Said Al Mazroui

On 11/10/09

 5 months child presented with 5 days history of loose motion

 for 3-4 times daily (normal 1-2 times/day). the diarrhea was associated with low grade fever ( not ducomented )  2 times vomiting only

 the fever was of low grade in nature, on/off with no sweating, rigors/chills, abdominal pain, respiratory distress, LOC or seizures.

 Mother noticed blood in the stool at 11:30pm  h/o increased crying.

 perinatal history is not eventful

Examination:

• • • • • looks lethargic and dehydrated.

No pallor, jaundice, cyanosis, LN.

HR=140/mint, RR=30/mit, t=36.9 C, O2 sat=98%, BP: 86/62 wt:8 kg Abdomen: soft, no distention , tenderness, no mass.

Other systemic examination: nad.

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DD

Plan:

 Start I.V.F

 Send CBC, U&E, Urine dipstix  Observation

UREA AND ELECTROLYTES

sodium potassium chloride Carbon dioxide urea creatinine 136 mmol/l 4.4 mmol/l 102 mmol/l 22 mmol/l 1.8 mmol/l 17 umol/l

CBC

hemoglobin hematocrit Mean cell volume Mean cell hg RBC dist. width Platelet count White cell count neutophils lymphocytes 11.4 g/dl 34 % 4.58 fl 74.2 pg 16.5

253 x10pwr9/1 9.8 x10pwr9/1 5.2 x10pwr9/1 3.8 x10pwr9/1

Urine dipstick:

 ketone 3+

After 4 hrs

 became playful and active  No crying throughout observation

 R u happy to d/c ???

 d/c on ORS  it was fully explained for the parents if the patient developed fever, bloody diarrhoea or vomiting to bring her back to the A&E or nearest local health center

On 13/10/09

 h/o vomiting x several times, poor oral intake persisting loose watery stools / mixed with blood ? red current jelly stools  No excessive (Inconsolable) crying

Examination

:

 afebrile, tachycardic 158/min, rr 28/min looks mod-sev dehydrated with dry mucus membrane, mild sunken eyeballs and ant fontanelle.

 chest: clear sat 100%  P/A: soft, non tender, + bs, no mass

Plan

US abdomen: (13/10)

There was a donut sign seen in the right mid abdomen suggestive of intusseption.

After manipulation is resolved spontaneously.

The spleen, liver, GB and both kidneys are normal.

No free fluid in the pelvis or abdomen.

\ Spontaneous resolution of Colico-colic intusussception

 Admitted for observation -NPO -start IVF 0.18 DNS 30 cc/hr -ceftriaxine 170mg IV OD

 Why she was admitted??

Definition

 telescoping of one segment of bowel into an immediately adjacent segment

Classification.

 Enterocolic(90%)  Colocolic  Enteroenteric

Causes of intussusception

 Idiopathic(90%)  Nonidiopathic. (hypertrophied Peyer patches secondary to infection, adenovirus infection, foreign bodies, parasitic infestation polyps, lipomas, Meckel's diverticulum, intestinal duplication, Henoch Schönlein purpura, lymphomas, (

EPIDEMIOLOGY

 2 per 1000 live births.  male-to-female ratio is 3:1.  Most common between 3-9 month  most common cause of intestinal obstruction between 6 and 36 months of age  Most episodes occur in otherwise healthy and well-nourished children

 Approximately 60 percent of children are younger than one year old, and 80 percent are younger than two  Intussusception is rare before three months and after six years of age

 Most patients recover if treated within 24 hours. Mortality with treatment is 1 3%. If left untreated, this condition is uniformly fatal in 2-5 days. Recurrence is observed in 3-11% of cases. Most recurrences involve intussusceptions that were reduced with contrast enema

History

 Abdominal pain(80-95%) :  The child appears to have intermittent abdominal pain ( manifest as episodic bouts of crying pallor and ) which is colicky, severe and may be accompanied by drawing up of the legs (guarded position )   Episodes typically occur 2-3 times/hour.

Infant may sleep or may appear lethargic or playful between episodes of pain.

 Vomiting (75%)  is usually a prominent feature  Initially nonbilious but may progress to bilious  Bowel motions  blood and/or mucus  classic red currant jelly stool is a late sign (60%)

 Diarrhea is quite common and can lead to a misdiagnosis of gastroenteritis .(can be an early sign of intussusception )  Lethargy is a relatively common presenting symptom with intussusception  There may be a preceding respiratory or diarrheal illness

 Classic triad(21% all three, 72% have two) 1-Intermittent abd. Pain(80-95%) 2-Bilious vomiting(75%) 3-Currant-jelly stool(60%)

Examination

 Abdomen:  Abdominal mass(65%) - sausage shaped mass in RUQ or mid abdomen variably tender  Abdomen may be soft, non tender or distended and tender

 Peristaltic wave may be present.

 Absence of bowel contents in RLQ ( Dance sign)  PR: may revealed blood or mass. (PR unnecessary if good evidence of intussusception).

Investigations

 Blood tests  FBC, U&E   Blood group and cross -match Blood glucose

 Plain abdominal Xray  Performed to exclude perforation or bowel obstruction  A normal AXR does not exclude intussusception  radiographic signs of intussusception are subtle  Signs of intussusception on a plain Xray include :

1-Target sign - two concentric circular radiolucent lines usually in the right upper quadrant 2-Crescent sign : intussusceptum protruding into a gas filled pocket, which often results in a crescent shaped gas pocket. 3-Signs of obstruction.

 Ultrasound scan :  Useful if there is a suggestive history but no mass palpable or signs on plain AXR  Sensitive and specific.

 Its use is limited by diagnostic and therapeutic use of air enema  Donut sign: hyperechoic core surrounded by hypoechoic rim

 Hydrostatic reduction( air or barium)  This intervention is both diagnostic and therapeutic  Diagnostic investigation of choice if high level of suspicion

Complications:

 Intestinal hemorrhage  Intestinal obstruction and dehydration.

 Bowel infarction leading to bowel resection  Bowel perforation  Peritonitis  Sepsis and shock  recurrence

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Prognosis

 Prognosis is excellent if diagnosed and treated early; otherwise, severe complications and death may occur.

Differential diagnosis

 Gastroenteritis  Enterocolitis  Infantile colic  Incarcerated inguinal hernia  meckel ’s diverticulum  HSP  others: polyps, appendicitis

Management

 Initial stabilization:  Secure IV access  Most children will require fluid resuscitation with normal saline 20mls/kg IV  Keep nil orally  nasogastric decompression  Surgical consultation.

 Hydrostatic reduction  Sucuss rate is 80% in <24h of intrassusception. Only 32% if >24h.,  recrrence is 10%(most within 24 hr post reduction)  CI: peritonitis, perforation, shock  Complications: perforation, reduction of necrotic bowel.

 Surgical reduction: indicated in: 1-suspected bowel gangrene or perforation.

2 -failure of hydrostatic reduction 3-multible recurrence.

Clinical pearls

 Intussusception is the most common cause of intestinal obstruction between 3 months and 2 years of age.

 high index of suspicion is essential  60% of Intussusception are initially misdiagnosed( GE is commonly confused with it)

 Colicky abdominal pain is the major symptom  Bilious vomitous and currant jelly stool are late finding  Profound Lethargy can be the sole presenting symptom (up to 10%) , which makes the diagnosis challenging  Morbidity and mortality increased with delayed diagnosis.

THANX