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Abdominal Pain Intussusception

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Since the intussusception cannot be reduced, surgery is necessary and should be ... Intussusception is a telescoping of one portion of the intestine into another, ... – PowerPoint PPT presentation

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Title: Abdominal Pain Intussusception


1
Abdominal Pain Intussusception
  • Author
  • Philip Wolfson, M.D.
  • Jefferson Medical College
  • Revision Editor
  • Linda Barney, M.D.
  • Joseph Iocono, M.D.

2
Emme Hall
  • Your patient in the ER is a 14-month-old female
    with a 12 hour history of irritability and
    abdominal discomfort.

3
History
  • What other points of the history do you want to
    know?

4
History, Emme Hall
Consider the Following
  • Characterization of symptoms
  • Temporal sequence
  • Alleviating / Exacerbating factors
  • Pertinent PMH, ROS, MEDS.
  • Relevant family hx.
  • Associated signs and symptoms

5
History, Emme Hall
  • Characterization of pain
  • Unable to verbalize but discomfort seems
    intermittent, in spasms
  • Temporal sequence
  • Has become more pronounced in past 4 hrs
  • Activity level
  • Much less active than usual, irritability with
    the pain alternating with periods of lethargy
  • Associated Signs Symptoms
  • Vomited 3 X, initially clear but now yellowish
    had a watery bowel movement with a mixture of
    blood and mucus
  • PMH
  • Born at 37 weeks gestation.
    Otitis media at age 8 months.
    Upper respiratory infection 2
    weeks ago

6
Physical Examination
  • What would you look for on physical examination?

7
Physical Examination, Emme Hall
  • Vital Signs T 101.2 P 144 R 22 BP
    80/55
  • General Well nourished, pale, irritable
  • Abdomen

    Inspection mild
    distention, symmetric, shallow breathing
  • Auscultation bowel sounds present but
    diminished
  • Percussion tympanitic elicits tenderness in
    RLQ and RUQ
  • Palpation - generally soft, but RUQ and RLQ
    tenderness
  • Rectal Normal patency, no mass palpable, gross
    blood on glove
  • Remainder of examination is within normal
    limits

8
What is your Differential Diagnosis?
9
Diagnostic Studies
  • What studies would you obtain?

10
Studies ordered, Emme Hall
  • CBC
  • Hgb
  • Hematocrit
  • WBC
  • Electrolytes
  • Abdominal x-rays

11
Laboratory Studies, Emme Hall
  • CBC
  • Hb 14.2
  • Hematocrit 41
  • WBC 15.6
  • Electrolytes 137/103/3.9/22

12
X-ray results, Emme Hall
  • Obstructive Series chest x-ray normal
    abdominal films show mildly dilated loops of
    small intestine. There is a paucity of gas in
    the right colon.

13
Clinical Studies, Emme Hall
  • The hemoglobin is normal. The white cell count
    is moderately elevated, suggesting an infection
    or inflammation. The serum electrolytes are
    normal. The abdominal x-rays suggest the
    possibility of an intestinal abnormality, but the
    findings are nonspecific.

14
What is your revised Differential Diagnosis?
15
Differential Diagnosis
  • Viral gastroenteritis
  • Intussusception
  • Appendicitis

16
Management
  • What would you do now?

17
Further management, Emme Hall
  • An attempt should be made to reduce this
    intussusception radiographically, using pressure
    from barium or air and visualized
    fluoroscopically. Some physicians prefer to have
    intravenous fluids running and administer broad
    spectrum antibiotics before this procedure.

18
Air enema
Sequential images with arrows demonstrating
reducing lead point of intussusception
19
Air enema
The air passes up through the large intestine
until it reaches the right side of the transverse
colon where it encounters a filling defect. The
radiologist is able to reduce the mass up to
the proximal right colon but no further.
20
Further Management
  • What does this mean?
  • What should be done next?

21
Management, Emme Hall
  • The intussusception can only be partially
    reduced, and there remains a filling defect in
    the cecum.

22
Management, Emme Hall
  • Since the intussusception cannot be reduced,
    surgery is necessary and should be performed
    immediately. Broad spectrum antibiotics
    effective for lower intestinal organisms should
    be administered preoperatively.

23
Management, Emme Hall
A right lower quadrant incision is made, and
the ascending colon is delivered. There is an
intussusception of the ileum half-way up the
right colon.
24
Management, Emme Hall
Using manual pressure on the colon above the
intussusception, the ileum is reduced. The bowel
is pink and viable no pathological lead point
is seen. An appendectomy is also performed.
25
Hospital Course
  • Emme Hall recovers uneventfully and is discharged
    the following day, tolerating a regular diet

26
Discussion
  • Intussusception is a telescoping of one portion
    of the intestine into another, and typically
    affects children between the ages of 6 to 18
    months. The ileum usually invaginates and
    advances a variable distance into the colon. It
    often follows a nonspecific viral illness and may
    be due to hypertrophy of Peyers patches rarely
    is there a pathological lead point in the
    intestinal wall. The patient presents with
    intermittent bouts of pain where they may draw
    their knees up to the chest in between episodes
    they may be irritable or lethargic. Vomiting is
    common and as the condition progresses there may
    be blood and mucus (classically the current
    jelly) in the stools as the mucosa becomes
    ischemic. Physical examination may be fairly
    normal initially but there may be irritability,
    somnolence, fever, and right sided abdominal
    tenderness occasionally a right upper abdominal
    mass can be palpated. Abdominal x-rays may
    appear normal or show a paucity of air in the
    right lower quadrant and some dilatation of the
    small intestine.

27
Discussion
  • Intussusception is considered to be an
    emergency, as the intestine can become necrotic.
    If the diagnosis is suspected, a contrast enema
    will be diagnostic and often therapeutic.
    Radiologists are increasingly utilizing air
    rather than barium because of the greater success
    with contrast reduction and lower morbidity if
    there should be a perforation. Some advocate
    administration of intravenous fluids and broad
    spectrum antibiotics at the time of the x-ray
    studies, especially if the child is ill.
    Successful radiographic reduction is confirmed if
    there is reflux of contrast into the ileum, in
    which case the child is admitted to the hospital
    for 24 hours of observation. If contrast
    reduction is unsuccessful, surgery is mandatory
    to reduce the intussusception manually. The
    appendix is usually removed. If the intestine is
    necrotic, a resection is necessary. Recurrence
    of intussusception occurs in approximately 5 of
    children.
  • The diagnosis of intussusception must be
    considered in any patient between 6 months and 2
    years with unexplained abdominal pain, and a
    contrast x-ray usually is obtained. There may
    also be a role for ultrasound as a screening test.

28
Adult Intussusception
  • Older children and adults with Intussusception
    usually have a pathological lead point, which is
    a malignant tumor in approximately half of all
    instances.
  • Patients present with small intestinal
    obstruction and have a "target" sign on CT scan. 
    Surgical intervention is usually required

29
CT Scan Ileo-colonic Intussusception
30
CT Scan Ileo-colonic Intussusception
31
QUESTIONS ??????
32
Summary
33
  • Acknowledgment
  • The preceding educational materials were made
    available through theASSOCIATION FOR SURGICAL
    EDUCATION
  • In order to improve our educational materials
    wewelcome your comments/ suggestions at
  • feedbackPPTM_at_surgicaleducation.com
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