Intussusception

Overview

Intussusception occurs when a piece of the intestine folds into the one next to it. Intussusception normally affects the small intestine and, in rare cases, the big bowel. Symptoms include intermittent stomach discomfort, vomiting, bloating, and bloody stool. It might cause a slight bowel blockage. Peritonitis and intestinal perforation are two more possible consequences.

 

Intussusception definition

Intussusception is a condition in which a section of the intestine invaginates into the adjacent intestinal lumen, obstructing the bowel. The death rate from intussusception in children is less than 1% with early diagnosis, proper fluid resuscitation, and management. However, if left untreated, this illness is always lethal within 2-5 days.

In children, the reason is usually unclear, although in adults, a cancer-related lead point is frequently evident. Infections, cystic fibrosis, and intestinal polyps are all risk factors in youngsters. Endometriosis, bowel adhesions, and intestinal malignancies are all risk factors in adults. Medical imaging is frequently used to support a diagnosis. In children, ultrasonography is the recommended diagnostic modality, however in adults, a CT scan is preferable.

Intussusception need immediate treatment. In most cases, children are treated with an enema, followed by surgery if the enema is unsuccessful. Adults are more likely to require the removal of a portion of their intestines. Children are more often than adults to suffer from intussusception.

Intussusception is more prevalent in children than in adults, and it is more common in boys than in girls. The average age of incidence is six to eighteen months.

 

Epidemiology

Intussusception is usually diagnosed in infancy and early childhood.

• In the first year of life, about 2000 children in the United States suffer with intussusception.
• Intussusception normally appears around five months of age, peaks between four and nine months, and then progressively reduces about 18 months.
• Intussusception affects boys more commonly than females, with an about 3:1 ratio.
• In adults, intussusception accounts for 1% of intestinal blockages and is linked to neoplasia.

 

Etiology

The causes of intussusception are unknown. Approximately 90% of occurrences of intussusception in children are caused by an unknown source. Infections, anatomical causes, and altered motility are some of them.

Known causes may include:

• Infections
• Anatomical factors
• Altered motility
• Meckel's diverticulum
• Duplication
• Polyps
• Appendicitis
• Hyperplasia of Peyer's patches
• Idiopathic

Intussusception was supposed to be caused by an early type of the rotavirus vaccination that is no longer used, but the newer vaccines are not firmly connected.

 

Pathophysiology

The ileum usually enters the cecum. A section of the ileum or jejunum seldom prolapses into itself. Almost all intussusceptions occur when the intussusceptum is close to the intussuscipiens. This is due to the intestine's peristaltic motion, which draws the proximal section into the distal segment.

• The intussusceptum is the component that prolapses into the other.
• The intussuscipiens is the portion that receives it.
• Approximately 10% of intussusceptions have an anatomic lead point.

Ischemia can occur if the confined piece of bowel loses its blood supply. Ischemia sensitizes the mucosa, which reacts by sloughing off into the stomach. This results in a "red currant jelly" stool composed of sloughed mucosa, blood, and mucus. "Red currant jelly" occurs in a small percentage of instances of intussusception and should be investigated in the differential diagnosis of any bloody stool in youngsters.

 

Intussusception symptoms

Periodic abdomen discomfort, nausea, vomiting (green from bile), dragging legs to the chest, and cramping abdominal pain are early signs. Because the gut segment sometimes stops contracting, the pain is sporadic.

Later symptoms include rectal bleeding, which is typically accompanied by "red currant jelly" feces, and tiredness. A "sausage-shaped" lump may be discovered during a physical examination. Children may weep, bring their knees up to their chest, or have dyspnea with pain paroxysms.

Fever is not a sign of intussusception, although a loop of bowel may become necrotic as a result of ischemia, leading to perforation and infection, both of which induce fever.

Intussusception is an uncommon complication of Henoch-Schönlein purpura. In addition to the usual symptoms of Henoch-Schönlein purpura, such individuals frequently report with significant stomach discomfort.

Physical examination

Intussusception is distinguished by a right hypochondrium sausage-shaped mass and emptiness in the right lower quadrant (Dance sign). This lump is difficult to detect and is best palpated between colic spasms when the infant is peaceful. If the blockage is complete, abdominal distention is common.

 

Diagnosis

Examination, including observation of the Dance sign, is frequently used to suspect intussusception. The dance sign involves examining the right lower quadrant of the abdomen for retraction, which might be an indicator of intussusception.

