Intussusception Treatment in Child

Intussusception is a medical emergency in which a segment of the intestine (intussusceptum) telescopes into an adjacent segment (intussuscipiens), leading to bowel obstruction, compromised blood flow, and potential ischemia.

• Age group: 6 Months to 3 Years; 90% present within the first three years.
• Common cause of bowel obstruction in children aged .
• Most cases are of ileo-colic variety caused by reactive hyperplasia of Peyer’s patches in the terminal ileum in response to upper respiratory or gastrointestinal infections.
• Small bowel intussusceptions such as jejuno-jejunal or ileo-ileal are usually transient and inconsequential.
• Secondary intussusception occurs when there is a pre-existing lesion in the gut that may act as a lead point.

History and examination

Age (peak incidence 6 months to 3 years), History of recent viral illness (preceding intussusception in some cases)

Symptoms	Signs
Sudden onset of intermittent, severe, Colicky abdominal pain with drawing of legs Vomiting Bloody stool (currant jelly stool) Lethargy and poor feeding Abdominal distension	Abdominal distension Palpable sausage-shaped mass in the abdomen Tenderness Inconsolable crying during pain episodes On digital rectal examination: Finger may feel the intussusceptum.

Dance sign: Evaluation of the right lower quadrant of the abdomen for retraction, which can be an indication of intussusception.

Differential diagnosis (D/D) & Complication

D/D	Complications
Gastroenteritis (diarrhea, vomiting, diffuse abdominal pain) Appendicitis (right lower quadrant pain, fever, rebound tenderness) Mesentric Adenitis Volvulus (bilious vomiting, abdominal distension, severe pain) Colicky pain Blunt abdominal trauma Teticular torsion	Bowel ischemia and necrosis Perforation Peritonitis Shock

Investigation

• Complete blood count (may show leukocytosis), electrolytes, blood gas (to assess for metabolic acidosis)
• Abdominal X-ray in upright position
• Abdominal ultrasound (first-line) showing target sign or doughnut sign
• Air or contrast enema (both diagnostic and therapeutic)

Abdominal X-ray Finding

• Target sign: Mass in the right upper quadrant
• Crescent sign: A soft tissue density projecting into the gas of the large bowel
• Absent liver edge sign: Also called absence of the subhepatic angle.
• Bowel obstruction: Distended loops of bowel with absence of colonic gas
• Absence of air: In right lower quadrant and right upper quadrant
• Soft tissue density: In right upper quadrant in 25-60% of patients
• Abnormal gas pattern: With an empty right lower quadrant and visible soft tissue mass in the upper abdomen

Admission criteria

• All children with suspected intussusception should be admitted for prompt evaluation and management

Management

Emergency management

• Maintain NPO (Nil Per Oral) status
• Secure IV line
• Fluid resuscitation to correct dehydration and electrolyte imbalances
• Insert nasogastric tube for gastric decompression

Inpatient:

Non-surgical

• Air or contrast enema reduction (successful in 70-90% of cases), performed by a radiologist or pediatric surgeon with pediatric surgery backup available

Surgical

• Indications: failed non-surgical reduction, bowel perforation, peritonitis, or signs of ischemia
• Surgery may involve manual reduction or resection of non-viable bowel segments

Referral

• Refer to a pediatric surgeon or pediatric gastroenterologist if the child is suspected to have intussusception or if the condition is recurrent

Follow up

• Follow up within 1-2 weeks after successful reduction to monitor for recurrence and assess overall recovery

References:

1. Applegate, K. E. (2009). Intussusception in children: evidence-based diagnosis and treatment. Pediatric Radiology, 39(S2), 140-143.
2. Bines, J. E., & Ivanoff, B. (2002). Acute intussusception in infants and children: a global perspective. Vaccine, 20, S146-S149.