What Is Meant by Intussusception?
Intussusception is a condition where one segment of the intestine slides inside another, leading to intestinal obstruction. While it can happen anywhere in the gastrointestinal tract, it typically occurs at the junction of the small and large intestines. The obstruction can result in swelling and inflammation, potentially causing intestinal injury. Although the exact cause of intussusception is unknown, it is often preceded by a viral infection that causes swelling of the intestinal lining. In some cases, it may be caused by congenital conditions like polyps or diverticula.
What Causes Intussusception?
The etiology behind intussusception needs to be clarified. It can be due to anatomical factors, motility, or any infection.
Some of the known causes are:
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Infection: It can be a virus that causes swelling of the intestine lining, which slips into the intestine beside it.
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Altered Motility: Abnormal intestinal contractions such as spasms.
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Meckel’s Diverticulum: This is a common congenital anomaly formed in the small intestine (gastrointestinal tract). It occurs due to incomplete obliteration of the vitelline duct (the embryonic duct that provides communication between the yolk sac and midgut during the gestation period for development). The leftover vitelline duct forms a true diverticulum in the small intestine.
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Hyperplasia of Peyer’s Patches: A group of lymphoid follicles in the mucous membrane lining the small intestine are called Peyer's patches. Enlargement of these lymphoid follicles is termed as hyperplasia of Peyer's patches.
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Appendicitis: Inflammation in the appendix (finger-like pouch projecting out from the colon of the large intestine).
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Polyps: Small, flat, bump-like tissue growth in the lining of organs.
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Duplication: It is a rare congenital disorder termed duplication of the alimentary tract (DAT) by Fiorami et al. The most affected site is the small intestine.
Which Population Is Most Affected by Intussusception?
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Infancy and early childhood are the most commonly affected ages.
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It is observed in the fifth month of life, at the most severe form between the fourth to the ninth month, and gradually subsides around the 18th month of life.
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Boys suffer more than girls in a ratio of approx. 3:1.
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It has less prevalence in adults, almost only 1 %, and is often associated with neoplasm.
What Is the Phenomenon of Intussusception?
In most cases, the ileum enters the cecum, and it is rarely seen that part of the ileum and jejunum prolapse into each other.
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Intussusceptum: The part that displaces into the other portion.
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Intussuscipiens: The part that receives the displaced part.
In almost all cases of intussusception, the intussusceptum is located proximal to the intussuscipiens. This happens because the peristaltic action of the bowel pulls the proximal segment into the distal segment.
Generally, the blood supply of the trapped segment is cut off, which leads to ischemia (restricted blood flow to a body part). Since the mucosa is sensitive to ischemia, it causes sloughing off into the gut. Due to this sloughing, a 'red currant jelly' stool is created consisting of sloughed mucosa, blood, and mucus. However, 'red currant jelly' stool is seen in very few cases of intussusception and should be called one of the related disorders.
What Are the Symptoms of Intussusception?
The symptoms of intussusception can be differentiated as early and late depending on the time of onset and duration of the disease in children.
Early Symptoms Include:
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Vomiting: The color can be green due to the presence of excessive bile.
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Abdominal pain and discomfort.
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Intermittent pain depends on the contractions of the affected bowel segment.
Later Symptoms Can Be:
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Rectal bleeding often with the presence of 'red currant jelly’ stool.
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'Sausage-shaped mass' was observed during the physical examination.
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Fever is not considered a sign of intussusception, but sometimes, secondary to ischemia, there can be sepsis, which can cause an increase in body temperature.
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Henoch-Schonlein Purpura: It is a condition in which there is inflammation and bleeding from the small blood vessels of organs such as the kidney, intestines, and skin. Intussusception can be a complication in a few cases of Henoch-Schonlein purpura.
What Are the Risk Factors of Intussusception?
Risk factors for intussusception include:
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Age: Intussusception is most frequently diagnosed in children, particularly those aged between six months and three years. It is the leading cause of bowel obstruction in this age group.
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Gender: Intussusception occurs more frequently in boys than in girls.
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Congenital Intestinal Abnormalities: Intestinal malrotation, where the intestine doesn't develop or rotate properly, increases the risk of intussusception.
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Certain medical conditions: Disorders such as cystic fibrosis, Henoch-Schonlein purpura (IgA vasculitis), Crohn's disease, and celiac disease can also increase the risk of intussusception.
How to Diagnose Intussusception?
Different diagnostic measures used for evaluating disease are:
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Observation of Dance Sign: It is a sign of retraction observed in the right lower quadrant of the abdomen, which can indicate intussusception.
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Ultrasound: The most important process for intussusception. The appearance of the 'doughnut sign' generally around 1.18 inches in diameter, confirms intussusception.
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Physical Examination: The rectum with the digits may help to feel the intussusception.
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CT-Scan: A doughnut sign is seen in the CT scan. This shape is created by the hyperechoic central core of the intestine.
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Longitudinal Imaging: A 'Sandwich-shaped' appearance of intussusception is observed.
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X-ray: Intestinal obstruction is elevated with the help of an X-ray and air enema.
What Are the Treatments for Intussusception?
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Since it is not an immediate life-threatening disorder, it can be successfully treated non-surgically by water-soluble barium or air enema. In this procedure, air or barium solution is instilled in the rectum through a small, soft tube, which creates pressure within the bowel and resolves the intussusception. Almost 80 % or more cases are successfully treated by this method, whereas up to 10 % may show recurrence within 24 hours.
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Some cases that cannot be reduced non-surgically require surgical squeezing of the part to release the obstruction.
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Laparoscopy (a small cut in the abdomen) can also be done to pull the intestine apart with forceps.
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In rare cases that are not cured by both enema and surgical squeezing, sectioning and removal of the affected part are done.
What Are the Complications of Intussusception?
Intussusception can lead to a dangerous complication by cutting off the blood supply to the affected part of the intestine. Without prompt treatment, this lack of blood flow can cause tissue death, leading to a tear in the intestinal wall, known as a perforation. Perforation can result in a serious infection of the abdominal cavity lining, called peritonitis. Peritonitis is a life-threatening condition requiring immediate medical attention. Symptoms include belly pain, swelling, fever, and vomiting. It can also lead to shock, characterized by clammy skin, rapid pulse, abnormal breathing, and extreme lethargy. If you suspect your child is in shock, seek emergency medical care immediately.
What Is the Prognosis of Intussusception?
The child can go home when they can eat normally, have no fever or incision drainage, and have regular bowel movements. They may need a few days of rest before returning to school and sports. A follow-up appointment will be scheduled in four weeks.
Conclusion:
While intussusception is a rare but serious condition, prompt recognition and treatment are crucial to prevent complications such as tissue damage, perforation, and peritonitis. Understanding the signs and symptoms of intussusception, especially in infants and young children, is vital for early diagnosis and intervention. Timely medical attention can significantly improve outcomes and reduce the risk of serious complications associated with this condition.