Sunday, September 16, 2012

Acute intussusception

It is telescoping or invagination of one portion of bowel into the adjacent segment. (proximal into distal)

Aetiology
  • It is common in weaning period of child, between 3-9 mths.


  • In children- associated with Meckls diverticulum, polyp, HSP, etc.


  • In adolescents and adults- submucus lipoma, leiomyoma, polyps in jejunum (Peutz-Jeghar syndrome), other polyps and carcinoma with papillary projections.

Pathology

  • Apex- is the one which advances.


  • Intussuscipiens- is the one which receives (outer sheath)


  • Intussusceptum- are the tube which advances (middle and inner sheath)


  • Apex and inner tubes will have compromised blood supply which lead to gangrene.


    Ischaemia leads to sloughing off of the apex which in turn lead to bleeding which mixes with mucus to produce the classic currant jelly that is passed per anum.

    Gangrene may lead to perforation and peritonitis.


C/F
  • Common at around 6 months.
  • Sudden onset of pain ( screaming with drawing up of the legs vomiting, with passage of currant-jelly stool.
  • It is recurrent.
  • When it gets reduced, child becomes asymptomatic.
  • On examination, a mass is felt on the left or right of the umbilicus which is sausage shaped with concavity towards umbilicus.
  • Right iliac fossa is empty (Sign of dance)
  • PR- Blood stained mucus maybe found on the finger.
          In extensive ileocolic and colocolic intussusception, the apex may be palpable or even protrude from the anus.
  • If unrelieved, pain becomes continuous with abdominal distension and profuse vomiting.
  • Ultimately small bowel obstruction or peritonitis secondary to gangrene may lead to death.

Investigations
  • Plain x-ray abdomen

     Absent caecal gas shadow in ileoileal or ileocolic cases
  • Barium enema

     Shows typical claw sign. (for ileocolic and colocolic)
  • CT scan- maybe be done for ileoileal intussusception which shows small bowel mass.




D/D
  • Acute enterocolitis
  • HSP
  • Rectal prolapse

T/T


  • Ryles tube aspiration



  • IV fluids



  • Antibiotics



  • Catheterization



  • Surgery

     
Midline incision
     
Then reducing by squeezing the most distal part of the mass in cephalad direction.
     
In difficult cases- Cope’s method- little finger gently inserted into the neck of the intussusception and separation of adhesion is tried.
                             
Thumb and finger are placed in such a way to deinvaginate the apex.
                             
Gentle pressure is applied and gradually increased to reduce edema around the ileocaecal valve
       
In case of irreducible or gangrenous intussusception- mass excision.

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