|Patient: 4 month old male|
|History: 4 month old male with hematochezia.|
Ultrasound shows an elongate mass in the right upper quadrant. Transverse images of the mass demonstrate a swirled appearance of alternating sonolucent and hyperechoic regions of presumed bowel wall typical of the loop-within-a-loop appearance of Intussusception. Longitudinal images of the mass demonstrate linear areas alternating sonolucent and hyperechoic regions of presumed bowel wall typical of the loop-within-a-loop appearance of Intussusception. "submarine sandwich sign"
Barium enema demonstrates a mass in the ascending colon and cecum which reduces with insufflation of air.
In infants aged 6 months to 2 years, intussusception is not unusual and often follows an upper respiratory tract illness; however, inciting factors may be absent. The male-to-female ratio of intussusception is 3:1-2.
Most intussusceptions are acute. The clinical picture is of a well-nourished infant with the following signs and symptoms of bowel obstruction:
The infant usually has one or more episodes of diarrhea mixed with blood and mucus (ie, currant-jelly stool), which is related to venous congestion. A palpable, slightly tender, sausage-shaped mass in the abdomen is characteristic. Although usually acute, chronic or recurrent intussusception may occur, with typical symptoms. In some patients, intussusception is painless; the infant may appear pale, diaphoretic, or lethargic. The physician may not suspect intussusception if unusual symptoms are present or if symptoms mask an upper respiratory infection.
Invagination of a bowel segment (usually, the small bowel) into the lumen of the more distal bowel (usually, the colon) occurs. The invaginated segment (intussusceptum) is carried distally by peristalsis. Mesentery and vessels become involved with the intraluminal loop and are squeezed within the engulfing segment (intussuscipiens). Almost all occurrences are acute. Venous congestion is a major factor both in symptomatology and in the characteristic presence of blood in the stool.
Recent illness may create a lead point for intussusception due to lymphoid hyperplasia. Intussusception is known to occur with greater frequency in children who have undergone recent abdominal surgery, either intraperitoneal or retroperitoneal operations. It is thought that early adhesions or focal edema of the bowel wall create a lead point for the intussusception. Children with postoperative intussusception may present with unexplained bowel obstruction within a time frame that is unusual for the development of bowel obstruction in postoperative patients.
Additional lead points in nonidiopathic intussusception may include the following:
In some countries, history and physical findings are sufficient criteria for undertaking reduction procedures for intussusception.
Once the patient is stabilized, reduction procedures should be initiated immediately; radiographic examination and physical examination should be performed to ensure that neither free air nor peritonitis is present. It should be ascertained by physical examination that no peritonitis is present. Spontaneous reduction has been reported, but it is unusual.
Surgical consultation should be sought early when intussusception is suspected. Despite positive results from reduction through the use of imaging techniques, reduction or re-intussusception may be unsuccessful, necessitating surgery. Surgeons should be made aware of the possible need for surgery. Rarely, complications from reduction with imaging techniques (perforation) require emergency surgery. Thus, alerting the surgical consultant is a prudent measure. The use of air, gas, or water-soluble contrast to reduce the intussusception decreases potential complications.
Unless perforation, peritonitis, or Henoch-Schönlein purpura is present, radiologic reduction should be attempted. The success rate is 50-85%, depending on factors such as the length of time of the intussusception and degree of edema of the loop and ileocecal valve. Reduction is still possible, although more difficult, in intussusceptions that have been in place for longer than 48 hours. In patients older than 2 years, it should be assumed that intussusception has a lead point etiology; in such cases, further investigation should be undertaken.
In the current method of air reduction, room air is introduced through a rectal catheter and is taped well in place. A manometer is attached to a Y-connector to monitor pressure in the colon. Pressure should never exceed 110 mm Hg. The air pressure on the intussusception usually forces the inverted bowel back through the ileocecal valve and into its proper position. When reduction occurs, the observed pressure falls precipitously.
Contrast reduction was widely used until the current decade. A large rectal tube is taped firmly in place, and dilute water-soluble contrast is introduced slowly by gravity drip into the rectum; hydrostatic pressure is used to reduce the intussusception. The fluid is placed a maximum of 3 feet above the level of the radiography table. No more than 3 attempts at reduction are undertaken, and the column is pressed against the intussusception mass no longer than 3 minutes at each attempt. Visualization of the small bowel usually indicates that intussusception has been reduced. The following rules need to be observed:
Intussusception recurs in approximately 10% of children. Intussusception can recur at any time and is not a contraindication to repeat reduction. Sedation to assist reduction does not greatly affect the reduction rate. Glucagon has been advocated, but its efficacy has not been established.
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Case Number: 40200015Last Updated: 04-27-2010 The reader is fully responsible for confirming the accuracy of this content.