Intestinal invasion: History, Symptoms, Causes, Pathophysiology, Diagnosis, Treatment and Prediction

It is the most common abdominal emergency that affects children under 2 years of age.

Intestinal intussusception is the most common cause of intestinal obstruction in children between 3 months and 5 years of age. It is extremely rare in children younger than 3 months or in older children and adults.

It happens when one part of the intestine slides towards the next, very similar to the pieces of a telescope.

When this “telescopic movement” occurs, the flow of fluids and food through the intestine can become blocked, the bowel can swell and bleed, and the blood supply to the affected part of the intestine can be cut off.

Eventually, this can cause the death of a part of the intestine.

Intussusception occurs in 1 to 4 of every 1,000 babies and is more common in babies 5 to 9 months of age, although older children may also have it. Children have intussusception more often than girls.

History

Intussusception, or intussusception, was first described by Barbette in 1674, and was successfully treated for the first time by Wilson in 1831.

In 1876, Hirschsprung first reported the technique of hydrostatic reduction, and in 1905, after monitoring a series of 107 cases, 35% reported mortality attributable to intussusception.

Vascular involvement and subsequent intestinal necrosis are the main concerns with intussusception. Among patients who undergo surgical reduction of intussusception, up to 10% may require intestinal resection.

Intussusception (medical disorder)

It is also known as “intussusception” is a medical condition in which a part of the intestine is folded in the adjacent section. It usually involves the small intestine and, less commonly, the large intestine.

Symptoms include abdominal pain that may come and go, vomiting, bloating, and bloody stools. It often results in a small bowel obstruction. Other complications may include peritonitis or intestinal perforation.

The cause in children is usually unknown, while in adults there is usually a starting point. Risk factors in children include certain infections, diseases such as cystic fibrosis and intestinal polyps.

Risk factors in adults include endometriosis , intestinal adhesions and intestinal tumors. Diagnosis is often supported by medical images. In children, ultrasound is preferred, while in adults, computed tomography is preferred.

Intestinal intussusception is an emergency that requires rapid treatment. Treatment in children is usually done through an enema with surgery if this is not successful. Dexamethasone may decrease the risk of another episode.

In adults, surgical removal of part of the intestine is most often required. Intussusception occurs more commonly in children than in adults. In children, men are more often affected than women. The usual age of onset is six to eighteen months.

Signs and symptoms of Intussusception

Early symptoms may include periodic abdominal pain, nausea, vomiting (sometimes green due to bile), babies and children with intussusception have severe abdominal pain, which often starts suddenly and causes the child to raise their knees the chest.

The pain often makes the child cry very loudly. As it decreases, the child may stop crying for a while and seem to feel better. The pain usually comes and goes in this way, but it can become very strong when it returns.

As the pain is intermittent, not because the intussusception is resolved temporarily, but because the intestinal segment invariably stops contracting. Symptoms may also include:

  • Abdominal swelling
  • Vomiting after eating.
  • Groans due to pain.
  • He cries constantly, especially when digesting food.

As the disease continues, the child may gradually weaken. He or she may develop a fever and appear to be in shock, a life-threatening medical problem in which the lack of blood flow to the organs of the body causes the heart to beat quickly and blood pressure to drop.

Some babies with intussusception may appear drowsy without vomiting, have changes in stool, or have abdominal swelling. Later signs include rectal bleeding, often with “red currant” stools (stools mixed with blood and mucus) and lethargy.

The physical examination may reveal a “sausage-shaped” mass, felt on palpation of the abdomen. Children, or those who can not communicate the symptoms verbally, may cry, bring their knees to their chest, or experience dyspnea (difficult or painful breathing) with paroxysms of pain.

Fever is not a symptom of intussusception. However, intussusception can cause a bowel loop to become necrotic, secondary to ischemia due to compression of the arterial blood supply. This leads to perforation and sepsis , which causes fever.

In rare cases, intussusception may be a complication of Henoch-Schönlein purpura (HSP), a disease of vasculitis mediated by the immune system in children.

Such patients who develop intussusception often have severe abdominal pain in addition to the classic signs and symptoms of Henoch-Schönlein purpura.

Fortunately, most cases are diagnosed early, and some studies describe that the development of stool with blood occurs in only one third of cases diagnosed.

Causes

The causes of intussusception are not clearly established or understood. About 90% of cases of intussusception in children are due to unknown causes. They can include infections, anatomical factors and altered motility.

An earlier version of the rotavirus vaccine that was no longer used was linked to intussusception, but the current versions are not clearly related.

Due to a potential risk, they are therefore not recommended in babies who have had intussusception.

Although most of the time, doctors do not know what causes intussusception. In some cases, it may be the result of a recent attack of gastroenteritis (or “stomach flu”).

Bacterial or viral gastrointestinal infections can cause swelling of the lymphatic tissue that fights infections that line the intestine, which can cause one part of the intestine to come in contact with the other.

