Intussusception

Gastroenterology

Clinicals - History

Fact Explanation
Paroxysmal, screaming attack with drawing up of legs due to abdominal pain which older children complain of. It typically lasts only a few minutes and the attack starts around 15 minutes later.
Abdominal pain is the most common presentation.
Commonly occur up to 2 years of age.
Paroxysmal, screaming attack with drawing up of legs due to abdominal pain which older children complain of.
It typically lasts only a few minutes and the attack starts around 15 minutes later.
Abdominal pain is the most common presentation.
Commonly occur up to 2 years of age.
Passage of redcurrent jelly stool/ Per rectal bleeding Initially the stool that is passed maybe normal. But later passage of blood and mucus gives rise to the characteristic "redcurrant jelly stool". Passage of redcurrent jelly stool/ Per rectal bleeding
Initially the stool that is passed maybe normal. But later passage of blood and mucus gives rise to the characteristic "redcurrant jelly stool".
Pallor and lethargy The exact mechanism is not known, but must be suspected in children with unexplained lethargy, this maybe the only initial symptom. Pallor and lethargy
The exact mechanism is not known, but must be suspected in children with unexplained lethargy, this maybe the only initial symptom.
Vomiting May not be present initially, but may occur later. Vomiting
May not be present initially, but may occur later.

Clinicals - Examination

Fact Explanation
Features of dehydration and even shock. Repeated vomiting and reduced fluid intake and depletion of fluid into the gut (due to the intestinal obstruction caused by intussusception) causes dehydration.
Look for rapid thready pulse, low blood pressure.
Features of dehydration and even shock.
Repeated vomiting and reduced fluid intake and depletion of fluid into the gut (due to the intestinal obstruction caused by intussusception) causes dehydration.
Look for rapid thready pulse, low blood pressure.
Abdominal distension In delayed presentation. Abdominal distension
In delayed presentation.
Palpable sausage-shaped abdominal mass May harden on palpation. The triad of this in association with abdominal pain and vomiting has high positive predictive value. Palpable sausage-shaped abdominal mass
May harden on palpation. The triad of this in association with abdominal pain and vomiting has high positive predictive value.
Positive sign of Dance Emptiness of the right iliac fossa is felt on palpation. Positive sign of Dance
Emptiness of the right iliac fossa is felt on palpation.
Rectal examination may produce "redcurrant jelly stool". Due to presence of blood stained mucus. Rectal examination may produce "redcurrant jelly stool".
Due to presence of blood stained mucus.
Palpation of the apex of the intussusceptum on digital rectal examination. Rarely the proximal part may extend through rectum. Palpation of the apex of the intussusceptum on digital rectal examination.
Rarely the proximal part may extend through rectum.

Investigations - Diagnosis

Fact Explanation
X ray abdomen Distended bowel proximal to the intussusception can be seen while the caecal gas shadow will be absent since it will be collapsed.
Positive meniscus sign(due to crescent of gas within the bowel due to intussusception)
Target sign(due to hypoechogenic bowel with hyperechogenic center due to mesentry).
X ray abdomen
Distended bowel proximal to the intussusception can be seen while the caecal gas shadow will be absent since it will be collapsed.
Positive meniscus sign(due to crescent of gas within the bowel due to intussusception)
Target sign(due to hypoechogenic bowel with hyperechogenic center due to mesentry).
Ultrasound scan of the abdomen. The mass created by intussusception can be seen.
Doughnut sign (hypoechogenic ring around the hyperechogenic bowel lumen formed mainly by returning limb of intussusceptum, this sign is seen mainly at the apex)
Crescent in doughnut sign (mainly seen in the base, due to the mesentery pulled along by the intussusceptum giving rise to increasing hyperechogenic crescentic pattern towards the base)
Sandwich sign(on longitudinal view, the altering hypo and hyperechogenic shadows of bowel wall, lumen and mesentry give rise to sandwich like pattern)
Pseudokidney sign(in longitudinal plane)
Enlarged lymphnodes maybe visible.
Presence of fluid in between layers of bowel indicate ischemia.
In older children the mass in the apex responsible for intussusception should be studied.
Ultrasound scan of the abdomen.
The mass created by intussusception can be seen.
Doughnut sign (hypoechogenic ring around the hyperechogenic bowel lumen formed mainly by returning limb of intussusceptum, this sign is seen mainly at the apex)
Crescent in doughnut sign (mainly seen in the base, due to the mesentery pulled along by the intussusceptum giving rise to increasing hyperechogenic crescentic pattern towards the base)
Sandwich sign(on longitudinal view, the altering hypo and hyperechogenic shadows of bowel wall, lumen and mesentry give rise to sandwich like pattern)
Pseudokidney sign(in longitudinal plane)
Enlarged lymphnodes maybe visible.
Presence of fluid in between layers of bowel indicate ischemia.
In older children the mass in the apex responsible for intussusception should be studied.
Barium enema For diagnosis as well as treatment. Barium enema
For diagnosis as well as treatment.

