Laura Jackson Clinical Research Fellow Bristol Children’s Hospital

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

Epidemiology Most common cause of intestinal obstruction in infants and young children Incidence 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10 months M:F = 3:2 Seasonal variation – link with viral and respiratory infections Link with rotashield vaccine (now withdrawn)

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

Pathogenesis

80% are ileocolic 10% are ileoileal Caecocolic, Colocolic, ileoileocolic, jejunojejunal increasing rarity

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

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

Pathological Lead Points

Meckels Diverticulum

Peutz-Jeghers Syndrome

Duplication Cyst

Submucosal Haematoma

Lymphoma

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

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

Clinical Presentation Diarrhoea - 20% Lethargy as condition progresses Pallor

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

Well or unwell???

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

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

Target Sign Pseudokidney Sign

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

Initial Management Resuscitation!

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

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

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

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 mmHg –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

Air enema reduction

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

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

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

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

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

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

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

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

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

Any Questions?