Surgery Book

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Intussusception

Aka: Intussusception, Intussusception Ultrasound
  1. Definitions
    1. Intussusception
      1. Bowel 'telescopes' onto itself in early childhood
  2. Epidemiology
    1. Most common cause Intestinal Obstruction age <6 years
    2. Incidence: 1 to 4 in 1000 newborns
    3. Ages affected
      1. Rare before age 3 months
      2. Most common ages 3 to 12 months (66%)
      3. Peak Incidence at 10 months of age
      4. Less common after age 36 months
    4. Gender predominence: Males > Females by 3:1 ratio
  3. Pathophysiology
    1. Bowel telescopes on itself, causing venous and lymphatic congestion, then ischemia, perforation and peritonitis
    2. Occurs most commonly at ileocecal junction (but may occur anywhere along ileum, jejunum or colon)
  4. Etiology
    1. Idiopathic (75-90%)
    2. Pathologic lesion at lead point of Intussusception
      1. Enlarged Peyer's Patch (follows recent gastrointestinal illness)
        1. Common cause
      2. Intestinal polyp
        1. Peutz-Jeghers Syndrome
        2. Juvenile Polyposis
        3. Familial Polyposis Coli
      3. Henoch-Schonlein Purpura
      4. Hemolytic Uremic Syndrome
      5. Hemangioma
      6. Meckel's Diverticulum
      7. Lymphosarcoma
      8. Abdominal Trauma, prior surgical scar or foreign body
  5. Risk Factors
    1. Cystic Fibrosis
    2. Indwelling gastrointestinal tubes
    3. Recent infection
      1. Upper Respiratory Infection
      2. Acute Gastroenteritis
  6. Symptoms
    1. Child often appears well between episodes of pain
      1. Appear agitated, inconsolable during painful episodes
      2. May be listless and pale between episodes
    2. Vomiting (delayed onset by 6-12 hours)
      1. Initially yellow Emesis progressing to Bilious Emesis
    3. Abdominal Pain
      1. Sudden onset
      2. Cramping, colicky with paroxysms of pain in 20 minute intervals (may flex knees to Abdomen in pain)
    4. Stool change
      1. Watery stools in first 12 to 24 hours
      2. Red Currant Jelly Stools (bloody mucus) are a late finding (occurs in 50% of cases, only 15% at presentation)
        1. Indicates infarcted or necrotic bowel
  7. Signs
    1. Children may be pain free in up to 20% of cases
    2. Lethargy may be only presenting finding (10% of cases)
    3. Evolution of abdominal examination
      1. Initial: Benign Abdomen
      2. Later: Abdominal distention with peritoneal signs
    4. Right upper quadrant or epigastric, sausage-shaped abdominal mass
  8. Differential Diagnosis
    1. Incarcerated Hernia
    2. Acute Gastroenteritis
    3. Testicular Torsion
    4. Acute Appendicitis
    5. Meckel Diverticulum
    6. Mesenteric Lymphadenitis
    7. Small Bowel Obstruction
    8. Abdominal Trauma
    9. Volvulus
  9. Evaluation
    1. Four clinical signs and symptoms are most associated with Intussusception
      1. Crying
      2. Abdominal mass
      3. Pallor
      4. Vomiting
    2. Interpretation
      1. All four clinical signs and symptoms: 95% Intussusception probability
      2. Intussusception is unlikely if all 4 criteria absent
    3. References
      1. (2014) Pediatr Emer Care 30:718-22 [PubMed]
  10. Precautions
    1. Consider in any child with irritability and Vomiting without Diarrhea (esp. with lethargy between episodes)
    2. Have a low threshold for evaluation (Ultrasound)
      1. Ultrasound is definitive (in experienced hands), non-invasive and inexpensive
      2. Missed Intussusception is lethal
    3. Listen to parents with concern regarding Abdominal Pain out of proportion to exam
    4. References
      1. Cantor (2016) Literature Review, ACEP PEM Conference, Orlando, attended 3/8/2016
  11. Imaging
    1. Ultrasound
      1. Preferred first screening for Intussusception
      2. Technique: General
        1. Linear Probe follows course of Large Bowel
        2. Normal colon with haustra and minimal peristalsis compared with Small Bowel
      3. Technique: Option 1
        1. Follow ascending colon from RLQ, then transverse colon from RUQ, then descending colon from LUQ
        2. Stomach may be used as acoustic window if there is Bowel Obstruction with fluid in Stomach
      4. Technique: Option 2 (Adam Sivitz, MD)
        1. Follow ascending colon from RUQ to RLQ (identifies most cases of Intussusception)
      5. Findings: Abnormal
        1. Transverse axis
          1. Target sign (concentric rings)
        2. Longitudinal axis
          1. Sandwich or pseudokidney (multiple bowel layers)
      6. Efficacy
        1. Emergency Bedside Ultrasound is accurate (but operator dependent)
          1. Test Sensitivity 85%, Test Specificity: 97%
          2. Riera (2012) Ann Emerg Med 60(3): 264-8 [PubMed]
      7. References
        1. Claudius and Seif in Herbert (2013) EM:Rap 13(11): 1-3
    2. Contrast Enema
      1. Sensitivity: 95% of Intussusception
      2. Curative in most early cases of Intussusception
      3. Contraindications
        1. Patient unstable
        2. Surgical Abdomen
    3. Abdominal XRay signs of Intussusception (variably present)
      1. Right lower quadrant abdominal mass
      2. Absent bowel gas in right upper quadrant
      3. Target sign or Cresent sign
        1. Air trapped between the bowel lumens
  12. Management: Reduction
    1. Immediate air or contrast enema if no contraindication
      1. Fluoroscopy guidance of air or contrast enema has typically been used
      2. Ultrasound guidance of saline enema has also been used
        1. Flaum (2016) J Pediatr Surg 51(1): 179-82 [PubMed]
    2. Surgical Consultation
    3. Consider prophylactic antibiotics prior to attempted reduction
  13. Management: Disposition
    1. Most patients are admitted and observed for recurrence for at least 24 hours
      1. Due to risk of recurrence in 5-10% of cases
    2. Indications for discharge after 6-8 hours of observation (studies support 3 hour observation)
      1. Asymptomatic for at least 3 hours after reduction AND
      2. Tolerating oral liquids AND
      3. Reliable family and able to return to Emergency Department if needed AND
      4. Reduction successful within 3 attempts AND
      5. No serious findings before reduction (e.g. bloody stool, fever, long prodrome)
      6. Ravel (2015) Pediatrics 136(5):e1345-52 +PMID: 26459654 [PubMed]
  14. Course (and Prognosis)
    1. Mortality
      1. Mortality 1 to 3% with early treatment
      2. Fatal if not treated within 2-5 days
    2. Recurrence in 3 to 11% of cases (most in first day)
  15. References
    1. Bisset (1988) Radiology 168(1): 141-5 [PubMed]
    2. West (1987) Surgery 102(4): 704-10 [PubMed]
    3. Yamamoto (1997) Am J Emerg Med 15(3):293-8 [PubMed]

