DR NITA MARIANA SPBA

History

Intussusception was recognized as a

disease in the late 1600s in Europe
(Barbette, Peyer)

Hunter provided the first detailed

description of intussusception in
1793.
Introduction

The word intussusception is derived from the

Latin words intus (within) and suscipere (to
receive).
Intussusception is the invagination of one part of
the intestine into another
Three cylinders of intestinal wall are
involved.

The inner and middle cylinders are the

invaginated bowel (intussusceptum),
and the outer cylinder is the recipient
of the invaginated bowel
(intussuscipiens).
Intussusception is one of the most frequent
causes of acute bowel obstruction in infants and
toddlers

Intussuscipien
Incidence and Demographics

Approximately 1 to 4 in 2000 infants

and children
Most series report more males than
females with intussusception, usually
at a 2:1 or 3:2 ratio
Intussusception is reported to occur in
greater numbers in Caucasian infants
and children.
The frequency of intussusception
displays a seasonal variation that
usually correlates with viral
infections

respiratory,
gastrointestinal, or both),
Children with intussusception have
been described as being generally

healthy, sturdy, well developed, and

well nourished
Pathophysiology

Each intussusception has the following

pathologic anatomy:
as the intussusception develops with its
prograde bowel peristalsis,
the proximal invaginated bowel
(intussusceptum)
carries its mesentery into the distal
recipient bowel (intussuscipiens).
Pathologic Lead Point

The incidence of intussusception

caused by a PLP in an infant or child
ranges from 1.5% to 12%
It 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-year olds.
The mesenteric vessels are angulated, squeezed,
and compressed between the layers of the
intussusceptum

This causes intense local edema of the

intussusceptum, which inturn produces venous
compression, congestion, and stasis leading to an
outpouring of mucus and blood from the
engorged intussusceptum, the classic red
currant jelly stool
If this process continues unabated, bowel
congestion and pressure increase and
ultimately produce ischemic changes
leading to bowel necrosis in the
intussusceptum.
In most cases, ischemic necrosis needs
more than 72 hours to develop
If the ischemic process goes undiagnosed,
bowel obstruction,perforation, or sepsis
leads to death within 5 days
TYPES

Intussusception can be categorized

into four main types:
general,
specific,
anatomic, and
other.
Clinical Findings and Physical
Examination
Intussusception should be suspected
with any of the

two classic symptoms (abdominal pain

or vomiting) or
two classic signs (abdominal mass or
rectal bleeding)
The sudden onset of severe, colicky,
intermittent abdominal pain, which
makes infants pull up their legs, in
about 85% of patients.
This pain episode typically lasts only a
few minutes.
Afterwards, the infant is often quiet,
pale, and sweaty and then returns to
normal activity for a while
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
The often curved, sausage-shaped
abdominal mass can be palpated in the
right upper quadrant of the abdomen
about 65% the transverse colon

The right lower quadrant may be flat

or empty, a finding known as the Dance
sign.
Occasionally, the intussusception
passes quite far distally and can be
palpated on rectal examination (5%).

Prolapse of the intussusceptum out

the rectum may be a grave sign and
can be mistaken for a rectal prolapse
LABORATORY STUDIES

No specific laboratory studies aid in

the diagnosis of intussusception.
As the intussuscepted bowel becomes
ischemic, associated leucocytosis,
acidosis, and electrolyte
abnormalities worsen.
Radiologic Diagnostic
Evaluation
ULTRASONOGRAPHY
Ultrasonography showing tip of intussusception (arrow)

in longitudinal plane just deep to the anterior abdominal wall .

COMPUTED TOMOGRAPHY AND MAGNETIC
RESONANCE IMAGING
CONTRAST ENEMA

If positive, the diagnostic procedure

may become therapeutic.
Treatment

Treatment of an infant or child with an

intussusception must start in the
emergency department, and the surgeon
should be involved from the initial
presentation.
It is paramount to promptly fluid
resuscitate the patient.
If the patient suffers from recurrent
vomiting, a nasogastric tube is placed
The treatment options are simple:
medical (under occasional and specific
situations), radiologic reduction or
operative reduction, resection,
closure of an enema perforation, or
excision of a PLP by laparotomy or
laparoscopy.
NONOPERATIVE MANAGEMENT

Medical

Henoch-Schonlein purpura (HSP)

steroids
RADIOLOGIC REDUCTION

Contraindications to attempted
enema reduction include clinical
evidence of dehydration, shock,
peritonitis, or radiographic evidence
of perforation with free air.
Several factors such as younger age
(<6 months), rectal bleeding,
radiographic signs of intestinal
obstruction, or longer duration of
signs and symptoms (>72 hours) have
been found in some series to
decrease the success rate of
reduction.
Pneumatic Air Enema

Once the intussusception is

encountered, reduction is followed
fluoroscopically until it is completely
reduced
One critical safety issue is to keep
air pressure below a maximum limit of
120 mm Hg to avoid the risk of
perforation
Hydrostatic Barium Enema

Ultrasound for monitoring of

hydrostatic reduction is relatively
easy to use and the imaging modality
of choice in many centers.
The “rule of threes” (three attempts,
each of 3 minutes’ duration and with
enema bags 3 feet above the table)
Some irreducible intussusceptions are
already found reduced after initiation
of general anesthesia in the operating
room.
Either they reduced spontaneously
or, more likely, reduction was induced
by the sedation and muscle relaxation
from general anesthesia.
glucagon
OPERATIVE MANAGEMENT

Laparoscopy

Laparotomy : The standard incision in

infants is a fairly small right-sided
transverse incision above or below
the umbilicus.
MORTALITY MORTALITY

Mortalities associated with pediatric

intussusception have seen a steady
decline.
The current overall mortality rate in
the pediatric population in developed
countries is low (<1%).