• A digital rectal examination is beneficial because a finger can detect the intussusceptum.
• Imaging modalities must be used to confirm a definitive diagnosis.
• Ultrasound is the preferred method of diagnosing intussusception. The emergence of the target sign or doughnut sign, which is typically roughly 3 cm in diameter, confirms the diagnosis.
• The picture generated by the hyperechoic central core of intestine and mesentery surrounded by the hypoechoic outside edematous bowel on transverse sonography or computed tomography is a doughnut shape.
• Intussusception may appear as a sandwich on longitudinal imaging.

An abdominal x-ray may be required to rule out intestinal blockage. An air enema can be used to diagnose a condition, and the same process can be used to cure it.

 

Ultrasound for intussusception

When Ultrasound imaging is in dispute, a CT scan is sometimes utilized to make a diagnosis. In young children, however, getting a CT scan frequently necessitates the use of anesthesia, and there is also the danger of intravenous contrast and radiation exposure.

 

Management

Clinically, separating children with intussusception into two categories is aided by a cutoff age of three years. Patients with intussusception aged 5 months to 3 years seldom have a lead point (ie, idiopathic intussusception) and are frequently receptive to nonoperative reduction. Adults and older children are more likely to have a surgical lead point to the intussusception and require operational reduction.

When compared to nonpediatric institutions, specialist pediatric hospitals had a lower rate of operational intussusception care. This is due to growing familiarity with the application of various radiologic reduction strategies.

Intussusception seen in patients older than age 2-3 years may be associated with various medical conditions or situations. The intussusception in these patients is usually small bowel to small bowel; therefore, therapeutic enemas are less helpful and are usually unsuccessful.

Start the infant on a regular age-appropriate diet as tolerated a few hours following nonoperative reduction. If a surgical reduction was performed, the diet should be advanced as with any postoperative patient. The only restrictions on activities after intussusception therapy are those imposed by the postoperative condition.

Cases that cannot be resolved non-surgically necessitate surgical intervention. During surgical reduction, the surgeon physically squeezes the telescoped component. If the surgeon is unable to decrease it successfully, the afflicted portion is surgically removed. Intussusception can also be treated by laparoscopy, which involves pushing the intestinal segments apart using forceps.

 

Surgical Reduction

If nonoperative reduction fails or there is apparent perforation, the newborn should be sent for surgical therapy as soon as possible.

The traditional method of entering the abdomen is by a right paraumbilical incision. Deliver the intussusception into the wound and try to reduce it without surgery. It is critical to extract the intussusceptum from the intussuscipiens. To avoid iatrogenic perforation, maintain modest physical pressure rather than ripping out the intussusceptum.

If operational reduction is effective, appendectomy is frequently performed if the appendix's blood supply is impaired. A cecopexy is not required. The risk of recurrence of intussusception following surgical reduction is less than 5%.

If manual reduction is not possible or there is perforation, a segmental resection with an end-to-end anastomosis is performed. A thorough check for any possible lead points is recommended, especially if the patient is older than 2-3 years.

In the treatment of intussusception, laparoscopy has been introduced to the surgical toolbox. In all instances of intussusception, laparoscopy can be done. It has been reported that intussusception can be reduced, radiologic reduction can be confirmed, and lead points can be detected.

Laparoscopy is related with shorter recovery times, shorter lengths of stay, shorter time to full feeds, and reduced pain medication usage.

 

Differential Diagnosis

• Abdominal hernias
• Appendicitis
• Blunt abdominal trauma in emergency medicine
• Colic
• Cycling vomiting syndrome
• Emergent treatment of gastroenteritis
• Gastric volvulus
• Internal hernia
• Testicular torsion
• Volvulus

 

Prognosis

If intussusception is detected and treated early, the prognosis is favorable; otherwise, serious complications and death may ensue.

The recurrence rate of intussusception following nonoperative reduction is typically less than 10%, but has been reported to be as high as 15%. The majority of intussusceptions repeat within 72 hours of the original incident; however, recurrences have been documented up to 36 months later. The presence of a lead point is indicated by the occurrence of more than one repetition.

A recurrence is frequently preceded by the emergence of the same symptoms that were present during the first incident. If a recurrence occurs, handle it similarly until the notion of a lead point is very strong.

