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Intussusception

  • Intussusception (ISS) – telescoping or invagination of one segment of bowel into the adjacent segment
  • Types
    • Antegrade – more common
    • Retrograde

Epidemiology

  • Most common in males
  • Most common cause of intestinal obstruction in children aged 6-18 months
    • Especially in the weaning period – 6-9 months
  • More prevalent in spring and winter months
  • Ileo-colic site is the most common – in the terminal 50m of ileum

Etiology

  • ISS can be triggered by
    • Dietary changes in the weaning period – leading to inflammation and edema of Payer’s patches
    • Upper respiratory tract viral infection can also cause edema of Payer’s patches
  • Causes in adolescents – submucous lipoma, leiomyoma, polyps in jejunum

Pathology

Parts of intussusception
  • Apex – the portion that advances
  • Intussuscipiens – the portion that receives (outer sheath)
  • Inussusceptum – the tube which advance (middle and inner sheath)

Pathophysiology

  • Apex and inner tubes have compromised blood supply – leads to gangrene
  • Due to ischemia, the apex sloughs off and bleeds, which mixes with the mucous to produce the classic red-currant jelly that is passed per anum
  • Gangrene can occur – leads to perforation and peritonitis

Clinical Features

  • 3 main signs – mass, colicky pain, melaena
    • Initial colicky pain, eventually becomes severe and persistent
  • Characteristic presentation – sudden onset of abdominal pain in male child with progressive abdominal distension, vomiting and passage of red-currant jelly stool

Physical exam

  • Mass felt on left or right hand side of umbilicus – sausage shaped with concavity towards umbilicus
    • Smooth, firm and resonant
  • Sign of dance – feeling of emptiness on palpation of the right lower quadrant of the abdomen, characteristic of intussusception

Complications

  • Intestinal obstruction
  • Perforation
  • Peritonitis

Investigations

  • Barium enema –  claw sign
  • Doppler – doughnut sign , useful to check blood supply of bowel
  • Plain XR – multiple air fluid levels

Treatment

  • Therapeutic enema
    • Tube inserted into anus → insufflation of air → dilates intestine → air compresses the head of the ISS and reduces it
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