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Refers to the invagination of one segment of the gastrointestinal tract into another adjacent section.
There are primary and secondary types which may involve the small bowel, small and large bowel and the colon alone.
Primary type usually in pediatric patients with 75-90% under the age of 2 years.
Most commonly seen in children younger than 1 year, and two thirds of children are younger than 1 year.
Most commonly, intussusception occurs in infants aged 5-10 months.
Estimated incidence is approximately 1 case per 2000 live births.
Overall, the male-to-female ratio is approximately 3:1.
Gender difference increases with age so that in patients older than 4 years, the male-to-female ratio is 8:1.
Most common cause of intestinal obstruction in patients aged 5 months to 3 years.
Condition occurs far more frequently among children and in most cases are primary cases and benign.
In children, the cause generally cannot be determined.
Account for as many as 25% of abdominal surgical emergencies in children younger than 5 years, exceeding the incidence of appendicitis.
Intestinal intussusception an uncommon condition and represents .003-.02% of hospitalizations, 1% of intestinal obstruction, and 5% of all intussusception.
Has been reported in the neonatal period, but is extremely rare.
Uncommon in children who are malnourished.
A common cause of abdominal pain in children suggested by a classic triad of signs and symptoms: vomiting, abdominal pain, and passage of blood per rectum.
The classic triad of vomiting, abdominal pain, and passage of blood per rectum occurs in only one third of patients.
Symptoms are often preceded by an upper respiratory infection.
Pain is colicky, severe, and intermittent.
Initially, vomiting is nonbilious, but is bilious when obstruction occurs, and any child with bilious vomiting is assumed to have intussusception.
Diarrhea can be an early sign.
Lethargy is a common finding.
Only 5% occur in adults
Intussusception-90% of cases primary type are without obvious cause but may show lymphoid hyperplasia in the terminal ileum wall.
Primary type lesions involve entercolic sites of ileocecal or ileocolic type in 80% of cases.
Secondary type lesions occur more frequently in adults and children over the age of 2 years.
Greater than 75% of adult intussusceptions related to an organic process that precipitates the event.
Adult intussusception is rare, accounting only for 1% to 5% of cases of bowel obstruction.
Adult intussusception usually presents with indolent symptoms.
Adult intussusception is less likely to be idiopathic in nature than childhood intussusception.
Adult intussusception more frequently associated with a pathologic predisposing factor.
Small intestine intussusception is mainly secondary to a benign etiology at includes: benign neoplasms, adhesions, Meckel’s diverticulum, lymphoid hyperplasia, celiac disease, presence of intestinal tubes, or following gastric surgery.
The abnormality occurs during peristalsis, and the associated section of bowel is tugged into the adjacent bowel causing invagination or intussusception.
Children present with the classic triad of cramping abdominal pain, bloody diarrhea, and a palpable tender mass.
In some patients, no lead is established and surgery may fail to reveal one.
Non-lead intussusception tends to be transient and may resolve spontaneously or with treatment of the underlying disease.
It is important to determine if the lead point or other indication for surgery such as bowel necrosis, exists prior to surgical intervention.
A CT scan maybe useful in discriminating lead point from non-lead point intussuusception.
Malignancy accounts for about 15% of cases of small intestine intussusceptions, with melanoma being the most common metastatic lesion.
Malignant etiology is more frequent in the large bowel accounting for 50% to 60% of cases.
Adenocarcinoma and lymphoma the most common underlying malignant lesions in the colon associated with intussusception.
Diagnosis is most often made by CT scan.
May be associated with a viral gastroenteritis or intra-abdominal surgery or a tumor in the intestine.
Most common Intussusceptions are found near the transition from the small to large bowel, so-called ileocolic intussusceptions.
Presents in 2 variants: idiopathic intussusception, which usually starts at the ileocolic junction and affects infants and toddlers, and enteroenteral intussusception (jejunojejunal, jejunoileal, ileoileal), which occurs in older children.
The latter is associated with Henoch-Schönlein purpura, cystic fibrosis, hematologic dyscrasias or may occur in the postoperative period.
Malignancies are related in 27-42% of adult intussusceptions with 33-54% of lesions in the colon and 13-24% of such lesions in the small bowel.
Secondary type lesions in children over the age of 2 years usually have a Meckel’s diverticulum or duplication cyst as the reason for the process.
Causes include tumors, endometrial implants, foreign bodies and unusual bowel infections such as ascariasis.
In the U.S. most cases due to benign or malignant neoplasms.
Felt to be secondary to an imbalance in the longitudinal forces along the intestinal wall, resulting in intestine invagination into the lumen of adjacent bowel.
The invaginating portion of the intestine telescopes into the receiving portion of the intestine.
The intussusceptum can proceed to the distal colon or sigmoid and even prolapse out the anus.
