Presentation

Dr. M. Adnan Haider Khan

PGR (MS) General Surgery

Clinical Vignette

A 20 years old female presents to emergency with complaints of severe abdominal pain, vomiting, constipation followed by bloody diarrhea for last 5 days. Pain was sudden in onset, severe, not radiating to back, cramping in character. Vomiting was spontaneous consisting of multiple episodes, on eating and drinking even few sips of water and containing bilious content. There was history of low grade fever just before these symptoms. On examination, she was pale, tachycardiac (Pulse 130), having BP of 100/70. Abdomen was mildly distended, soft, tender at epigastric region. There was a suspicion of mass at the epigastric region. Bowel sounds were high-pitched. Digital rectal examination was normal, however, rectum was empty.

Clinical Vignette

Investigations done were as follows: Hb 7.8g/dL, TLC 8300, Neutrophils 85%, Sodium 134 mmol/L, Serum Potassium 3.7 mmol/L, RFTs and LFTs within normal limits. X Ray abdomen done 2 days back showed multiple air fluid levels. Repeat X ray showed dilated jejunum loops. Abdominal ultrasound showed “Target sign”.

Diagnosis?

INTUSSUSCEPTION

INTUSSUCEPTION

Definition�

• This is the invagination of a portion of intestine into its lumen.
• This occurs when one portion of the gut invaginates into an�immediately adjacent segment; almost invariably, it is the�proximal into the distal �

Incidence

• Most common in children
• Peaks at 5-10 months of age
• It may occur at any time between 3 months and 2 years
• Occasionally in younger and older age group than above mentioned age range

Etiology

• 90 % of cases are IDIOPATHIC.

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Idiopathic Cases (Etiology)

• An upper respiratory tract infection or gastroenteritis may precede the condition. (Hyperplasia of Peyer’s Patches in the terminal ileum may be the initiating event).
• Weaning
• Loss of passively acquired maternal immunity
• Common viral pathogens

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Etiology

• Pathological Lead Point

Pathological Lead Point (Etiology)

• Meckel’s diverticulum
• Polyp
• Henoch-Shconlein Purpura
• Appendix

It is to be noted that after the age of 2 years, a pathological lead point is found in at least one-third of affected children.

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Etiology (In Adults)

• Almost invariably associated with a lead point.
• Polyp e.g. Peutz-Jegher’s syndrome
• Submucosal lipoma
• Any other tumor

Pathology

• An intussusception is composed of three parts
• The entering or inner tube (Intussusceptum)
• The returning or middle tube
• The sheath or outer tube (Intussuscipiens)

Pathology

• The part that advances is the APEX
• The mass is the intussusception.
• And the neck is the junction of entering layer with the mass.

Anatomical Division

Anatomical Division

• In most children, the intussusception is ileocolic.
• In adults, colocolic intussusception is more common.

Clinical Features

• Before I delve into its clinical features, I would like to show two tables.

Clinical Features

• Classic quartet of
• Pain
• Distension
• Vomiting
• Absolute Constipation

Clinical Features

• The nature of presentation will also be influenced by whether the obstruction is
• Complete
• Incomplete

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Clinical Features

• A complete small bowel obstruction will have all the cardinal features.
• A complete large bowel obstruction may lack preceding symptoms.

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Clinical Features

• Other manifestations:
1. Dehydration
2. Hypokalemia
3. Pyrexia
4. Abdominal tenderness
5. Clinical features of strangulation

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Clinical Features of Strangulation

• The diagnosis is mainly clinical
• Constant and severe pain
• Tenderness with rigidity and peritonism
• Shock
• When pain persists despite conservative management, even in the absence of above signs, strangulation should be presumed.

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Classic Presentation of Intussussception

• Episodes of screaming and drawing up of legs in a previously well male infant
• Vomiting that is conspicuous and bile stained
• ‘Redcurrant jelly’ stool
• Non distended abdomen (Initially)
• Sausage shaped lump that hardens on palpation (60%)
• Feeling of emptiness in the right iliac fossa (The sign of Dance)
• Blood stained mucus on DRE
• Apex may be palpable on DRE or even protrude from the anus

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Classic Presentation of Intussussception

• Progressive dehydration
• Abdominal distension
• Peritonitis secondary to gangrene

IMAGING IN INTUSSUSCEPTION

• A plain abdominal radiograph
• Small bowel obstruction
• Large bowel obstruction
• Absent cecal gas shadow in ileocolic cases
• A barium enema may be required (But only for colocolic or ileocolic cases)

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Imaging in intussusception

• Abdominal Ultrasonography
• Typical doughnut appearance of concentric rings in transverse section

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IMAGING IN INTUSSUSCEPTION

• CT scanning
• Most sensitive with a diagnostic accuracy of 58-100%
• ‘Target’ or ‘sausage’-shaped soft tissue mass with a layering effect
• Mesenteric vessels within the bowel lumen

Treatment of Intussusception

• Resuscitation with intravenous fluids
• Broad spectrum antibiotics
• Nasogastric drainage
• Non-operative reduction

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Non-operative reduction

• Air or barium enema
• Contraindicated if
• Signs of peritonitis or perforation
• Known pathological lead point
• Presence of profound shock
• Signs of strangulation
• More than 70% of intussusception can be reduced by this method

Non-operative reduction

• Complications:
• Perforation of the colon
• Recurrence (10%)

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Surgery

• When radiological reduction has failed or is contraindicated
• Transverse right abdominal incision
• ‘Gentle reduction of the most distal part of intussusception towards its origin’, making sure not to pull
• Last part of reduction is most difficult
• After reduction, the terminal part of small bowel and the appendix will be bruised and edematous

Surgery

• The viability of the whole bowel should be checked carefully
• Resection and primary anastomosis is required if
• Intussusception is irreducible
• Complicated by infarction
• Has a pathological lead point

Food for thought

Thank you!