Investigations - Management

Fact Explanation
Ultrasound scan of the abdomen. To confirm that the intussusception has been reduced after treatment Ultrasound scan of the abdomen.
To confirm that the intussusception has been reduced after treatment
Color doppler Presence of blood flow indicates viability of the bowel thus barium enema would be the primary treatment modality, while absence of it suggests the need for surgical intervention. Color doppler
Presence of blood flow indicates viability of the bowel thus barium enema would be the primary treatment modality, while absence of it suggests the need for surgical intervention.
Ultrasound scan Presence of fluid between layers of bowel indicate ischemia, thus surgical reduction is needed. Ultrasound scan
Presence of fluid between layers of bowel indicate ischemia, thus surgical reduction is needed.

Management - Supportive

Fact Explanation
Pediatric surgical care maybe necessary. It is a surgical emergency. If pediatric surgical facility is not available, initial resuscitation and diagnosis with ultrasound should be done before transferring. Pediatric surgical care maybe necessary.
It is a surgical emergency. If pediatric surgical facility is not available, initial resuscitation and diagnosis with ultrasound should be done before transferring.
Intravenous fluids. Anticipate and manage possible hypovolemic shock. Inadequate fluid therapy may result in high mortality. Intravenous fluids.
Anticipate and manage possible hypovolemic shock. Inadequate fluid therapy may result in high mortality.
Antibiotics Routine antibiotics seem to be of small value. Antibiotics
Routine antibiotics seem to be of small value.

Management - Specific

Fact Explanation
Ultrasound (US) guided hydrostatic reduction. Exclude peritonitis (by abdominal examination) and bowel perforation (by presence of pneumoperitoneum in imaging). Hydrostatic reduction has a lesser chance of perforation than air reduction because hydrostatic pressure exerts a relatively more constant pressure than in air reduction. Ultrasound (US) guided hydrostatic reduction.
Exclude peritonitis (by abdominal examination) and bowel perforation (by presence of pneumoperitoneum in imaging). Hydrostatic reduction has a lesser chance of perforation than air reduction because hydrostatic pressure exerts a relatively more constant pressure than in air reduction.
Barium enema reduction. Exclude peritonitis and bowel perforation. Barium enema has high risk of radiation exposure while US guided reduction has none. Barium enema reduction.
Exclude peritonitis and bowel perforation. Barium enema has high risk of radiation exposure while US guided reduction has none.
Rectal air insufflation. Exclude peritonitis and bowel perforation. Caution should be taken to avoid perforation and subsequent pneumoperitoneum which could be life threatening. Great caution should be adopted if performed where emergency paediatric surgery is not readily available. Rectal air insufflation.
Exclude peritonitis and bowel perforation. Caution should be taken to avoid perforation and subsequent pneumoperitoneum which could be life threatening. Great caution should be adopted if performed where emergency paediatric surgery is not readily available.
Operative reduction. Laparoscopic and open surgery. Laparoscopic surgery is preferred over open surgery where an early diagnosis has been established and there are no signs of peritonitis.
Should be considered when rectal air insufflation or barium enema has failed or in the presence of a pathological lead point at the apex (mucocele of appendix, Meckel's diverticulum, Benign polyp, Ileal duplication, Lymphosarcoma).
The resected bowel should be sent for histopathological study.
Operative reduction. Laparoscopic and open surgery.
Laparoscopic surgery is preferred over open surgery where an early diagnosis has been established and there are no signs of peritonitis.
Should be considered when rectal air insufflation or barium enema has failed or in the presence of a pathological lead point at the apex (mucocele of appendix, Meckel's diverticulum, Benign polyp, Ileal duplication, Lymphosarcoma).
The resected bowel should be sent for histopathological study.

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