Intussusception (C0021933)

Definition (MSHCZE) Invaginace – vchlípení jedné části střeva do části následující (podobně jako u teleskopu). Náhlá příhoda břišní, ke které dochází nejč. u malých dětí. Projevuje se silnou kolikovitou bolestí, neklidem dítěte, krvavou stolicí připomínající malinové želé. Bez léčby stav vyústí v odumření (gangrénu) části střeva a životu nebezpečný zánět pobřišnice (peritonitidu). Vyžaduje včasnou léčbu. Též intususcepce. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) Telescoping or invagination of a part of the intestine into an adjacent segment.
Definition (MSH) A form of intestinal obstruction caused by the PROLAPSE of a part of the intestine into the adjoining intestinal lumen. There are four types: colic, involving segments of the LARGE INTESTINE; enteric, involving only the SMALL INTESTINE; ileocecal, in which the ILEOCECAL VALVE prolapses into the CECUM, drawing the ILEUM along with it; and ileocolic, in which the ileum prolapses through the ileocecal valve into the COLON.
Concepts Disease or Syndrome (T047)
MSH D007443
ICD9 560.0
ICD10 K56.1
SnomedCT 197055000, 155772009, 35327006, 49723003
English Intussusception, Intussusceptions, Intususception, Intususceptions, Intussusception NOS, Intestinal Invagination, Intestinal Invaginations, Invagination, Intestinal, Invaginations, Intestinal, INTUSSUSCEPTION, intussusception (diagnosis), intussusception, Intussusception [Disease/Finding], intususception, Intussusception of bowel, intestinal intussusception, introsusception, intussusceptions, intussuception, bowel intussusception, Intussusception NOS (disorder), Intussusception (disorder), Intestines--Intussusception, Introsusception, Intussusception of intestine, Invagination of intestine, Intestinal intussusception, Intussusception of the intestine, ISN - Intussusception, Intussusception (morphologic abnormality), Intussusception of intestine (disorder), Invagination of intestine or colon, intussusception of bowel
Dutch invaginatie van de ingewanden, Invaginatie, intussusceptie, Darminvaginatie, Intussusceptie, Invaginatie, darm-
French Invagination de l'intestin, INVAGINATION (INTESTINALE), Invagination, Invagination intestinale, Intussusception
German Invagination des Darms, INVAGINATION (DARM), Darminvagination, Intussuszeption, Invagination, intestinale, Invagination
Italian Invaginazione dell'intestino, Intussuscezione, Invaginazione intestinale, Invaginazione
Portuguese Invaginação do intestino, INTROSSUSCEPCAO / INVAGINACAO, Invaginação, Intussuscepção, Invaginação Intestinal
Spanish Invaginación de intestino, introsuscepción, invaginación del intestino (trastorno), intususcepción del intestino, intususcepción del intestino (trastorno), invaginación del intestino, intususcepción, SAI, intususcepción, SAI (trastorno), Invaginación, intususcepción, invaginación intestinal (anomalía morfológica), invaginación intestinal, Intususcepción, Invaginación Intestinal
Swedish Intussusception
Japanese チョウジュウセキ, チョウジュウセキショウ, 重積, 腸重積症, 腸重積, 重積症
Czech intususcepce, Intususcepce, Invaginace střeva, invaginace střevní
Finnish Suolentuppeuma
Russian KISHECHNIKA INVAGINATSIIA, KISHECHNAIA INVAGINATSIIA, КИШЕЧНАЯ ИНВАГИНАЦИЯ, КИШЕЧНИКА ИНВАГИНАЦИЯ
Korean 장중첩증
Polish Wgłobienie jelita
Hungarian Intussusceptio, Bél invaginatiója
Norwegian Invaginasjon, tarmen, Tarminvaginasjon
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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