Chapter 28. Unique Considerations in the Neonate and Infant 261
viral respiratory tract infections. The typical history is of a child experiencing episodes of severe abdominal colic with drawing up of their legs and non billous vomiting. In between these episodes of colic they are quieter than normal and often falls asleep. As the intussusception progresses the child passes a mixture of blood and mucus per rectum, the so called “red currant jelly” stool. If the condition remains untreated there is progression to small bowel obstruction indicated by billous vomiting and worsening lethargy secondary to dehydration.
The classical triad of abdominal colic, vomiting and passage of a red currant jelly stool is present in only 30% of children. The most common symptom is colicky abdominal pain while atypical presentations include diarrhoea, lethargy, irritability or simply a reluctance to feed.3 There may be a history of a pyrexial illness a few days prior to the development of symptoms.
Examination of a child with a suspected intussusception should focus on their hydration status. If symptoms have been present for longer than 24 h it is likely that signs of dehydration such as increased capillary refill and tachycardia will be present.
In 30% of children a sausage shaped mass will be palpable in the right upper quadrant. Abdominal tenderness or guarding indicates the presence of bowel ischemia, necrosis or perforation. A rectal examination is useful to determine the presence of blood if there is no history of passage of a bloody stool. Rarely an intussusception may be noted protruding from the rectum.
28.3 Investigations
If a diagnosis of intussusception is suspected IV access is obtained, full blood count and biochemical analysis performed and a cross match taken. Fluids are run at maintenance rate. If the child is dehydrated 20 mL/kg boluses of
0.9% normal saline should be administered as appropriate. They should not be moved to the radiology department for imaging until their clinical status improves. Mortality in
262 J.I. Curry
FIGURE 28.2. Ultrasound picture of intussusception.
intussusception can be due to hypovolemic shock secondary to inadequate fluid resuscitation. If there is significant abdominal distension an NG tube is passed. A dose of broad spectrum antibiotics should be given.
The gold standard in the diagnosis of intussusception is an abdominal ultrasound. In experienced hands the sensitivity and specificity approaches 100%. The appearances of an intussusception on ultrasound are a target or donut sign (Fig. 28.2). This pattern represents the walls of the intussusception. There is little role for an abdominal x-ray in the diagnosis of intussusception. The sensitivity of an x-ray is 45% with a false negative rate of 20%.4 While an x-ray may show the presence of free air indicating a perforation, this will often be apparent on examination.
28.4 Management
Once the diagnosis of intussusception is made the treatment is reduction by air enema. Contraindications are the
Chapter 28. Unique Considerations in the Neonate and Infant 263
presence of peritonitis, indicating bowel necrosis or perforation. A catheter is inserted into the child’s rectum and air is introduced under measured pressure control. Fluoroscopy is performed to track the progress of the reduction. The rule of threes is employed, namely three effective attempts at air reduction lasting 3 min each. If the intussusception does not reduce with this protocol further attempts at reduction are unlikely to be successful. The success rates with air enema reduction are approximately 70–80% and are often related to the duration of symptoms. Reasons for failure of intussusception reduction are the presence of ischemic or necrotic bowel, an identifiable lead point or technical failure related to inability to generate significant intra luminal pressure. The perforation rate with air enema reduction is 0.8%.5 Ultrasound guided air and water reduction of intussusception has been reported although no direct comparison has been made with the fluoroscopic technique.
28.5 Surgical Management
Open reduction of an intussusception is through a right illac fossa incision. Gentle pressure is applied to the distal portion of bowel to squeeze out the invaginated proximal portion. If significant ischemia or frank necrosis is present, reduction should not be attempted and resection and primary anastamosis is indicated. Occasionally a negative laparotomy is performed as the intussusception has spontaneously reduced in the interval between the failed air enema reduction and surgery. In view of this laparoscopy prior to open surgery has been advocated (Fig. 28.3). The results of laparoscopic reduction of intussusceptions are less convincing with success 70% in comparison to 100% with the open technique.6
There is a 10% recurrence rate with intussusception, usually within a year of the first episode, and is more likely to be associated with a pathological lead point.
264 J.I. Curry
FIGURE 28.3. Laparoscopic view of ileocolic intussusception.
References
1.Kaiser AD, Applegate KE, Ladd AP. Current success in the treatment of intussusception in children. Surgery. 2007;142:469-475. discussion 475–477.
2.Huppertz HI, Soriano-Gabarro M, Grimprel E, et al. Intussusception among young children in Europe. Pediatr Infect Dis J. 2006;25: S22-S29.
3.O’Ryan M, Lucero Y, Pena A, et al. Two year review of intestinal intussusception in six large public hospitals of Santiago, Chile. Pediatr Infect Dis J. 2003;22:717-721.
4.Best evidence topic reports. Bet 4. Role of plain abdominal radiograph in the diagnosis of intussusception. Emerg Med J. 2008;25: 106-107.
5.Daneman A, Navarro O. Intussusception. Part 2: An update on the evolution of management. Pediatr Radiol. 2004;34:97-108. quiz 187.
6.Bonnard A, Demarche M, Dimitriu C, et al. Indications for laparoscopy in the management of intussusception:A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI). J Pediatr Surg. 2008;43:1249-1253.