In children younger than 3 months or older than 5 years, intussusception is more likely to be caused by an underlying condition, such as enlarged lymph nodes, a tumor, or an abnormality of the blood vessels in the intestines.

Pathophysiology of Intussusception

Intussusception is telescopy or intussusception of a proximal portion of the intestine in a more distal portion. The intussusception may be ileoileal, colocolic, ileoileocolic or ileocolic.

In the most frequent type of intussusception, the ileum enters the blind. However, there are other types, such as when a part of the ileum or jejunum is prolapsed in itself. Almost all intestinal invaginations occur when the segment that is envaginates is located proximally to the invaginating segment.

This is because the peristaltic action of the intestine pulls the proximal segment towards the distal segment. However, there are rare reports that the opposite is true.

An anatomic reference point (ie, a portion of intestinal tissue that protrudes into the intestinal lumen) is present in approximately 10% of the intussusceptions.

The trapped section of the intestine may have its blood supply cut off, causing ischemia (lack of oxygen in the tissues). The mucosa (lining of the intestine) is very sensitive to ischemia and responds by sliding into the intestine.

This creates the stool of “red currant jelly” described classically, which is a mixture of mucous, blood and mucus detached.

One study reported that, in fact, only a minority of children with intussusception had stools that could be described as “red currant gelatin” and, therefore, intussusception should be considered in the differential diagnosis of children presenting any type of stool with blood.

Classification

  • Ileoileal – 4%.
  • Ileocolic (or ileocecal) – 77%.
  • Ileo-ileo-colic – 12%.
  • Colocolic – 2%.
  • Multiple – 1%.
  • Retrograde – 0.2%.
  • Others – 2.8%.

In children, insususception at the ileocecal junction accounts for 90 percent of all cases.

When to call the doctor?

Intestinal intussusception is a medical emergency. If you are concerned that your child has some or all of the symptoms of intussusception, such as recurrent abdominal pain from colic, vomiting, drowsiness, or gooseberry jelly droppings, call your doctor or seek emergency medical help immediately.

Most babies who are treated within the first 24 hours recover completely without problems.

But untreated intussusception can cause serious problems that get worse quickly. Therefore, it is extremely important not to delay the treatment; Every second counts. Deferred treatment greatly increases the risk of irreversible tissue damage, intestinal tear, infection and possibly death.

Diagnosis

Doctors usually check for intussusception if a child has repeated episodes of pain, stretching of the legs, vomiting, feeling drowsy or stool evacuation with blood and mucus.

During the visit, the doctor will ask about the child’s general health, the family’s health, the medications they are taking and any allergies they may have. Then, the doctor will examine the child, paying special attention to the abdomen, which may be inflamed or sensitive to touch.

Sometimes, the doctor may feel the part of the intestine involved. Intussusception is often suspected based on observation of the Dance sign . A digital rectal exam is particularly useful in children, since part of the intussusception can be felt with the finger.

A definitive diagnosis often requires confirmation by means of diagnostic imaging. Ultrasound is the imaging modality of choice for the diagnosis and exclusion of intussusception, due to its high precision and lack of radiation.

The appearance of the white sign (also called “donut sign”) on an ultrasound, usually about 3 cm in diameter, confirms the diagnosis.

The image seen on transverse sonography or computed tomography is donut-shaped, created by the central nucleus hyperechoic intestine and mesentery surrounded by the hypoechoic external edematous bowel.

In longitudinal images, intussusception resembles a sandwich.

An x-ray of the abdomen may be indicated to detect intestinal obstruction or free intraperitoneal gas. The latest finding implies that intestinal perforation has already occurred. Some institutions use air enema for diagnosis, since the same procedure can be used for treatment.

If the doctor confirms intussusception, the child can be sent to an emergency room. Usually, doctors will ask a pediatric surgeon to see the child immediately.

The emergency doctor may order an abdominal ultrasound or an x-ray, which can sometimes show a blockage in the intestines. If the child looks very sick, suggesting damage to the bowel, the surgeon can take the child to the operating room immediately to correct the bowel obstruction.

In a surgical reduction, the surgeon opens the abdomen and squeezes manually (instead of pulling) the part of the intestine that has been inserted.

If the surgeon can not successfully reduce it or the intestine is damaged, they resect the affected section. More often, intussusception can be reduced by laparoscopy , separating the segments of the intestine with forceps.

Differential diagnosis of Intussusception:

An intussusception has two main differential diagnoses:

  • Acute gastroenteritis
  • Rectal prolapse.

Abdominal pain, vomiting and stools with mucus and blood are present in acute gastroenteritis, but diarrhea is the main symptom.

The rectal prolapse can be differentiated projecting the mucosa that can be felt in continuity with the perianal skin, while in the intussusception the finger can pass indefinitely to the depth of the groove.

Treatment

The condition is usually not immediately fatal.

Intussusception can be treated with a contrast enema soluble in barium or water or with an enema with air contrast, which confirms the diagnosis of intussusception and, in most cases, reduces it successfully.

Two types of enemas (an air enema or a barium enema) can often diagnose and treat intussusception at the same time.