The mesentery of the intussusceptum is invaginated with the intestine, leading to bowel obstruction, impaired lymphatic drainage, increased pressure within the wall of the intussusceptum, and venous drainage is impaired, and if persistent arterial circution is inhibited, and infarction of the bowel ensues.
Ischemic mucosa sloughs off, leading to the heme-positive stools and subsequently to the classic “currant jelly stool”, a mixture of sloughed mucosa, blood, and mucus.
In approximately 2-12% of children with intussusception, a surgical lead point is found such as Meckel diverticulum[, enlarged mesenteric lymph node, tumors of the mesentery or of the intestine, including lymphoma, polyps, ganglioneuroma,and hamartomas associated with Peutz-Jeghers syndrome, mesenteric cysts,submucosal hematomas, cctopic pancreatic and gastric rests, appendiceal stumps, sutures and staples along an anastomosis, foreign bodies, intestinal hematomas.
Patients with hemophilia and other bleeding disorders may develop intestinal submucosal hematomas, which can lead to intussusception.
Intussusception is a rare postoperative complication, occurring in 0.08-0.5% of laparotomies, and is due to a difference in bowel activity between segments of the intestine recovering from an ileum.
Postoperative intussusception is suggested by a sudden onset of a small bowel obstruction after a period of ileus, usually within the first 2 weeks after surgery.
Indwelling jejunal catheters can lead to intussusception by acting as a lead point.
Occurs in approximately 1% of patients with cystic fibrosis precipitated by the thick, inspissated stool material that adheres to the mucosa and acts as a focal point.
The course in cystic fibrosis induced intussusception may be indolent and chronic.
Electrolyte abnormalities can produce aberrant intestinal motility and lead to intussusception.
An association was found between the administration of rotavirus vaccine and the development of intussusception.
It was suspected that the vaccine caused reactive lymphoid hyperplasia, which acted as a focal point to precipitate intussusception.
Rare case associated in a familial pattern.
In most infants and toddlers with intussusception have idiopathic intussusception.
Possible etiology of idiopathic intussusception: occurs because of an enlarged Peyer patch as often the illness is preceded by an upper respiratory infection, the ileocolic region has the highest concentration of lymph nodes in the mesentery, and enlarged lymph nodes are often observed in patients who require surgery.
The cause in adults is usually organic, occurring secondary to conditions that produce a mechanical lead point, carcinoma, polyps, Meckel’s diverticulum, colonic diverticulum, a structure, or a benign neoplasm.
Supine and upright plain radiographs of the abdomen identify the small bowel obstruction associated with intussusception.
Postoperative intussusception can take place independently of the site of the operation.
Indwelling jejunal catheters can lead to intussusception by acting as a focal point.
Experimental studies show that abnormal intestinal release of nitric oxide, an inhibitory neurotransmitter, causes relaxation of the ileocecal valve, predisposing to ileocecal intussusception.
Antibiotics may cause ileal lymphoid hyperplasia and intestinal dysmotility, with resultant intussusception.
Prognosis in patients with intussusception is excellent if the condition is diagnosed and treated early.
May result in severe complications and death.
The recurrence rate of intussusception after nonoperative reduction is usually less than 10%, but may be as high as 15%.
Most intussusceptions recur within 72 hours of the initial event, but recurrences have been reported as long as 36 months later.
More than 1 recurrence suggests the presence of a focal point abnormality in which case, surgical exploration should be contemplated performed.
The recurrence rates after air enema and barium enema are 4% and 10%, respectively.
Recurrences respond to nonoperative reduction in almost 95% of cases.
In about 80% of young patients, pneumatic for hydrostatic reduction via air enema or Bariun enema sufficient to resolve process. I
Complications include perforation during nonoperative reduction, wound infection, hernias, sepsis from peritonitis, intestinal hemorrhage bowel perforation, necrosis and bowel perforation and recurrence.
Mortality rate from intussusception in children is less than 1%.
Uniformly fatal in 2-5 days, if left untreated.
Children present with periods of lethargy alternating with crying every 15-30 minutes.
Physical findings include a right hypochondrium mass and emptiness in the right lower quadrant, and abdominal distention, peritonitis signs with abdominal rigidity and guarding.
Occult blood in the stools is the first sign of impaired mucosal blood supply and later hematochezia and the currant jelly stools appear.
Fever and leukocytosis are late findings and suggest bowel gangrene and infarction.
Often frequently have no classic signs and symptoms, and can lead to an unfortunate delay in diagnosis.
The differential diagnosis include: incarcerated hernia, other causes of intestinal obstruction, gastrointestinal allergy, adhesive band, volvulus, Meckel’s diverticulum, appendicitis, abdominal trauma, colic, and gastroenteritis.