Download - Catalyst

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