Laura Jackson Clinical Research Fellow Bristol Children’s Hospital

1. Laura Jackson Clinical Research Fellow Bristol Children’s Hospital

2. History of Intussusception • First described in 1674 • First successful operation in a 2 year old child in 1873 • Harald Hirschsprung described a systematic approach to hydrostatic reduction in 1876 • Holt described air reduction enema in 1897 • Ravitch popularised barium enema reduction

3. Epidemiology • Most common cause of intestinal obstruction in infants and young children • Incidence 1.5-4 cases per 1000 live births • 90% of patients present between 3 months and 3 years • 50% of cases occur between 3 and 10 months • M:F = 3:2 • Seasonal variation – link with viral and respiratory infections • Link with rotashield vaccine (now withdrawn)

4. Pathogenesis • Telescoping of one portion of intestine into the adjacent more distal intestine • Proximal portion is the intussusceptum • Distal portion is the intussuscipiens

5. Pathogenesis

6. Pathogenesis • 80% are ileocolic • 10% are ileoileal • Caecocolic, Colocolic, ileoileocolic, jejunojejunal increasing rarity

7. Pathogenesis • Primary (idiopathic) • Most common type • 88-98% of cases • Principally seen in infants • Assumed to be related to hyperplasia of Peyers patches which act as lead point • Adenoviruses and rotavirus have been implicated in up to 50% of cases

8. Pathogenesis • Secondary (Pathological lead point) • 2-12% cases • Occur more commonly outside typical age range • 20% of children >2 years have a pathological lead point • 95% adults have pathological lead point • Should be sought in recurrent intussusception

9. Pathological Lead Points

10. Meckels Diverticulum

11. Peutz-Jeghers Syndrome

12. Duplication Cyst

13. Submucosal Haematoma

14. Lymphoma

15. Other Pathological Lead Points • Benign/malignant tumours • Foreign body • Gastrojejunostomy tubes • Ectopic pancreatic/gastric mucosa • Inspissated stool (CF)

16. Clinical Presentation • Sudden onset of symptoms in an otherwise healthy infant • Colicky abdominal pain - 80-100% • Vomiting - 80% • Blood and mucus per rectum (redcurrant jelly) - 60% • Triad of above three symptoms in 1/3 patients

17. Clinical Presentation • Diarrhoea - 20% • Lethargy as condition progresses • Pallor

18. Physical Examination • General • Relatively well child if early presentation • Lethargic • Irritable • Pale • Dehydrated • Fever • Shock (septic/hypovolaemic)

19. Well or unwell???

20. Well or unwell???

21. Physical Examination • Abdominal • Sausage shaped mass, usually RUQ (60-80%) • Empty RLQ • Blood stained mucus on PR • Intussusceptum palpable PR • Prolapse of intussusceptum through anus • Peritonitis if perforation

22. Imaging • Abdominal USS gold standard investigation • Sensitivity>98% • Specificity 100% in experienced hands • Target sign on transverse section • Pseudokidney sign on longitudinal section • Amount of abdominal free fluid can be determined • Doppler to show blood flow within intussusception

23. Pseudokidney Sign Target Sign

24. Imaging • AXR • Normal • Small bowel obstruction • Abnormal distribution of gas • Soft tissue mass • Contrast enema • Diagnostic and therapeutic • Meniscus Sign • Coiled spring sign • CT • Intraluminal mass • Characteristic layered appearance

25. Initial Management • Resuscitation! • Resuscitation! • Resuscitation!

26. Initial Management • IV access • FBC, electrolytes • IV fluids • Fluid bolus – Minimum 20ml/kg 0.9% NaCl • Deficit + maintenance + ongoing losses • Large bore nasogastric tube • Analgesia • IV paracetamol, morphine • IV antibiotics • Amoxicillin, metronidazole, gentamicin

27. Non-Operative Management • Fluoroscopically Guided • Hydrostatic Reduction • Water soluble contrast • Pneumatic Reduction • Air • Carbon dioxide • USS Guided • Hydrostatic • Saline solution • Pneumatic • Air

28. Non-Operative Management • Hydrostatic Reduction • Foley catheter inserted into rectum • Contrast allowed to run into rectum from a height of 3m above the patient • Progress monitored fluoroscopically • Constant hydrostatic pressure is continued as long as reduction occurs • Can be repeated 2 or 3 times • Reduction achieved when free flow of contrast into distal ileum

30. Non-Operative Management • Pneumatic Reduction • Fluoroscopic monitoring • Foley catheter inserted into rectum • Catheter connected to pressure monitor with cut off at 120mmHg • Initial pressure of 80-100mmHg • Up to 3 attempts of 3 minutes duration • Over 90% successful reduction are performed with screening time of < 10 minutes • Reduction achieved when reflux of air into ileum • Successful in 75-80% of cases

31. Air enema reduction

32. Pros of pneumatic reduction • Quicker • Less messy • At least equally efficacious with hydrostatic reduction • Minimal contamination if perforation occurs

33. Cons of pneumatic reduction • Tension pneumoperitoneum • Poor visualisation of lead points • Relatively poor visualisation of reduction process resulting in false positive reductions

34. Non-Operative Management • Hydrostatic or pneumatic reduction may be repeated after 2-4 hours if child stable • 50% success rate at second sitting • If reduction successful then usually kept NBM for 12 hours • Complications • Perforation rate 1% • False positive reduction • Failed reduction • More likely if history >48hours

35. Operative Management • Required in children with • Peritonitis • Shock • Incomplete hydrostatic or pneumatic reduction • Residual intraluminal filling defect after enema reduction • Suspected ileo-ileal intussusception • Child with condition pre-disposing to a lead point

36. Procedure • Right sided transverse muscle cutting incision • Deliver caecum • Manipulate bowel pushing lead point back to normal position • Resection if questionable viability or unable to reduce (40-50%) • Examine for pathologic lead point

38. Laparoscopic Management • Controversial role • Earlier reports concluded there is often little role for laparoscopy • Role in recurrent intussusception • Role in questionable but probable reduction • However more recent reports • Completed lap in 70-95% • No difference in complications • Shorter length of stay • Shorter time to feeds

39. Recurrent Intussusception • Up to 10% of cases have a recurrence • 30% in 24 hours • 70% in 6 months • Less likely to occur after surgical reduction • 1-4% of cases • Success of air enema reduction for recurrence comparable to initial episode • Investigate for lead point if • <2 years old with more than 2 recurrences • >2 years old with 1 recurrence

40. Post-operative Intussusception • Accounts for 5% intussusceptions overall • Most occur within 1 month of procedure (average 10 days) • After thoracic surgery • After abdominal surgery • Particularly after retroperitoneal dissection • Post-op chemo or radiotherapy • Ususally ileo-ileal • ? Resumption of proximal small bowel peristalsis with persisting distal ileus • Preferred operative treatment

41. Long-Term Outcomes • Mortality approx 1% • Preterm neonates mortality higher (20%) • Excellent long-term outlook even if recurrent • If due to an underlying disease prognosis usually determined by underlying disease

42. Any Questions?