Intussusception

Intestinal obstruction due to telescoping of intestine into a distal segment in young children (3 mo – 6y).

Enlarged submucosal Peyer’s patch may become a lead point to telescope a bowel loop leading to engorged blood vessels, ischemia, obstruction, perforation or peritonitis. Intussusception could be ileocolic (commonest), ileoileal or rarely colocolic.

 

Causes

– Viral gastroenteritis (commonest cause in infants)

– Intestinal Polyps, lipoma

– Meckels diverticulum

– Henoch-Schönlein purpura

 

History

– Infants classically present with a triad of episodic abdominal pain, red current jelly stools and palpable abdominal mass, however this is rare.

– Most infants present with episodes of screaming, drawing-up legs and pallor; but may appear well between episodes.

– Progressive symptoms include bilious vomiting, abdominal distension, palpable mass and red-current jelly stools (blood and mucus mixed), peritonitis or circulatory shock (due to third space fluid losses).

 

Examination

– Ensure observation for several hours or overnight if suspecting intussusception.

– Repeat examination multiple times, including assessment of hydration and circulatory status

– Abdomen may be tender with guarding ‘surgical’ if peritonitis; palpable ‘sausage shaped’ mass may be present sometimes in right upper quadrant; bowel sounds may be enhanced ‘tinkering’.

– Examine blood in nappies or in rectal area

 

Investigation

– Abdominal x-ray may show features of bowel (generally small intestine) obstruction or a soft tissue ‘mass’ shadow. There may be ‘empty’ right quadrant with no gas shadow in ileo-coecal telescoping.

– Ultrasound abdomen can demonstrate telescoping as a ‘dough-nut sign’

– Barium enema can shows a ‘claw sign’ if colon is telescoped & can be a therapeutic procedure

 

Management

– Stabilise initially with ‘drip and suck’ with NGT on free drain (especially if bilious vomiting) and IV rehydration including fluid boluses (if required)

– Appropriate analgesia & broad-spectrum antibiotics (especially if peritonitis or perforation suspected)

 

– In early presentation (without suspected perforation or peritonitis) arrange radiological reduction of intussusception by rectal air insufflation (under fluoroscopy) or barium enema if facilities exist.

– If above contraindicated (suspected perforation or peritonitis) or if above fails, open laparotomy is needed to reduce intussusception to prevent ischemic gangrene of bowel.

 

Recurrence is rare, but can happen despite radiological or laparotomy procedure. Recurrent cases require further investigation for finding a ‘leading point’.