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Internal Medicine

Intussusception (ISS)

Telescoping/invagination of a proximal bowel segment into a distal segment, commonly at the ileocecal junction.

  • Males > females
  • M/C in children (peak at 5-10 months age)
Intussusception of small bowel
Intussusception of small bowel. | Image courtesy Dr Chaigasame

Terminology:

  • Apex: Advancing part
  • Intussuscipiens: Receiving end (outer sheath)
  • Intusssusceptum: Advancing tube (middle & inner sheaths)

Etiopathogenesis

  • Idiopathic (M/C, 90%)

Pathological lead point:

  • Children (13 cases after 2 years age):
    • Meckel’s diverticulum (M/C)
    • Intestinal polyps, appendix,
    • Henoch–Schönlein purpura (HSP) (IgA vasculitis)
  • Adults: Intraluminal mass/tumour
    • Submucous lipoma
    • Leiomyoma (intestine)
    • Carcinoma
    • Peutz–Jeghers syndrome

Peyer’s patches (inflammation & oedema):

  • U-RTI
  • Gastroenteritis
  • Weaning of maternal immunity
  • Common viral pathogens
Colonoscopy. Revealing the presence of the inverted terminal ileum (intussusceptum) in the ascending colon (intussuscipiens) in a patient with an ileo-cecal intussusception due to an ileal lipoma.
Colonoscopy. Revealing the presence of the inverted terminal ileum (intussusceptum) in the ascending colon (intussuscipiens) in a patient with an ileo-cecal intussusception due to an ileal lipoma. | Marinis, A., Yiallourou, A., Samanides, L., Dafnios, N., Anastasopoulos, G., Vassiliou, I., & Theodosopoulos, T. (2009). Intussusception of the bowel in adults: a review. World Journal of Gastroenterology, 15(4), 407–411. https://doi.org/10.3748/wjg.15.407

Types:

  • Ileocolic (M/C, 77%): Common in children and M/C overall
  • Ileoileocolic (12%)
  • Ileoileal (5%)
  • Colocolic (2%): Common in adults
  • Multiple (1%)
  • Retrograde (0.2%)
  • Others (2.8%)

Infection

Hyperplasia of Peyer’s patch

Double jejuno-jejunal intussusception found at laparotomy
Double jejuno-jejunal intussusception found at laparotomy | Spiridis, C., Kambaroudis, A., Ntinas, A., Papadopoulos, S., Papanicolaou, A. and Gerasimidis, T. (2011) ‘Intussusception of the small bowel secondary to malignant metastases in two 80-year-old people: a case series’, Journal of Medical Case Reports, 5(1), p. 176. doi: 10.1186/1752-1947-5-176

Presentation

Triad:

  1. Colicky abdominal pain: Sudden onset & later persistent and severe
  2. Vomiting
  3. Red-current jelly stool (infants): From sloughing off of apex & bleed, mixed with mucus
  • Progressive distension of abdomen

Complications:

  • Intestinal obstruction
  • Perforation
  • Peritonitis

Diagnosis

Clinical examination:

  • Palpable abdominal mass
    • Sausage shaped with concavity toward umbilicus
    • Smooth, firm, resonant, mobile, not moving with respiration
    • Contracts under palpating fingers
  • Dance’s sign: Right iliac fossa is empty
  • Step-ladder peristalsis
  • Features of intestinal obstruction/peritonitis (later)

Contrast enema:

Can be both diagnostic and therapeutic. Contraindicated in recurrent ISS secondary to a pathological lead point or in perforations
  • Claw/pincer sign

CT scan:

  • Target sign

Differential diagnosis:

  • Children:
    • Acute gastroenteritis
    • Purpura with intestinal symptoms
  • Adults:
    • Carcinoma colon
    • Mesenteric mass

Management

Initial management (Resuscitation):

  • Ryle’s tube aspiration
  • IV fluids
  • Broad-spectrum antibiotics
  • Nasogastric drainage

Conservative management (70% cases):

  • Air or barium enema
  • Contraindications:
    • Peritonitis/perforation
    • Shock
    • Pathological lead point

Surgical management:

Intraoperative findings: Intussusseption
Intraoperative findings. A: Thickened, congested and inflamed terminal ileum with proximal small bowel obstruction in a 75-year old woman with ileo-colonic intussusception; B: The surgical specimen after the en bloc resection of the terminal ileum and the ascending colon in the same patient; C: The cause of the intussusception was a lipoma of the ileo-cecal valve (arrow). | Marinis, A., Yiallourou, A., Samanides, L., Dafnios, N., Anastasopoulos, G., Vassiliou, I., & Theodosopoulos, T. (2009). Intussusception of the bowel in adults: a review. World Journal of Gastroenterology, 15(4), 407–411. https://doi.org/10.3748/wjg.15.407
  • Indications:
    • ISS > 48 hours
    • Features of perforation, strangulation, peritonitis
    • Recurrent ISS
    • Adult
  • Methods:
    • Cope’s method
    • Laparoscopic approach
    • Ileocolic resection
  • Irreducible intussusception:
    • Resection + primary anastomosis

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