Acute intussusception
Intussusception is an intestinal obstruction caused by the entry of a segment of the intestine into the adjacent intestine. The incidence of this disease is very high in China, much higher than that in Europe and the United States.
In the 18th century, Hunter described this disease, and in 1913, Ladd first used fluoroscopic enema successfully. At present, for the treatment of intussusception, foreign countries mostly use barium enema repositioning method, late or repositioning failure to use surgery treatment.
In recent years, the success rate of non-surgical procedures has increased significantly and the surgical mortality rate has been decreasing, but there are still deaths caused by late diagnosis, necrosis of the intestinal canal, poisoning, shock, high fever failure, and occasional air or barium enema perforation.
Morbidity]
The incidence rate varies among different ethnic groups and regions. The incidence is 1.5 to 4 per 1,000 live newborns.
(A) gender many reports prove that more males than females, about 1.5 to 3:1, the high 3.9:1.
(b) Age Although intussusception is occasionally seen in adults or neonates, it is most often seen in infants less than 1 year old. The literature reports that about 60-65% of cases are below 1 year of age, with a peak at 4-7 months of age. 2 years of age onwards decreases with increasing age, and after 5 years of age is very rare. Neonatal intussusception accounts for about 9.3% of this disease, and most of them are combined with intestinal atresia.
(c) Seasonal intussusception can be seen throughout the year, but the incidence is more concentrated in late spring and early summer; this may be related to adenovirus-induced infection of the upper respiratory tract and intestinal lymphatic system. According to statistics, about 10-30% of children have a history of upper respiratory tract infection before the onset of the disease. It has been suggested that the disease occurs in well-nourished, above-normal weight infants; however, the findings do not fully support this conclusion.
(D) Genetic Recently, there are reports of the relationship between intussusception and family, according to incomplete statistics, a total of 47 families were found, the incidence of which accounts for about 1/145 to 1/13 of the overall number of intussusception, with wide variations reported by local authors.
[Etiology].
The cause of intussusception is still unknown, and about 80-90% of adults with intussusception can find organic lesions, mostly due to tumors. In children, less than 8% of organic lesions can be found; among them, Meckel’s diverticulum takes the first place, followed by polyps, hemangioma, abdominal purpura, pancreatic cell ectopic, lymphoma, intestinal cyst, appendiceal invagination, etc. There are many different reasons for the onset of the disease in those without organic lesions, and so far there is no one theory that can explain all cases, some of which may be only causative.
(a) Dietary changes and food stimulation in infancy do not immediately adapt the intestine to the stimulation of the newly added food, resulting in intestinal dysfunction, prompting one segment of the intestine to become trapped in the other. Infant intussusception mostly occurs between 4 and 10 months of age, when food is added to the breast, so there may be a causal relationship between the two.
(B) local anatomical factors a large number of literature confirmed that infants and young children intestinal loop occurred in the ileocecal region accounted for about 95%, it can not be considered that the occurrence of this disease and the ileocecal region of local anatomical factors. The development of the internal organs of infants has not yet been completed, nearly 50% of the active appendix, while only 17% of the adult appendix is still not fixed. 90% of the ileocecal flap is lip-like convex into the cecum, up to 1 cm or more, coupled with the rich lymphatic tissue in the area, inflammation or food stimulation is easy to cause edema, hypertrophy, intestinal peristalsis when the hypertrophic ileocecal flap is pushed forward, or can pull the intestinal wall to form a ligature.
(iii) Phytogenic factors have been suggested that intussusception is caused by delayed sympathetic nerve development and dysfunctional activity of the phytogenic nervous system.
(d) Spasticity factor is due to various causes of stimulation, such as food, inflammation, diarrhea, bacterial or parasitic toxins, which cause spasm of the intestine and dysregulation of the motor rhythm or retroperistalsis.
(E) Hyperplasia of the terminal ileal collecting lymph nodes and hypertrophy of the mesenteric lymph nodes and proliferation of the ileocecal collecting lymph nodes in intussusception may be the cause of intussusception. After birth, lymphatic tissue proliferates at a high rate until about 1 year of age, and then gradually declines after 5 years of age. This period of proliferation and decline coincides with the high incidence of intussusception within 1 year of age and the rare occurrence of intussusception after 5 years of age. Therefore, lymph node hyperplasia causing intussusception is recognized by many scholars.
