Overview
Definition:
Intussusception is a pediatric surgical emergency where one segment of the intestine, known as the intussusceptum, telescopes into another segment, the intussuscipiens
This leads to obstruction, edema, and potential vascular compromise
Laparoscopic reduction aims to resolve this telescoping minimally invasively.
Epidemiology:
It is the most common cause of intestinal obstruction in infants and young children, typically occurring between 3 months and 3 years of age
The peak incidence is between 6 and 12 months
Idiopathic intussusception is more common in younger infants, while a lead point (e.g., Meckel's diverticulum, lymphoid hyperplasia, polyp) is found in a higher percentage of older children
The ileocolic region is the most common site (75-90%), followed by ileoileal and colocolic.
Clinical Significance:
Prompt diagnosis and management are crucial to prevent complications such as bowel ischemia, perforation, peritonitis, and even mortality
Laparoscopic techniques offer potential benefits of reduced pain, shorter hospital stays, and faster recovery compared to open surgery, making it a preferred approach for suitable candidates.
Clinical Presentation
Symptoms:
Sudden onset of intermittent, severe, colicky abdominal pain
Child appears well between episodes
Vomiting, which may become bilious if obstruction is significant
Passage of currant-jelly stool (mucus and blood) is a classic sign, but often occurs late or not at all
Lethargy or irritability may be present
Abdominal distension can occur in later stages.
Signs:
Palpable, sausage-shaped abdominal mass, often in the right upper quadrant or epigastrium
Tenderness on abdominal examination, which may be localized or generalized depending on the duration and severity
Peritoneal signs (rebound tenderness, guarding) indicate complications like perforation or ischemia
Signs of dehydration and shock may be present in severe cases
Digital rectal examination may reveal blood-stained mucus or the intussusceptum.
Diagnostic Criteria:
Diagnosis is primarily clinical, supported by imaging
While no formal diagnostic criteria exist, the combination of colicky abdominal pain, palpable mass, and currant-jelly stool in a child within the typical age range is highly suggestive
Ultrasound findings (target sign, pseudokidney sign) are considered the gold standard for diagnosis.
Diagnostic Approach
History Taking:
Detailed history of the onset, frequency, and duration of abdominal pain
Any preceding viral illness or vaccination should be noted
Character of emesis (non-bilious initially, then bilious)
Bowel movements (frequency, consistency, presence of blood or mucus)
Any history of prior abdominal surgery or known gastrointestinal anomalies
Red flags include persistent, severe pain, signs of peritonitis, or prolonged symptoms suggesting ischemia.
Physical Examination:
A thorough abdominal examination is paramount
Inspect for distension or surgical scars
Palpate for masses and tenderness, noting their location and consistency
Auscultate bowel sounds, which may be hyperactive early on and diminished with obstruction
Perform a digital rectal examination to assess for blood or the intussusceptum
Assess hydration status and vital signs.
Investigations:
Abdominal Ultrasound: High sensitivity and specificity for diagnosing intussusception
Findings include a target or pseudokidney appearance of the telescoped bowel loops, absence of peristalsis at the lead point, and presence of free fluid
Plain abdominal X-rays: May show signs of bowel obstruction (dilated loops, air-fluid levels) and a paucity of gas in the right lower quadrant (if ileocolic)
Can also help rule out perforation (free air)
Laboratory tests: Complete blood count (CBC) to assess for leukocytosis and anemia
electrolytes and renal function tests to assess hydration status and electrolyte balance
Contrast enema (radiographic or air): Historically used for diagnosis and therapeutic reduction, but less common now with ultrasound
It can confirm intussusception and potentially reduce it if performed under fluoroscopic guidance.
Differential Diagnosis:
Gastroenteritis: Common in infants and young children, but typically associated with diarrhea rather than severe colicky pain
Mesenteric adenitis: Often follows a viral illness and causes abdominal pain, but a mass is usually absent
Appendicitis: Pain is typically migratory and associated with fever and localized tenderness
Volvulus: Can cause obstruction, but pain is usually constant and severe
Pyloric stenosis: Presents with projectile vomiting in younger infants, typically around 4-6 weeks of age.
