أسئلة الثامنة جراحة رابعة دمياط (أطفال)

• Intussusception involves the telescoping of a bowel segment (intussusceptum) into an adjacent segment (intussuscipiens).
• The incidence is highest in infants aged 5-9 months, with 80% of patients under 2 years old.
• Intussusception is the most common cause of intestinal obstruction in children aged 6 months to 2 years.
• Males are more frequently affected than females, with a ratio of 3:2.

Types of Intussusception

• Ileocolic is the most common type, where the terminal ileum telescopes into the right colon.
• Ileo-ileal intussusception also occurs.
• Colo-colic intussusception also occurs.

Etiology

• In 95% of cases, intussusception is idiopathic.
• Adenovirus infections may be a cause, with hypertrophied Peyer's patches often noted on the leading edge of the bowel, and incidence being higher in midsummer and midwinter.
• Mechanical factors can contribute, including Meckel's diverticulum, polyps, hemangioma, enteric duplication, intramural hematoma (Henoch-Schönlein purpura), and intestinal lymphoma.
• Postoperative intussusception can occur at any age due to differential return of bowel motility, especially after retroperitoneal surgery, with the site being ileoileal or jejunojejunal.

Clinical Picture

• Typical patients are well-nourished infants aged 3-12 months

Symptoms

• Abdominal pain is a key symptom, where the child awakens from sleep with severe abdominal colics and screams, drawing their knees up onto the abdomen, and it occurs in episodes lasting about 1 minute, alternating with periods of well-being where the child asks for food.
• Vomiting occurs in 85% of cases; it can be an early reflex caused by the pain, with late vomiting being due to bowel obstruction.
• Red currant jelly stool, which is mucus and blood, is passed per rectum, is not actually stool, and results from venous infarction.

Signs

• General signs include pallor and sweating which is common during colic, and progressive dehydration resulting from repeated vomiting and obstruction.
• Local signs detected upon inspection include a sausage-shaped mass, which is usually palpable along the colon's distribution, most commonly in the right upper quadrant of the abdomen, and distension, which is usually absent in early cases but denotes possbile perforation or gangrene.
• Signe de Dance is an empty right iliac fossa.
• Palpation can reveal distension.
• A DRE (digital rectal examination) reveals bloody mucus in 60% of cases, and sometimes the head of the intussusception can be felt.

Complications

• Prolonged intussusception can lead to edema and hemorrhagic or ischemic infarction of the intussusceptum which leads to gangrene.

Investigations

• Ultrasound examination plays a diagnostic role in 60-80% and can feature the "target sign".
• Barium enema serves a diagnostic and therapeutic role in cases of doubtful diagnosis and it shows the "claw sign." which is characteristic.

Treatment

• Preoperative resuscitation involves I.V. hydration, insertion of a NG tube, and antibiotics.

Hydrostatic vs Pneumatic Reduction

• Indicated in early cases.
• The method employs a contrast enema using either barium or air.
• If barium is used, the column of contrast should not stand > 100 cm above the patient to minimize perforation risks.
• If air is used, it is pumped into the colon at a pressure of 60-80 mm Hg, but never > 120 mm Hg
• Success Rate is 75-95%.
• Success of reduction is confirmed by free flow of barium or air into the small intestine for > 5cm, prompt clinical improvement with no further colics, and observation of the baby for 24 hours.

Contraindications

• Contraindications include a doubtful diagnosis, late cases, and abdominal distension or rigidity (suspected peritonitis).

Surgery

• Hydrostatic or pneumatic reduction fails or if there is presence of perforation or peritonitis from the start .
• Procedure: Squeeze method (milking).
• At laparotomy, the head of the intussusception is squeezed backwards out of the containing colon.
• The proximal ileum should never be pulled backwards to avoid intestinal tears.
• If the intussusception is irreducible or gangrenous, bowel resection and anastomosis is needed.