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EPIDEMIOLOGY
Is the most common cause of
intestinal obstruction in infants
between 6 and 36 mo of age. 60 % of
children are younger than one year
old, and 80 % are younger than two.
Intussusception is less common
before 3mo and after 6yr of age.
Most episodes occur in otherwise
healthy and well-nourished children.
male:female ratio of 3:2.
PATHOGENESIS
Occurs most often near the ileocecal
junction (ileocolic intussusception).
Ileo-ileo-colic, jejuno-jejunal, jejuno-ileal,
or colo-colic. The intussusceptum, a
proximal segment of bowel, telescopes
into the intussuscipiens, a distal
segment, dragging the associated
mesentery with it. This leads to the
development of venous and lymphatic
congestion with resulting intestinal
edema, which lead to ischemia,
perforation, and peritonitis.
Idiopathic
Approximately 75 % of cases are
idiopathic because there is no clear
disease trigger or pathological lead
point most common in children
between 3mo and 5yr of age.
Lead point
A lead point is a lesion or variation in
the intestine that is trapped by
peristalsis and dragged into a distal
segment of the intestine, causing
intussusception.
A Meckel diverticulum, polyp,
tumor, hematoma, or vascular
malformation can act as a lead
point for intussusception.
Underlying disorders
25 % of cases( a pathological lead point),
which may be focal or diffuse. Such triggers
greater in children younger than 3MO or older
than 5Yr.
Meckel diverticulum, polyps, small
bowel lymphoma, duplication cysts,
vascular malformations, inverted
appendiceal stumps, parasites (eg,
Ascaris lumbricoides), Henoch-Schnlein
purpura, cystic fibrosis, and hemolyticuremic syndrome. Meckel diverticulum is
the most common, followed by polyps,
and then either duplication cysts or
Henoch-Schnlein purpura.
CLINICAL MANIFESTATIONS
sudden onset of intermittent, severe, crampy, progressive
abdominal pain, accompanied by inconsolable crying and
drawing up of the legs toward the abdomen. The episodes
usually occur at 15 to 20 min intervals. They become more
frequent and more severe over time. Vomiting may follow
episodes of abdominal pain. Initially, emesis is non-bilious,
but it may become bilious as the obstruction progresses.
Between the painful episodes, the child may behave
relatively normal and be free of pain. As a result, initial
symptoms can be confused with gastroenteritis. As symptoms
progress, increasing lethargy develops, which can be
mistaken for meningoencephalitis.
A sausage-shaped abdominal mass may be felt in the right
side of the abdomen. In up to 70 %of cases, the stool
contains gross or occult blood. The stool may be a mixture of
blood and mucous, giving it the appearance of currant jelly.
DIAGNOSIS
Depends on the clinical suspicion for intussusception
(typical or atypical presentation) and experience
radiologists.
Patients with a typical presentation (sudden onset of
intermittent severe abdominal pain with or without rectal
bleeding) or characteristic findings on radiography, may
proceed directly to nonoperative reduction using
hydrostatic (contrast or saline) or pneumatic (air)
enema, performed under either sonographic or
fluoroscopic guidance. In these cases, the procedure is
both diagnostic and therapeutic.
If diagnosis is unclear at presentation. In this case,
initial workup may include abdominal ultrasound or
abdominal plain films. If the study supports the
diagnosis of intussusception, nonoperative reduction is
then performed.
Ultrasonography
Is the method of choice to detect
intussusception. The sensitivity and
specificity approach 100 % in the hands of an
experienced. US is better than fluoroscopic in
detect pathological lead points , monitor the
success of a reduction , not expose the
patient to radiation
The classic ultrasound image is a "bull's eye"
or "coiled spring" lesion representing layers
of the intestine within the intestine (picture 2).
In addition, a lack of perfusion in the
intussusceptum detected with color duplex
imaging may indicate ischemia. US can
diagnose the rare ileo-ileal intussusception
and identify the lead point of intussusception
2/3of cases .
CT scan
However, CT cannot be used to
reduce the intussusception and can be
time-consuming in children who may
require sedation. Thus, CT generally
is reserved for patients in whom the
other imaging modalities are
unrevealing, or to characterize
pathological lead points for
intussusception detected by
ultrasound.
TREATMENT
Stable patients with a high clinical suspicion
and/or radiographic evidence of
intussusception and no evidence of bowel
perforation should be treated with
nonoperative reduction.
Surgical treatment is indicated in acutely ill
or perforation. radiographic facilities and
expertise to perform nonoperative reduction
are not available. nonoperative reduction is
unsuccessful, or for evaluation or resection of
a pathological lead point.
intussusception limited to the small bowel
(ileo-ileal, jejuno-ileal, or jejuno-jejunal).
Nonoperative reduction
Fluoroscopic or sonographic
guidance
Reduction is typically performed under
fluoroscopic guidance, using either
hydrostatic (contrast) or pneumatic
(air) enema. Has high success rates
(80 to 95 %) and is an appropriate
choice if the treating physicians have
more experience with this technique
than with ultrasound-guided reduction.
Successful reduction ;
1. free flow of contrast or air into the small bowel. Reduction is
complete only when a good portion of the distal ileum is filled
with contrast.
2. Relief of symptoms and disappearance of the abdominal
mass. A characteristic sound also may be appreciated with
auscultation.
3. In occasional patients, the contrast material does not reflux
freely into the small bowel even with a complete reduction,
however a successful reduction is suggested by lack of a
filling defect in the cecum (apart from the ileocecal valve),
and clinical resolution of symptoms and signs.
A post-reduction filling defect in the cecum commonly is seen,
probably the result of residual edema in the ileocecal valve.
However, this finding cannot be distinguished from a focal
lead point by radiologic examination alone. As a result, a
repeat study or even laparotomy may be indicated if there is
any concern of a focal lead point.