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INTUSSUSCEPTION Vijisha Vijayan

INTUSSUSCEPTION Vijisha Vijayan

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INTUSSUSCEPTION Vijisha Vijayan

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  1. INTUSSUSCEPTION Vijisha Vijayan 2002 Batch

  2. DEFINITION “INTUSSUSCEPTION IS THE TELESCOPING OF ONE PORTION OF INTESTINE INTO THE OTHER, FROM PROXIMAL TO DISTAL, BY PERISTALSIS, PULLING THE MESENTERY ALONG WITH IT.”

  3. HISTORY • In the late 17th century, Paul Barbette described the invagination of one bowel segment into another • In 1971, Sir Jonathan Hutchison reported the first successful surgical resection

  4. AETIOLOGY • Primary or Idiopathic – usually in children • Secondary to a pathological lead point – incidence increases with age

  5. PATHOLOGICAL LEAD POINTS - Meckel’s diverticulum - Benign and malignant neoplasms - Appendix / appendiceal stump - Henoch-Schonlein Purpura - Jejuno-gastric Intussusception - Post-operative - Others

  6. PRIMARY / IDIOPATHIC INTUSSUSCEPTION

  7. PATHOLOGY • Composed of three parts -Entering inner tube -Returning or Middle tube -Sheath or Outer tube *Apex - advancing part *Intussusception – mass *Neck – junction of entering layer with mass

  8. NECK APEX

  9. It is an example of Strangulating Obstruction as the blood supply of the inner layer is impaired • The degree of ischaemia depends on the tightness of invagination • Later may lead to Gangrene and Perforation

  10. TYPES • Ileo colic77% • Ileo-ileo colic12% • Ileo-ileal5% • Colo colic2% • Multiple1% • Retrograde0.2%

  11. CLINICAL FEATURES • Age5-10 months • ABDOMINAL PAIN In children, suspicion should be aroused in case of a healthy child having sudden, severe, intermittent, cramping abdominal pain. Between the episodes of pain, the child is quiet. Later the child becomes lethargic

  12. VOMITINGBilious • RED-CURRANT JELLY STOOLS On examination, • Palpable abdominal mass, sausage-shaped, located in the right upper quadrant of abdomen, right lower region is empty – SIGN DE DANCE • Dehydration,abdominal distension • P/R Bleeding

  13. DIAGNOSIS • History • Physical examination • Confirm by investigations

  14. INVESTIGATIONS • Plain abdominal radiograph - air-fluid level with a paucity of gas in the right lower quadrant - sparse gas within the colon - soft tissue mass

  15. MULTIPLE AIR FLUID LEVELS

  16. Small bowel dilatation & paucity of gas in the right lower &upper quadrants .

  17. Ultrasound -’Target’ of intussuscepted layers of bowel on transverse view -’Pseudo-kidney’ sign when seen longitudinally

  18. PEUDO KIDNEY SIGN TARGET SIGN

  19. Barium enema – both diagnostic and therapeutic Pre-requisites; -intravenous hydration -nasogastric intubation -broad-spectrum antibiotics -sedation Finding – ‘claw-sign’

  20. Contraindications; 1). Peritonitis 2). Haemodynamic instability 3). Intussusception located fully in small intestine

  21. CLAW SIGN

  22. DESCENDING COLON INTUSSUSCEPTION

  23. TREATMENT 1) Hydrostatic Reduction Procedure - prepare patient - contrast material (Barium enema) is elevated 36 inches above the table and reduction monitored by fluoroscopy - reduction confirmed by resolution of mass, reflux of barium into proximal ileum Complication – perforation (1-3% ) Recurrence – 11%

  24. 2) Air reduction -Column of insufflated air is monitored so as not to exceed 80mmHg in infants <6 months and 120mmHg in older infants for periods of three minutes -Reduction is noted when caecal mass disappears and the small bowel becomes distended with air

  25. AIR REDUCTION IN INTUSSUSCEPTION

  26. 3) Operative management Indications; -Failure with previous methods -Recurrence -Peritonitis -Necrotic bowel

  27. Procedure; -Transverse muscle-cutting incision in right lower quadrant -Mass identified and manual reduction attempted by retrograde milking of the intussucepiens proximally, NEVER pull it out -Appendicectomy

  28. REDUCTION END TO END ANASTOMOSIS

  29. -If ischaemic and reduction not possible – LIMITED RESECTION with a primary end-to-end anastomosis -Perforation and significant fecal soiling - ENTEROSTOMY

  30. SECONDARY INTUSSUSCEPTION

  31. 1). MECKEL’S DIVERTICULUM • Diverticulum invaginates into intestine and is carried forward by peristalsis • May be ileoileal or ileocolic • Clinical features - urge to defaecate -early vomiting -red-currant jelly stools -palpable mass • Treatment – surgical resection

  32. 2). NEOPLASMS • Benign – common • Can cause partial or total bowel obstruction • Cramping abdominal pain • Palpable mass • Treatment - Surgery Colon: Intussusception with neoplasm - adenocarcinoma

  33. 3)APPENDIX • Rare • Difficult to diagnose – symptoms non-specific • Intussusception of appendiceal stump after appendicectomy –within 2 weeks post-operative -present as abdominal pain, vomiting, bleeding P/R, palpable mass • Diagnosis – Barium enema, CT scan • Treatment - Surgery

  34. 4). HENOCH-SCHONLEIN PURPURA • Causes sub-mucosal haematoma • Common in children

  35. 5). JEJUNO-GASTRIC INTUSSUSCEPTION • Rare, long-term complication of Billroth II surgery • Clinical features non-specific • Efferent limb, rather than afferent is the intussusceptum

  36. Diagnosis – water-soluble upper g.i. contrast study shows ‘coiled-spring’ appearance within gastric remnant • Endoscopy will show jejunal segments as they migrate in and out of gastric remnant between episodes of intussusception • CT Scan

  37. Treatment – Surgery 1) efferent limb can be anchored to the parietal peritoneum OR 2) a new GJ possibly using a Roux-en-Y reconstruction

  38. 6)INTERNAL INTUSSUSCEPTION • Laxity of rctal fixaton at the sacrum cause prolapse • It is a precursor to complete rectal prolapse • Incidence increased with ageing ,connective tissue disorders etc…

  39. Symptoms • Mucous discharge • Rectal bleeding • Incomplete evacuation INVESTIGATIONS • COLONOSCOPY • BARIUM ENEMA

  40. Treatment • Corret rectal prolapse • Glycerine suppository • Small enema SURGERY INDICATION – severe symptoms,chronic bleeding from ulcer,anal incontinance

  41. 7)POST OPERATIVE • Signs of early small bowel obstruction within a week of surgery

  42. 8)MISCELLANEOUS • Foreign body • Ectopic pancreatic or gastric tissue • Intestinal duplication

  43. SUMMARY • Intussusception is the telescoping of one portion of intestine into the adjacent part by peristalsis pulling the mesentery along with it • Abdominal pain ,vomiting and red currant jelly stools are the classical triad • Barium enema is both diagnostic and therapeutic

  44. Contd…. • Surgery if the above fails • The associated morbidity and occasional mortality is directly related to delay in diagnosis