(vi) Viral factors The age and season of onset of intussusception are the period of viral susceptibility, thus many authors believe that adenovirus as a causative factor causing intussusception is beyond doubt.
(vii) immune response factors 75%-85% of the age of onset of intussusception is below 1 year, when the immune function is not yet perfect and immunoglobulin is at a low level. Therefore, in addition to the aforementioned factors, the occurrence of intussusception and pediatric immune function should also be thought of a certain relationship.
(H) endocrine factors domestic Jin has measured 105 cases of infants with intussusception serum gastrin content, found significantly higher than normal and non-intussusception small intestine obstruction infant control group.
Although many of the above factors can be found on objective basis, or animal experiments have been confirmed, but so far, except for a few found to have organic lesions, most children with intussusception is still difficult to determine the cause.
Clinical manifestations
(A) abdominal pain is the earliest symptom, sudden onset, crying and restlessness. The abdominal pain is paroxysmal and lasts for a few minutes each time, but after an interval of 10 to 20 minutes, the attack is repeated, repeatedly. Abdominal pain is present in about 90% or more of cases of intussusception.
(B) Vomiting about 80% of the sick children appear vomiting, vomiting milk, milk lumps or other food. The vomiting is infrequent, gradually vomiting bile, and in the late stage contains feces.
(iii) Bloody stools are mostly excreted 8 to 12 hours after the onset of the disease, and are thick, jam-like stools. Sometimes it is dark red blood and water, which indicates serious damage to the intestinal wall, and special caution should be exercised when non-surgical repositioning. The natural discharge of bloody stool accounts for only about 30%, while the anal finger examination or into the anal canal to find bloody stool accounts for about 60%; therefore, routine anal examination can find bloody stool accounts for about 90%, which is very helpful to confirm the diagnosis.
(D) abdominal examination early when the child is lying quietly, while keeping the abdominal muscles relaxed is to examine. 75% of children can find a salami-shaped mass, slightly hard and tough feeling. It is most often found in the right upper abdomen under the hepatic margin, and the child has discomfort when the mass is palpated, sometimes with reactive tension in the abdominal muscles. In the late stage, because of the obvious abdominal distension, and then intestinal strangulation and necrosis, inflammatory exudation stimulates the peritoneum causing abdominal muscle tension, at this time the child can not cooperate, it is difficult to palpate the mass.
(E) the general condition of the child in the early stage is generally good, the body temperature and pulse rate is normal. 24 hours later, as the symptoms worsen, the condition gradually deteriorates, the child’s expression is indifferent, depressed, drowsy, pale, the whole body is seriously dehydrated, the body temperature rises to more than 39 ℃, the pulse rate accelerates, 48 hours later because of the abdominal distension is serious, the diaphragm is elevated, affecting breathing. After the occurrence of intestinal necrosis, there were signs of peritoneal irritation and abdominal muscle tension. The child’s systemic toxic symptoms are increasing, with a fine and rapid pulse rate, high fever above 40 ℃, coma, shock, failure and even death.
(F) The characteristics of children with intussusception Generally speaking, the difference between children with intussusception and infants with intussusception is not great, but the older the child is, the slower the onset of the process, the symptoms of subacute intestinal obstruction. Abdominal cramps and abdominal masses are common, but vomiting and blood in stool are less common. According to statistics, about 40% of children with intussusception have blood in the stool, while more than 80% of infants with intussusception have blood in the stool. In terms of systemic conditions, severe dehydration and shock are rare in children with intussusception.
Treatment
(a) Non-surgical treatment: 70%-90% success rate of rectification can be obtained.
1, air enema: widely carried out in China, the success rate is high.
2, non-diagnostic air enema: now less used, suitable for the application of primary hospitals lack of imaging equipment.
3.Barium enema: more commonly used in Europe and America.
4.B ultrasound saline pressurized enema: currently carried out in China, the success rate is also high.
(ii) Surgical treatment
Non-surgical treatment failure, or late combined with other intestinal disorders, multiple recurrence, or chronic intussusception should be operated.