RECURRENT INTUSSUSCEPTION IN AN INFANT

Dr. Rashidi AhmadEmergency Department

HUSM

OBJECTIVES

• Incidence of recurrent intussusceptions

• Radioimaging diagnosis and therapeutics

• The best option of intussusceptions management in ED

INTRODUCTION

• The commonest cause of intestinal obstruction among infant and young childhood

• Leading cause of mortality of GI emergencies

Jay L Grosfeld. Intussusception Then and Now: A historical Vignette. J Am Coll Surg, 2005:830-832

MANAGEMENT OPTIONS• Management option

surgical non-surgical

pneumatic barium

● Non-surgical reduction proves to be superior to surgery

Eur J Pediatr 1999;158:707- 710.

ISSUES

• Risk of recurrence is 0-5.4% (post surgery)

• The recurrence may be overlooked by junior or inexperienced doctors

Koh C-C, Sheu J-C, Wang N-L, et al. Pediatr Surg Int 2006 September);22:725- 728

Recurrent intussusception post surgical reduction

• What is the best tool to detect intussusceptum and intussuscepient

• Conservative (barium or pneumatic reduction) versus surgical reduction

CASE PRESENTATION

10/12 old boy with acute onset of abdominal pain andvomiting

abdominal pain and vomiting since early morning

NBO and crying throughout the day

Less active and poor oral intake

CHIEF COMPLAINT

PRESENTING ILLNESS

Vitals sigs:NormalAfebrileFairly hydrated

Abdomen: soft, no palpable mass

Other systems unremarkable

CLINICAL FINDINGS

PAST MEDICAL HISTORY

Intussusception at 8/12 old –underwent surgical reduction(? type of surgery) (? reason for failed non-surgical reduction)

Supine abdominal radiograph

Plain abdominal radiograph

• Normal radiograph does not exclude the diagnosis

• Significant signs:

- target sign

- paucity of air in the bowel

- little or no stool in the colon or small

- bowel soft tissue mass in the RUQ (50%)

- SBOJames D’Agostino, 2002

SIEMENS Elegra MEDISonoline

Color Doppler USG

• Estimate the reducibility

- color signal within intussususceptum

• Predicts bowel ischemia

- does not always true

Urgent pneumatic reduction

• Patient was sedated

• Prone position

• Foley’s catheter sized 22F inserted into the rectum

• Air inflated till 120 mmHg and sustained at about 80 mmHg for 30 min

1st trial 2nd trial

PSEUDOKIDNEY?• Thick-walled “doughnut” (intussuscepiens)

with inner echogenic mesenteric fat (intussusceptum)

CLINICAL PROGRESSION

• Close observation in pediatric surgical ward

• Discharged well on the second day of pneumatic reduction

FINAL DIAGNOSIS

RECURRENT INTUSSUSCEPTION

RECURRENT INTUSSUSCEPTION

• Early diagnosis is crucial• Index of suspicious • Ultrasonography has a high diagnostic accuracy

rate for intussusception and safer than x-rays• Pseudokidney? S & S (94%)• Suggestion: NO MORE x-ray in suspected

intussusception

Harrington et al. Ultrasonography and Clinical Predictors of Intussusception. Journal of Paed 1997;132:836-839

• Factors affecting the successfulness of pneumatic reduction–Coexisting intestinal pathology–Delay in diagnosis

Journal of Pediatric Surgery 2007;42:1504-1508

CONCLUSION

• Ultrasonography is the best diagnostic method of intussusception

• A successful pneumatic reduction of intussusception require a multidisciplinary approach

Harrington et al. Journal of Pediatrics 1997;132:836-838K Rosenfeld, K McHugh. Clinical Radiology 1999;54:452-458