Management
Initial Management:
NPO (nil per os) status
Intravenous fluid resuscitation to correct dehydration and electrolyte imbalances
Nasogastric tube insertion for gastric decompression if vomiting is significant or obstruction is evident
Pain management with analgesics
Close monitoring of vital signs and abdominal status.
Medical Management:
Not applicable for definitive treatment of intussusception
Antibiotics are indicated if perforation or peritonitis is suspected.
Surgical Management:
Indications for surgery include: failure of non-operative reduction, signs of perforation or peritonitis, suspicion of a lead point that cannot be reduced laparoscopically (e.g., tumor), strangulation, or prolonged duration of symptoms leading to bowel compromise
Laparoscopic reduction is the preferred surgical approach
It involves diagnostic laparoscopy to confirm the intussusception
Reduction is then performed gently, manually or with laparoscopic graspers, by milking the intussusceptum out of the intussuscipiens
Careful assessment of bowel viability is crucial
If irreducible or if signs of non-viability are present, conversion to open surgery and resection of compromised bowel with or without anastomosis may be necessary
If a clear lead point is identified and easily removable (e.g., small polyp), it may be resected laparoscopically
For extensive lead points or non-viability, bowel resection and anastomosis (ileocolic anastomosis, or ileo-rectal anastomosis for certain cases) is performed
The use of a laparoscopic linear stapler can facilitate resection and anastomosis.
Supportive Care:
Postoperative care includes continued NPO status until bowel sounds return and flatus is passed, followed by gradual advancement of diet
Intravenous fluids and analgesia are continued as needed
Antibiotics are usually continued postoperatively if given preoperatively
Close monitoring for signs of complications such as leak, ileus, or wound infection
Early mobilization is encouraged.
Complications
Early Complications:
Recurrent intussusception (especially if a lead point is present and not addressed)
Bowel perforation
Peritonitis
Intra-abdominal abscess
Wound infection (in laparoscopic or open surgery)
Anastomotic leak (if resection performed)..
Late Complications:
Bowel obstruction due to adhesions
Chronic abdominal pain
Short bowel syndrome (rare, following extensive resection).
Prevention Strategies:
Prompt diagnosis and timely reduction (operative or non-operative) are key to prevent ischemia and perforation
Careful assessment of bowel viability during surgery
Meticulous surgical technique to minimize adhesions
Addressing identifiable lead points during surgery, when feasible.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and treatment
Presence of complications such as perforation or ischemia
Age of the child
Underlying cause (lead point)
Successful reduction (non-operative or operative).
Outcomes:
With prompt diagnosis and treatment, the prognosis is generally excellent
Recurrence rates vary but are typically around 2-10%
Laparoscopic reduction is associated with shorter hospital stays and quicker recovery compared to open surgery
Outcomes after resection and anastomosis are generally good, with recurrence rates influenced by the nature of the lead point.
Follow Up:
Follow-up is typically recommended to monitor for recurrence, especially in children with identified lead points
This may involve clinical assessment and potentially imaging if symptoms recur
For children who have undergone bowel resection, long-term follow-up may be necessary to assess for growth and potential nutritional deficiencies.
Key Points
Exam Focus:
The most common site is ileocolic
Peak incidence is 6-12 months
Ultrasound is diagnostic (target sign)
Laparoscopic reduction is preferred for suitable cases
Indications for surgery include failed reduction, peritonitis, or non-viability
Recurrence is a known complication.
Clinical Pearls:
Always consider intussusception in an infant with colicky abdominal pain, even without currant-jelly stool
The palpable mass is often mobile and may be mistaken for constipation
Be prepared to convert to open surgery if laparoscopic reduction is not feasible or if bowel viability is questionable.
Common Mistakes:
Delayed diagnosis due to misinterpretation of symptoms as simple gastroenteritis
Failure to adequately assess bowel viability during surgery
Inadequate fluid resuscitation in critically ill children
Aggressive non-operative reduction attempts in the presence of peritoneal signs.