For an air enema, a small soft tube is placed in the rectum and air is passed through the tube. The air travels to the intestines and delineates the intestines on X-rays. If the intussusception is present, it shows the doctors the telescopic piece in the intestine.

At the same time, the air pressure deploys the intestine that has turned inward and heals the blockage. Barium, a liquid mixture, is sometimes used in place of air to fix the blockage in the same way.

Both types of enema are very safe, and children usually do very well. However, it is important to remember that intussusception may return in 1 out of 10 cases. This usually occurs within 72 hours after the procedure.

If the bowel breaks, an enema does not work or if the child is too sick to try an enema, the child will need surgery. This is often the case in older children. Surgeons will try to correct the blockage, but if too much damage has been done, that part of the bowel will be removed.

After treatment, the child will remain in the hospital and will be fed intravenously (IV) through a vein until he can eat and return to normal bowel function.

The doctors will watch the child closely to make sure the intussusception does not return. Some babies may also need antibiotics to prevent infections.

The success rate is more than 80%. However, approximately 5-10% of these recurrence within 24 hours.

The cases in which it can not be reduced by an enema or the intestine is damaged require a surgical reduction.

Prognosis of intussusception

Intestinal intussusception can become a medical emergency if it is not treated early, as it eventually causes death if it is not reduced.

Intestinal intussusception produces intestinal obstruction, followed by congestion and edema with venous and lymphatic obstruction. This progresses to arterial obstruction and subsequent necrosis of the intestine.

Ischemia and then necrosis result in fluid retention and bleeding from the gastrointestinal (GI) tract. If left untreated, the intestine can perforate, resulting in sepsis.

In developing countries where medical hospitals are not easily accessible, especially when other problems complicate intussusception, death becomes almost inevitable.

When intussusception or any other serious medical problem is suspected, the person should be taken to the hospital immediately.

The prognosis for intussusception is excellent when treated quickly, but when left untreated it can cause death within two to five days.

It requires a quick treatment, because the longer it prolapses the segment of the intestine, the longer it passes without blood flow and the less effective it is a non-surgical reduction.

Prolonged intussusception also increases the likelihood of intestinal ischemia and necrosis, requiring surgical resection.

Epidemiology

The condition is diagnosed more frequently in childhood and early childhood. It attacks about 2,000 babies (one in every 1,900) in the United States during the first year of life.

Its incidence begins to increase between one and five months of life, reaches its peak at four and nine months of age, and then gradually decreases around 18 months.

Intussusception occurs more frequently in boys than in girls, with a ratio of about one person in three.

In adults, intussusception is the cause of approximately 1% of intestinal obstructions and is often associated with malignancies or other types.

Etiology

Intestinal intussusception is ileocolic in 80% of cases, but it can also be ileoileal, colocolic or ileoileocolic. Most infants and young children (95%) with the condition do not have a specific point of identifiable referral.

In these idiopathic cases, careful examination may reveal hypertrophic mural lymphoid tissues (Peyer’s patches), which are due to adenovirus or rotavirus infection.

It has also been found that intussusception increases the risk of tonsillar disease (ie, chronic or acute tonsillitis ) and tonsillectomy in children.

A specific lead point is identified that attracts the proximal bowel and its mesentery inward and propagates it distally through peristalsis in only 5% of cases, and is found most frequently in cases of ileoileal intussusception.

Specific lead points are found more frequently in children older than 3 years and almost always in adults with intussusception.

Meckel’s diverticulum is the most common starting point, followed by polyps, such as those seen with Peutz-Jeghers syndrome and intestinal duplications.

Other main points described include lymphomas, lymphangiectasias, submucosal hemorrhage with Henoch-Schönlein purpura, trichobezoars with Rapunzel syndrome, caseifying granulomas due to abdominal tuberculosis, hemangiomas, and lymphosarcomas.

Intussusception associated with pathological landmarks may be more likely to recur.

Children with cystic fibrosis (CF) may have intussusception due to meconium thickened in the terminal ileum.

Although intussusception is usually seen as a complication in older children with cystic fibrosis, neonatal intussusception with meconium plug syndrome associated with cystic fibrosis has been reported.

The postoperative jejunoileal or ileoileal intussusception, which does not have a specific point in most cases, represents approximately 1% of the intussusceptions in children of all ages.

When there is a point of advance with postoperative intussusception, several cases have been reported after appendectomy with inversion of the stump.

Other rare types of intussusception include retrograde jejunojejunal intussusception after repair of duodenal atresia and an ileoileal type resulting from closed abdominal trauma.

Although the vast majority of cases of intussusception are idiopathic, Oshio et al . In Japan, they reported a familial anatomical tendency that may predispose the condition to viral infection.

Of the 554 families who had at most one third-degree relative with an idiopathic case of intussusception, the authors found an incidence of approximately 7%, or 1 per 14.2 cases.

Family history can help in the study, and more genetic tests can eventually identify the gene responsible for this predisposition.