The recurrence rates after air enema and barium enema are 4% and 10%, respectively. Recurrences respond to nonoperative therapy in more than 95% of cases. Complications related with intussusception include the following, which occur seldom when the diagnosis is prompt:

Perforation during nonoperative reduction

• Wound infection
• Internal hernias and adhesions causing intestinal obstruction
• Sepsis from undetected peritonitis 
• Intestinal hemorrhage
• Necrosis and bowel perforation
• Recurrence

 

Intussusception in Adults

Adult intussusception is a difficult diagnosis that necessitates a high level of clinical suspicion. The difficulties arise because abdominal pain is not only one of the most commonly assessed complaints in the emergency room, but it is also a vague complaint. The intensity of signs and symptoms present during the examination determines the severity of stomach pain assessment and therapy.

Although a history, physical exam, and lab values might help, imaging is typically required to make a diagnosis. Adults find it difficult to identify intussusception since it mimics many other conditions. If not appropriately identified, it can lead to significant consequences and poor patient outcomes.

Surgical intervention is the definitive therapy, and good patient outcomes are dependent on rapid diagnosis and the recruitment of an interprofessional team comprised of doctors, nurses, and technicians. This exercise focuses on gaining a thorough grasp of this uncommon but potentially life-threatening emergency. 

 

Etiology

Unlike in children, approximately 90% of adult cases had a pathological lead point, most usually a tumor. Other risk factors include: 

• Mass (benign or malignant)
• Anatomical changes 
• Post-surgical adhesions
• Endometriosis
• Idiopathic
• Fibroids
• Gastrostomy tube
• Jejunostomy tube

 

Pathophysiology

Intussusception is a condition in which a segment of the intestine folds into the section next to it. A part of the proximal colon slips into the neighboring distal segment, causing bowel blockage and intestinal ischemia.

The blood flow to the afflicted gut is squeezed, compromising its function. Perforation and sepsis occur when a section of the intestine becomes necrotic as a result of ischemia; the patient becomes feverish as a result of this process. Fever is typically not a sign of intussusception until necrosis and intestinal perforation have occurred.

Intussusception normally affects the small intestine and, in rare cases, the big bowel. Cramping stomach discomfort, which can be sporadic or continuous, vomiting (which can be bilious), bloating, and even bloody feces are all symptoms.

It can cause intestinal blockage, either little or big. Secondary to problems such as intestinal necrosis or infection, the patient may develop signs and symptoms of decompensation such as hypothermia or hyperthermia, hypotension, and tachycardia. Peritonitis and intestinal perforation are two more possible consequences.

Adult intussusception is classified into four major groups based on the place of genesis. The four most prevalent categories are as follows:

• Enteric
• Ileocolic
• Ileocecal
• Colonic

The enteric and colonic kinds can only be found in the small and large intestines, respectively. Ileocolic intussusceptions occur when an ileum segment protrudes into the colon via the ileocaecal valve. Furthermore, ileocaecal intussusceptions are distinguished by the ileocecal valve as the leading point. Although it may be recognized radiologically, clinical judgment based on the presentation can be quite difficult for the ileocecal and ileocolic.

 

Symptoms 

The history and physical examination, while important, may not give significant clues to the diagnosis, but they can guide care. One of the most prevalent ailments addressed in the emergency room is abdominal discomfort.

Adult intussusception patients will complain of stomach discomfort, bloating, nausea, and vomiting. The discomfort might come and go, and the vomiting can be bilious. If the patient suffers from ischemia as a result of bowel telescoping, they may experience bloody diarrhea due to the sloughing of necrotic tissue. Necrosis can cause intestinal perforation, resulting in peritonitis. Patients may acquire fever as a result of sepsis, which is a late discovery.

A physical examination may reveal diffuse or localized stomach discomfort, bloating, and reduced bowel sounds. As a result of intestinal ischemia, pain may be disproportionate to inspection.

 

Evaluation

Abdominal computed tomography (CT) appears to be the most sensitive diagnostic tool in obtaining a preoperative diagnosis of adult intussusception, particularly in individuals with non-specific abdominal discomfort.

It is also useful in discovering pathological lesions that may act as lead points, guiding in the identification of potentially life-threatening vascular compromise, and, interestingly, it can anticipate the probability of self-resolution in some cases. 

Furthermore, while the ultrasound abdomen has a lower sensitivity in diagnosing adult intussusception than the abdominal CT, it can identify the typical target sign in some cases, particularly in individuals presenting with a palpable abdominal mass, where it is more than 90% sensitive.

