Read to find out :-)
Intussusception is the invagination of one segment of intestine into another
(usually the proximal segment invaginates into the distal segment).
In simple terms, one part of the bowel slides into the next, much like the pieces of a telescope.
Click to view Telescoping sign
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Intussusception is the most common cause of intestinal obstruction in
infants aged 6 months to 2 years.
(more common in first born males)
Remember: It can occur in any age group but common btw 6 mts to 2 yrs age
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Causes:
In infants, the cause is usually idiopathic/not known (possible factors that lead to intussusception due to enlargement of Peyers patches are: Post URTI with adenorotaviruses, Alteration in GI flora due to weaning) .
In adults, it is always secondary to another condition (such as Peutz-Jeghers syndrome, Polyps, Tumors, Submucous lipoma, Meckel's diverticulum).
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Clinical features
Symptoms:
• Abdominal pain (child screams with pain + facial pallor, alternating lethargy and irritability, sleeps between spasms but wakes up suddenly with colic pain,Children may cry, draw their knees up to their chest, or experience dyspnea with paroxysms of pain.)
• Vomiting 3-4 times (initially non-bilious, later bilious) initially due to pylorospasm. Later, due to obstruction.
• One attack of red currant jelly stools is characteristic. (seen in infants, not in adults)
This occurs due to ischemia of the bowel leading to mucosal irritation.
Blood supply to the trapped section of the bowel is cut off, which causes ischemia. The mucosa is sensitive to ischemia and responds by sloughing off into the gut (due to mucosal irritation). This creates a "red currant jelly" stool, which is sloughed mucosa, blood, and mucus.
Signs:
• A contracting, hardening mass in and around the umbilical region can be felt (sausage-shaped mass). The mass is resonant and mobile.
• Dance's sign-signe de dance: Emptiness in the right iliac fossa (first described by french pathologist Dr Dance ).
• Rectal examination reveals blood-stained mucus on the examining finger.
• Features of peritonitis occur in untreated cases.
Investigations:
- In most cases, the diagnosis is established on clinical grounds.
-Ultrasound - practical investigation of choice
Doughnut sign (or) Target sign - During ultrasound imaging of abdomen, hypoechoic edematous outer loop of bowel is seen around a hyperechoic compressed inner loop of bowel (looks like a doughnut that has outer and inner circular layers) - Click for ultrasound image link
-CT scan: Most sensitive imaging modality in the diagnosis of intussusception. Sausage-shaped mass, with blood vessels within bowel lumen are typical findings -Click for CT scan image link
Treatment
- Hydrostatic reduction with Air or barium enema; 85% reduce with hydrostatic pressure (i.e., barium meter elevation air maximum of 120 mm Hg);
- If unsuccessful, then laparotomy and reduction by “milking” the ileum from the colon should be performed
Few more points to note:
The most common site: Terminal ileum involving ileocecal valve and extending into ascending colon
The most common cause: Hypertrophic Peyer’s patches, which act as a lead point; many patients have prior viral illness
Intussuscipiens = Recipient segment of bowel
Intussusceptum = Leading point or bowel that enters the intussuscipiens
Rarely, intussusception can be seen outside the anus due to long mesentery.
References:
Child Intussusception - Stat Pearls
Pediatric Intussusception in one coffee by Alan Giles,Emergency Physician
Do watch this video to consolidate what you learnt & aid clinical application.
Happy learning :-)
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