IMAGE OF THE WEEK 2014

IMAGE 10

 

INTUSSUSCEPTION

 

Figure 1a: Abdominal ultrasound showing presence of a lymph node acting as a lead point resulting in intussusception of the small bowel, as indicated by a target or doughnut sign on ultrasound of the affected bowel segment.

(Click on image to enlarge)

 

 

Intussusception is a clinical condition caused by the invagination of a segment of small bowel into the adjoining bowel lumen, resulting in bowel obstruction. It is a common cause of intestinal obstruction in children aged between 6 months to 2 years.  The incidence then to be higher in the male gender than female with a ratio of 3:1.

The higher incidence of intussusception in children above 6 years of age has been thought to be linked to the starting of solid feeding in a child.

Clinical signs and symptoms of intussusception in a child includes the following:

         Vomiting which is non-bilious initially but becomes bilious when bowel obstruction sets in,

         Abdominal pain is colicky and severe, which cannot be settle with normal parental measures,

         Passage of blood mixed with mucus, typically described as red current jelly generally indicate a more advance stage of intussusception due to sloughed mucosa from ischaemia, diarrhoea may be an early sign of intussusception,

         Abdominal distension in the presence of bowel obstruction.

 

Imaging is the main stay of diagnosis of intussusception which includes the following:

         Plain abdominal x-ray may reveals signs suggestive of intussusception in 60% of cases,

         Ultrasonography is the gold standards as shown in the above images, which includes typical donut shaped mass or target sign (Figure 1 & 2 ) and pseudokidney signs,

         Contrast enema is the traditional and most reliable way to make the diagnosis of intussusception in children (Figure 3)

Figure 1b: Magnified image from Figure 1a showing the intussusception of the small bowel.

(Click on image to enlarge)

 

Figure 2: Abdominal ultrasound showing magnified image from Figure 1a with an image of a dognut insert, reflecting the similarity of the ultrasound image of the bowel intussusception.

(Click on image to enlarge)

 

Figure 3: Small and large bowel enema showing the intussusception (three white arrows). The enema can be used to reduce the intussusception.

(Click on image to enlarge)

 

The initial management of intussusception is resuscitation by ensuring rehydration of the child or patient with iv fluids. Non-operative radiological reduction can be performed using therapeutic enemas which can by hydrostatic with barium or water soluble contrast or pneumatic with air insufflation.

 

Surgical reduction is reserve for failed medical management and is traditional performed through a right paraumbilical incision. The intussusception is delivered into the wound and manual reduction performed. If manual reduction cannot be performed or in the presence of perforation, a segmental resection of the affected segment including the lead point should be carried out with end to end anastomosis. This procedure can also be carried out successfully using laparoscopic approach.

 

 

 

Images contributed by

Dr Ian Bickle, Department of Radiology,RIPAS Hospital.

Text contributed by

Mr William Chong, Department of General Surgery,RIPAS Hospital.

 

All images are copyrighted and property of RIPAS Hospital.

 

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