Shenlie

BSN III-A Group-2

Olivarez College Parañaque

Intussusception

Intussusception occurs when one portion of the bowel slides into the next, much like the
pieces of a telescope. When this occurs, it creates an obstruction in the bowel, with the
walls of the intestines pressing against one another. This, in turn, leads to swelling,
inflammation, and decreased blood flow to the intestines involved.

The most common cause of intestinal obstruction in children between the ages of 3 months
and 6 years, intussusception:

• occurs most often in children between 5 and 10 months of age (80% occur before a
child is 24 months old)
• affects between one and four infants out of 1,000
• is three to four times more common in boys than in girls.
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Intraoperative appearance of ileoileal intussusception.

Frequency
The incidence of intussusception is 1.5-4 cases per 1000 live births, with a male-to-female
ratio of 3:2. The greatest incidence of idiopathic intussusception is in infants aged 9-24
months. A seasonal incidence has been described, with peaks in the spring, summer, and
the middle of winter. These periods correspond to peaks in the occurrence of seasonal
gastroenteritis and upper respiratory tract infections.

Etiology
Intussusception is ileocolic in 80% of cases but may also be ileoileal colocolic, or
ileoileocolic. Most infants and toddlers (95%) with the condition do not have an
identifiable specific lead point. In these idiopathic cases, careful examination may reveal
hypertrophied mural lymphoid tissues (Peyer patches), which are due to adenovirus or
rotavirus infection. Intussusception has also been found to increase the risk of tonsillar
disease (ie, chronic or acute tonsillitis) and tonsillectomy in children.

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Diagram illustrating the anatomy of intussusception.

Pathophysiology
Intussusception results in bowel obstruction, followed by congestion and edema with
venous and lymphatic obstruction. This progresses to arterial obstruction and subsequent
necrosis of the bowel. Ischemia and then necrosis results in fluid sequestration and
bleeding from the GI tract. If untreated, the bowel may perforate, resulting in sepsis

Major criteria

1. Evidence of intestinal obstruction: This is a history of bile-stained emesis, along

with abdominal distention or abnormal or absent bowel sounds.
2. Features of intestinal invagination: This includes at least one of the following:
Abdominal mass, rectal mass, or rectal prolapse, as well as an abdominal radiograph,
sonogram, or CT scan showing visible intussusceptum or a soft-tissue mass.
3. Evidence of intestinal vascular compromise or venous congestion: This manifests as
rectal bleeding or “red currant jelly” stool or blood on rectal examination.
Minor criteria

Minor criteria include any of the following:

• Male infants younger than 1 year

• Abdominal pain
• Vomiting
• Lethargy
• Pallor
• Hypovolemic shock
• Abdominal radiograph showing nonspecific abnormality

Physical

Upon physical examination, the patient is usually chubby and in good health.
Intussusception is uncommon in children who are malnourished. The child is found to have
periods of lethargy alternating with crying spells, and this cycle repeats every 15-30
minutes. The infant can be pale, diaphoretic, and hypotensive if shock has occurred.
• The hallmark physical findings in intussusception are a right hypochondrium sausage-
shaped mass and emptiness in the right lower quadrant (Dance sign). This is hard to
detect and is best palpated when the infant is quiet between spasms of colic.
• Abdominal distention frequently is found if obstruction is complete.
• If intestinal gangrene and infarction have occurred, peritonitis can be suggested on
the basis of rigidity and involuntary guarding.
• Early in the disease process, occult blood in the stools is the first sign of impaired
mucosal blood supply. Later on, frank hematochezia and the classic currant jelly stools
appear.
• Fever and leukocytosis are late signs and can indicate transmural gangrene and
infarction.
• A rare presentation of intussusception is prolapse of the intussusceptum through the
anus.
○ This prolapse of the intussusceptum can be confused with rectal prolapse.
Careful examination can differentiate between the 2 presentations.
○ The anal crypts are everted with rectal prolapse and not with intussusception.
○ An examining finger can be passed between the prolapse and the anus in
patients with intussusception but not in patients with rectal prolapse.
• Patients with intussusception often have no classic signs and symptoms, which can lead
to an unfortunate delay in diagnosis and disastrous consequences.
• Maintaining a high index of suspicion for intussusception is essential when evaluating a
child younger than 5 years who presents with abdominal pain or when evaluating a child
with Henoch-Schönlein purpura (HSP) or hematologic dyscrasias.
Intraoperative Details

• The abdomen and bowel are typically explored through a right lower quadrant
transverse incision, although some advocate a right transverse supraumbilical or even
an upper midline incision. After inspection for signs of perforation, the intussusception
is identified and delivered into the wound. First, an attempt is made at manual
reduction by retrograde milking of the intussusceptum. Although gentle pulling may aid
in reduction, avoid vigorous pulling apart of the intussuscepted segment of bowel.
• If manual reduction is unsuccessful, if a mass or pathologic lead point is present, or if
perforation has occurred, segmental bowel resection is necessary. After resection, a
primary anastomosis may be performed. Often, after successful manual reduction, the
involved segment of bowel appears edematous, hyperemic, or ischemic. These findings
do not necessarily mandate resection. An incidental appendectomy is often performed,
particularly if a right lower quadrant incision was made for access to the abdomen, as it
may be presumed that the patient has had an appendectomy.
• Laparoscopy in the management of intussusception was initially limited to a diagnostic
role. It was used to confirm unreduced bowel following an enema with prompt
conversion to an open procedure. The laparoscope allowed the surgeons to avoid
unnecessary open procedures in cases of spontaneous reduction following enema and
enhanced the efficacy of hydrostatic or pneumatic reductions, reducing the need for
an open procedure in approximately 30% of cases. Continued experience with
laparoscopy and improved technology has led some centers to successfully utilize the
technique for therapeutic reduction in confirmed cases of pediatric intussusception.

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• Intraoperative appearance of ileocolic intussusception.

•
Intraoperative appearance of ileocolic intussusception.
 Intraoperative appearance of ileoileal intussusception.

Relevant Anatomy

Intussusception is the telescoping or invagination of a proximal portion of intestine into a

more distal portion. Intussusception may be ileoileal, colocolic, ileoileocolic, or ileocolic,
which is most common. The primary concern with intussusception is vascular compromise
and subsequent bowel necrosis. In addition to bowel obstruction, edema with venous
obstruction and eventual obstruction of arterial flow leads to ischemia and eventual full-
thickness necrosis of the intussuscepted bowel and mesentery.

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• Diagram illustrating the anatomy of intussusception.

Diagram illustrating the anatomy of intussusception.

Intussusception
The walls of the two "telescoped" sections of intestine press on each other,
causing irritation and swelling. Eventually, the blood supply to that area is cut off,
which can cause damage to the intestine.