Abdominal Pain Intussusception

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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?

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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

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What is your Differential Diagnosis?
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Diagnostic Studies

• What studies would you obtain?

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Studies ordered, Emme Hall

• CBC
• Hgb
• Hematocrit
• WBC
• Electrolytes
• Abdominal x-rays

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Laboratory Studies, Emme Hall

• CBC
• Hb 14.2
• Hematocrit 41
• WBC 15.6
• Electrolytes 137/103/3.9/22

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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.

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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.

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What is your revised Differential Diagnosis?
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Differential Diagnosis

• Viral gastroenteritis
• Intussusception
• Appendicitis

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Management

• What would you do now?

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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.

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Air enema
Sequential images with arrows demonstrating
reducing lead point of intussusception
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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.
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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.

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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.
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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.
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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.

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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.

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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

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CT Scan Ileo-colonic Intussusception
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CT Scan Ileo-colonic Intussusception
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QUESTIONS ??????
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Summary
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