Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Michael J. Campbell, MD Virginia Mason Medical Center Seattle, Washington Case Presentation HPI: ISH is a 9 month old healthy boy with 12 hours of worsening, intermittent abdominal pain. Colicky episodes lasting 5 minutes with 30 minute periods of sleep intervening. Increasing frequent. Mom noted him assuming the fetal position during the attacks. One episode of non-bilious vomiting. One episode of non-bloody diarrhea. No preceding viral illnesses PE: AF, low grade tachycardia to 160s, but otherwise stable. Gen: Comfortable, and sleeping Abd: soft, mod distended. Mildly tender with a questionable soft mass in the RLQ. LABS: WCT of 17.1 with 17% bands Case Presentation Case Presentation Case Presentation Taken to the Fluoroscopy suite where pneumatic decompression was attempted. Resolution of the evident intussusception, but not able to pass air or contrast into the small bowel Subsequently, watched on the floor and returned for a plain film and US 4 hrs later which showed no evidence of intussusception Started on a diet and d/c’d the next day. Case Presentation Case Presentation Background Intussusception refers to the invagination of a part of the intestine into itself. It is the most common abdominal emergency in early childhood Epidemiology Intussusception is the most common cause of intestinal obstruction in infants between 6 and 36 months of age. Approximately 60 percent of children are younger than one year old, and 80 percent are younger than two. Male predominance, with a male:female ratio of approximately 3:2. Pediatrics. 2007 Sep;120(3):473-80. Pathophysiology Intussusception occurs most often near the ileocecal junction Approximately 75 percent of cases of intussusception in children are considered to be idiopathic Pathophysiology In the majority of cases in adults, a pathologic cause is identified In children, pathologic lead points include: Meckel’s Diverticulum Polyps Lymphoma HSP Pathophysiology Viral infections, can stimulate lymphatic tissue in the intestinal tract, resulting in hypertrophy of Peyer patches of terminal ileum acting as a lead point for ileocolic intussusception Pathophysiology Small bowel intussusception (usually jejuno-jejunal or ileo-ileal) has been described in the postoperative period The intussusception is thought to be caused by uncoordinated peristaltic activity and/or traction from sutures or devices Clinical Manifestations Classic Triad Colicky abdominal pain Palpable sausageshaped abdominal mass Currant jelly stool Diagnosis Abdominal plain film features consistent with intussusception include signs of intestinal obstruction, which may include massively distended loops of bowel with absence of colonic gas Diagnosis Target Sign Crescent Sign Diagnosis The classic ultrasound image of intussusception is a "bull's eye" or "coiled spring" lesion representing layers of the intestine within the intestine Diagnosis Contrast or Air Enema is both diagnostic and therapeutic Treatment Treatment Nonoperative Reduction Surgery Treatment Reduction of intussusception is typically performed under fluoroscopic guidance, using either hydrostatic (contrast) or pneumatic (air) enema Successful reduction is indicated by the free flow of contrast or air into the small bowel. Pneumatic technique Air enemas reduce the intussusception more easily, and may be advantageous if perforation occurs The technique begins with insertion of a Foley catheter into the rectum. Reflux of air into the terminal ileum and the disappearance of the mass at the ileocecal valve usually indicates reduction Risks and Complications Perforation of the bowel, occurs in 1 percent or fewer patients Risk factors for perforation include age younger than six months, long duration of symptoms (eg, three days or longer), evidence of small bowel obstruction Success Rates Nonoperative reduction using hydrostatic or pneumatic techniques is successful in approximately in 80 to 95 percent of patients with ileocolic intussusception In some institutions, repeated, delayed attempts at nonoperative reduction are made for patients in whom the initial attempt was unsuccessful. The intussusception recurs in approximately 10 percent of children after successful nonoperative reduction