Intussusception in children

What is intussusception?

Intussusception is when one section of the intestine telescopes into another, and it is one of the common causes of intestinal obstruction in young children. The usual cause is enlargement of lymphoid tissue at the end of the ileum due to an upper respiratory tract infection or gastroenteritis, leading to the end of the ileum telescoping into the caecum and colon (ileocolic intussusception). Occasionally, intussusception is triggered by related intestinal conditions such as Meckel's diverticulum or polyps.

Intussusception is common in infants and young children; approximately 75% cases occur in children aged between zero and two years, with the highest incidence among infants aged between five and nine months.Patients typically experience paroxysmal abdominal colic (intermittent crying) and vomiting, followed by the possible appearance of blood and mucus in the stools (dark red, blackcurrant-jam-like stools).

Intussusception is a medical emergency that requires prompt diagnosis and treatment. If delayed, it can lead to complications and even death.

Diagnosis
Doctors need a high level of vigilance for early diagnosis. If clinical examination fails to confirm the diagnosis, imaging examinations such as ultrasound can be arranged for confirmation.

Treatment
Initial treatment
If a patient is in a critical condition, they will receive appropriate emergency treatment; in addition, depending on the needs of each child, they will receive the following treatments:

• No food or drink
• Intravenous fluid replacement
• Regularly monitor vital signs
• Blood test
• +/- Insertion of nasogastric tube
• Insertion and removal of urinary catheter to monitor urine output

Intussusception reduction
To prevent the intestine from becoming ischaemic and necrotic due to obstruction, intussusception must be reduced as soon as possible. If there are no specific contraindications, non-surgical hydrostatic reduction is the best treatment method.
Contraindications for rectal prolapse reduction

• Peritonitis, bowel perforation

Relative contraindications for rectal inflation reduction

• Shock
• Suspicion of intussusception caused by intestinal diseases such as Meckel's diverticulum or polyps.

Enema reposition

Enema reduction should be performed in the radiotherapy department under the supervision of a radiotherapy specialist and a paediatric surgeon. Intussusception reduction may be treated using an air or liquid enema, with progress monitored via fluoroscopy or ultrasound.The success rate is approximately 80%. Following successful reduction of the intussusception, the patient should remain under clinical observation, with feeding resumed at an appropriate time. If enema reduction fails, emergency surgery is required; however, in some patients, a second enema attempt may be made.

Complications that may be involved in enema reduction

• Bowel perforation
• Sepsis
• The intussusception has not completely reduced.
• Intussusception recurrence
• Death

Surgical reduction
If an enema repositioning cannot be performed due to contraindications, or if it fails, emergency surgery under general anaesthetic will be required. The patient will need to remain nil by mouth, receive intravenous fluids, and be closely monitored. The paediatric surgeon will explain the details of the surgery, including the risks and post-operative care. Once the parents fully understand, they can sign the consent form for the operation. Additionally, the anaesthetist will assess the child and explain the anaesthetic procedure and potential risks in detail. If the child has any past medical history or drug sensitivities, it is essential to inform the doctor.

Caesarean section
First, make a transverse incision on the right side of the abdomen. After examining the intestine, carefully attempt to reduce the intussusception. If repositioning is successful, examine the intestine for signs of necrosis or any intestinal diseases. If the intestine is normal, the abdomen can be closed. Otherwise, if the intestine is necrotic, the intussusception cannot be reduced, or there are intestinal pathologies such as Meckel's diverticulum or polyps, the affected intestinal segment will be resected and the ends of the intestine will be sutated together.

Laparoscopic surgery
Where appropriate, instruments such as a laparoscope can be used to reduce intussusception. A laparoscopic trocar is inserted through a small umbilical incision, the abdomen is insufflated with carbon dioxide, and then the laparoscope is inserted. Two further small abdominal incisions are made to introduce laparoscopic instruments for examining the intestines and carefully attempting to reduce the intussusception. If there is intestinal necrosis, the intussusception cannot be reduced, or there are intestinal pathologies such as Meckel's diverticulum or polyps, intestinal resection will be necessary, which can be performed by widening the umbilical incision or through a separate abdominal incision.

Post-operative care
After surgery, the abdominal wound will be covered with a dressing, and doctors or nurses will recommend care methods. In the early post-operative period, the child may still require a nasogastric tube and urinary catheter, and will be unable to eat or drink, requiring intravenous fluids for hydration. Medical staff will also closely monitor the child's recovery progress to determine when to resume oral feeding. For pain relief, medication can be administered orally, rectally, intravenously, or by intramuscular injection. Following a laparotomy, particularly for infants and young children, admission to the Paediatric Intensive Care Unit may be necessary to provide appropriate monitoring, mechanical ventilation, and pain management, with improvement expected within one to several days.

Complications
As patients suffering from intussusception are usually in critical condition, the risks of surgery are higher than for other non-emergency procedures.

General risk

1. Bleeding
2. Wound haematoma
3. Wound infection, abscess, dehiscence
4. Hypertrophic scar

Specific risk

1. Vomiting, aspiration pneumonia
2. Prolonged paralytic ileus
3. Unstable blood pressure or shock
4. Sepsis
5. Intussusception recurrence
6. Intestinal fistula
7. Ascites or abscess in the abdominal cavity
8. Adhesive intestinal obstruction

Rare but serious risk

1. Damage to major abdominal blood vessels, intestines, or other internal organs
2. Severe bleeding

Follow-up appointment
Depending on the clinical situation, children are generally discharged a few days after treatment and scheduled for follow-up appointments at an outpatient clinic.

Notes
This leaflet is for reference only and does not list all possible complications. Other unforeseen complications may occur. The actual risks may differ for certain categories of patients. Please contact your doctor for more information.

Source: https://www.ekg.org.hk/pilic/public/surgery_pilic/paedsurg_intussusceptioninchildren_0155_chi.pdf