Furthermore, plain abdomen films and upper and lower contrast investigations play only a little impact in the diagnosis of this illness. Target and doughnut signs are seen in transverse view, while the pseudo-kidney sign is seen in longitudinal view. Ultrasound has various drawbacks, two of which are the masking of recognizable characteristics by gas-filled intestinal loops and operator reliance.

 

Management

The emergency department's management is helpful. Depending on the patient's appearance, it is critical to offer pain management, antiemetics, IV hydration, a nasogastric tube, and maybe antibiotics. Patients suspected of having intussusception should be placed on NPO in preparation for surgical surgery.

Because of the increased risk of cancer, adult intussusception demands surgical surgery. Due to the high occurrence of underlying intestinal cancer, formal resections utilizing suitable oncologic procedures are recommended in patients with ileocolic, ileocecal, and colo-colic intussusceptions. The dangers of manipulating the tumor include tumor cell spread.

The surgical treatment is determined by the location, size, and etiology of the intussusception, as well as the viability of the intestine. In most situations, laparotomy is used to determine the source of intussusception. The laparoscopic or open surgery is determined by the patient's clinical state and, in particular, the surgeon's advanced laparoscopic experience.

The following approach is adopted based on the location of the lesion. 

 

Colo-Colic intussusception:

The management of colo-colic intussusception is frequently disputed. Because most adult intussusceptions have underlying disease, laparotomy rather than reduction is also favored. The sole point of contention is whether or not the intussusception lesions should be minimized during the procedure. Previous research indicates that decreasing lesions before resetting them is preferable.

The main downside of this approach is the likelihood of the underlying malignant cells spreading. While another school of thought supports this since it may avoid needless bowel resection, small gut syndrome is easily prevented. 

 

Gastroduodenal intussusceptions:

Typically, the reduction of followed by surgical excision of the lead point is required for the treatment of gastroduodenal intussusceptions.

 

Coloanal intussusceptions:

In coloanal intussusceptions, clinicians frequently agree on reducing the lesion first, followed by surgical excision. This method is also beneficial to the patient's future quality of life because it results in sphincter-saving surgery. However, decreasing the lesion might be difficult and may result in the spread of the malignant cells.

Most physicians use the abdominal method for resection, although in recent years, practitioners have been using the perianal and anal approaches more frequently. 

 

Key points during the surgical approach:

• When trying reduction, one important characteristic is to extract the intussusceptum from the intussuscipiens.
• Never pull out the intussusceptum; always apply modest physical pressure. It may result in iatrogenic perforation.
• When the operational reduction is effective, an appendectomy can frequently be performed; nevertheless, the blood supply of the appendix is critical to this method.
• The majority of the evidence does not support cecopexy since the chance of recurrence is 5% even after resection.
• Finally, selecting between a laparoscopic and an open technique is a contentious subject. The laparoscopic technique is chosen depending on the surgeon's competence and the general condition of the patient.

 

Prognosis

Given the rarity of this condition and the incidence of malignancy, the prognosis is often poor. Because of its unusual character, diagnosis and adequate treatment are frequently delayed. When the patient is on the operating table, the physician generally makes the definite diagnosis, and delays in treatment can lead to serious complications with high death rates.

Intussusception has the potential for life-threatening consequences because to the high likelihood of delayed identification due to ambiguous symptoms and large working differential diagnosis.

Complications Include:

• Peritonitis 
• Bowel ischemia
• Bowel necrosis 
• Bowel perforation 
• Sepsis 
• Tumor Seeding

 

Conclusion 

If not treated promptly, intussusception is a medical emergency that can lead to death. Death is practically unavoidable in impoverished nations.

An interprofessional team comprised of a radiologist, pediatrician, emergency department physician, and pediadritic surgeon manages the disease. The vast majority of instances are successfully decreased non-surgically. Cases that cannot be decreased by air or barium require surgery. In most cases, no bowel resection is necessary. Complications are uncommon following surgery, and recurrences are extremely rare.

Adult intussusception is uncommon and difficult to diagnose. The administration, on the other hand, is straightforward. Early detection of the illness process is critical for reducing pre-surgical or even operational problems and achieving favorable results.

If treated promptly, the prognosis for intussusception is favorable; but, if left untreated, it can result in death within two to five days. The longer an intestinal segment remains prolapsed and without a blood supply, the less successful a non-surgical reduction becomes. Prolonged intussusception causes intestinal ischemia and necrosis, which necessitates surgical excision.