PANCE Blueprint GI and Nutrition (10%)

Intussusception (ReelDx)

REEL-DX-ENHANCED

Patient will present as →  a child with sudden onset of significant, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting.  Stool if passed will contain mucus and blood (currant jelly stools). A sausage-like mass may be felt on abdominal examination.

Intussusception is telescoping of one portion of the intestine (intussusceptum) into an adjacent segment (intussuscipiens), causing intestinal obstruction and sometimes intestinal ischemia.

  • The initial symptoms are sudden onset of significant, COLICKY ABDOMINAL PAIN that recurs every 15 to 20 min, often with vomiting.
  • > 95 percent of cases are in children, most common from 6-12 months of age. In adults, it is usually the result of neoplasm.
  • Paroxysmal abdominal pain is the main symptom. The child appears relatively well between episodes or may appear lethargic.
  • Later, as intestinal ischemia develops, pain becomes steady, the child becomes more lethargic, and mucosal hemorrhage causes heme-positive stool on rectal examination and sometimes the spontaneous passage of a CURRANT-JELLY STOOL.
  • The latter, however, is a late occurrence, and the physician assistant should not wait for this symptom to occur to suspect intussusception.

A palpable abdominal mass, described as SAUSAGE SHAPED, is sometimes present.

Perforation results in signs of peritonitis, with significant tenderness, guarding, and rigidity. Pallor, tachycardia, and diaphoresis indicate shock.

Diagnosis is made by ultrasonography - will show "target sign"

Abdominal x-ray will reveal a Crescent sign or a Bull's eye/target sign/coiled spring lesion” representing layers of the intestine within the abdomen.

Air or barium enema may be curative for children*

Barium enema was once the preferred initial study because it revealed the classic coiled-spring appearance around the intussusceptum. In addition to being diagnostic, barium enema was also usually therapeutic; the pressure of the barium often reduced the telescoped segments. However, barium occasionally enters the peritoneum through a clinically unsuspected perforation and causes significant peritonitis. Currently, ultrasonography is the preferred means of diagnosis; it is easily done, relatively inexpensive, and safe.

For adults barium enema should not be used.  CT is the best means of establishing the diagnosis, often this is a diagnosis made during surgery.

Air enema or surgery if enema unsuccessful or if perforation present

If intussusception is confirmed, an air enema is used for reduction, which lessens the likelihood and consequences of perforation. The intussusceptum can be successfully reduced in 75 to 95% of children. If the air enema is successful, children are observed overnight to rule out occult perforation. If the reduction is unsuccessful or if the intestine has perforated, immediate surgery is required.

When reduction is achieved without surgery, the recurrence rate is 5 to 10%.

 

Intussusception EN

IM_NUR_Intussusception_v1.2_ Intussusception is the most common cause of intestinal obstruction in children between the ages of 3 months and 3 years. It is more common in boys, and presents with episodic abdominal pain along with diarrhea. Patients have characteristic red, currant jelly stools, while physical exam findings can include a sausage shaped mass. Conservative treatment of this disorder involves air or barium enema, while surgical reduction may be done for complicated or refractory cases, as this is a potentially life threatening issue.

View Intussusception Picmonic

Question 1
A 7-month old male infant presents with sudden onset intermittent abdominal pain that subsides after a few seconds only to be repeated after intervals of some minutes; abdominal distention, bilious vomiting, passage of red-currant jelly stool. Abdominal pain is associated with screaming. Physical exam of the abdomen reveals a sausage-shaped mass at the right upper quadrant. The right lower quadrant feels empty. What is the most likely diagnosis?
A
Acute appendicitis
Hint:
Doesn’t lead to passage of red-currant jelly stool and no mass at the right upper quadrant.
B
Intussusception
C
Acute gastric volvulus
Hint:
Presents as abdominal pain, retching and inability to pass a nasogastric tube.
D
Gastroenteritis
Hint:
Diarrhoea is more prominent. Although the stools may contain blood and mucus, they are fecal and bile-stained.
Question 1 Explanation: 
Intussusception is the invagination or a segment or bowel into another immediately adjacent to it. It occurs most commonly between 5–10 months of age. It classically presents as stated above.
Question 2
The initial management of intussusception includes all of the following except
A
Passage of nasogastric tube placed for decompression
Hint:
See D for explanation
B
Placing an intravenous line for rehydration.
Hint:
See D for explanation
C
Starting intravenous antibiotics.
Hint:
See D for explanation
D
Hydrostatic barium enema.
Question 2 Explanation: 
Adequate resuscitation must be carried out before hydrostatic barium enema is done to confirm the diagnosis and to reduce the uncomplicated intussusception. Options A – C are resuscitative measures.
Question 3
‘Target sign’ associated with intussusception is seen with which imaging modality?
A
Barium enema
Hint:
Barium enema shows a filling defect at the apex of the intussusception and a typical coiled-spring appearance of barium between the intussuscipiens and intussusceptum.
B
Abdominal Ultrasonography
C
Abdominal radiograph
Hint:
In early cases, plain abdominal X-rays often show absence of gas shadow in the right colon but air-fluid levels in the small bowel in the erect film and gaseous distension of ileal loops in the supine film.
D
None of the above
Hint:
See B for explanation
Question 3 Explanation: 
Diagnosis of intussusception is made by ultrasound. A ‘Target’ sign - two rings of low echogenicity separated by a hyperechoic ring can be seen on transverse section.
Question 4
Which is the gold standard for confirming the diagnosis of intussusception in children?
A
Barium enema
B
Abdominal ultrasonography
Hint:
Is mostly used as the first-line diagnostic test for suspected intussusceptions, but is not the gold standard.
C
Abdominal radiograph
Hint:
Plain abdominal radiograph reveals signs that suggest intussusceptions in only 60% of cases.
D
None of the above
Question 4 Explanation: 
Barium enema is the “gold-standard” diagnostic study for infants with suspected intussusception. It is both diagnostic and therapeutic in identifying and reducing intussusceptions.
Question 5
Which of the following statement about intussusceptions is wrong?
A
Pneumatic reduction under fluoroscopy using air as a contrast medium is a treatment option.
Hint:
See C for explanation
B
Hydrostatic reduction is contraindicated if the child has signs of peritonitis or gangrenous bowel.
Hint:
See C for explanation
C
In adults, intussusception almost always is caused by viral infection.
D
Intussusception is the invagination of a segment of bowel into another immediately adjacent to it.
Hint:
See C for explanation
Question 5 Explanation: 
In adults, intussusception almost always is caused by neoplasm. Intussusception occurs most commonly in children following a viral infection. All other statements are correct.
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