Intussusception is a segment of the intestine that becomes lodged in the lumen of the intestine to which it is attached and causes obstruction to the passage of intestinal contents. Intussusception accounts for the largest number of intestinal obstructions in pediatric patients.
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I. Etiology
According to the site of intussusception and the presence of obvious organic lesions, it is divided into primary intussusception and secondary intussusception, and secondary intussusception is mostly seen in tumor, trauma and post-surgery and inflammatory lesions of the intestine.
Primary.
The intestinal segment in which intussusception occurs and its vicinity cannot find obvious organic factors, accounting for 80-90% of the number of pediatric intussusception. In addition, sudden changes in the nature of food, food allergies, diarrhea, etc. in infants and young children may become a contributing factor to the development of intussusception.
Tumor.
It is the most common cause of intussusception in older children, including: Meckel’s diverticulum, appendix, polyps, tumors, submucosal bleeding due to allergic purpura, lymphoma, foreign body, ectopic pancreatic or gastric mucus, and intestinal duplication malformation, among which Meckel’s diverticulum is most common. And the site of overlapping is all in the small intestine. The older the child is, the greater the likelihood of secondary intussusception.
Trauma and surgery (about 1%).
Intussusception occurs after abdominal trauma and surgery, and 90% occurs within 2 weeks after surgery. The causes of intussusception after trauma or abdominal surgery are not known, and it is speculated that it may be related to intestinal wall hematoma, edema, adhesions, intestinal dysfunction, electrolyte imbalance, intestinal lumen built-in tube and chronic intestinal dilatation, and poor intestinal anastomosis alignment.
Other causes.
Intestinal inflammation causes intestinal peristaltic disturbance, mainly limited ileitis, non-specific ileocecal ulcer, acute ileocecal flap, acute and chronic appendicitis, etc. In addition, intestinal tuberculosis, bacillary or typhoid ulcer can cause intestinal entrapment, congenital malformations such as Meckel diverticulum, cecum agenesis, ileocolic linear connection and intestinal ascariasis, small intestinal cyst, idiopathic allergic purpura intestinal wall hematoma, etc. are the causes of intestinal entrapment The symptoms
Typical symptoms: peritoneal irritation, blood in stool, abdominal pain, shock, abdominal distension, acute abdomen
1. Acute intussusception: abdominal pain, vomiting, blood in stool, masses and changes in general condition.
(1) paroxysmal abdominal pain or paroxysmal crying: the first symptom of intussusception, accounting for 90% to 100% of the complaints, because after the formation of intussusception, the intestinal cavity is obstructed, the proximal intestinal segment occurs violent peristalsis and spasmodic contraction, with each peristaltic wave, so that the sleeve into the segment constantly forward, the mesentery into the sheath and produce severe pain, well-nourished, healthy infants often appear paroxysmal crying After 10-20 min, the infant will sleep quietly or play as usual, and after a few minutes, the infant will have a sudden attack, and so on, and so on, and the infant who is weak or has intussusception on the basis of enteritis or dysentery may not have violent crying, but only show bouts of restlessness and pallor, and the interval between episodes of abdominal pain is generally longer in larger children with intussusception.
(2) Vomiting: one of the early symptoms of intussusception in infants, often occurring soon after the beginning of the paroxysm of crying, vomiting mostly milk or other food, later often with bile, 12 to 24 hours later, vomiting can gradually stop, but there is often a refusal to breastfeed or eat, and later again vomit, or even vomit for fecal odor liquid.
(3) Blood in stool: In the early stage of intussusception, the peristalsis of the colon increases, the pressure in the intestinal cavity rises, and the child passes a small amount of normal stool.
(4) Abdominal mass: usually seen in the early stage of the disease, when the abdominal pain is relieved and the abdominal muscle is relaxed, parents can feel a mass like salami or banana in the right upper abdomen of the child. The lump is slightly elastic, smooth and slightly movable, which is the most valuable sign for diagnosing intussusception in children.
(5) Systemic condition: with the progress of intussusception may appear depression, indifferent expression, serious illness appearance, 48h after the emergence of intestinal necrosis can produce signs of peritonitis, systemic condition worsens, often with high fever, serious water-electrolyte imbalance, obvious toxic symptoms and shock and other manifestations.
2, chronic intussusception (5%): mostly in older children, mostly organic lesions (common polyps, hemangiomas, lymphoma, Merkel’s diverticulum, etc.), and occasionally idiopathic intussusception. Early symptoms are atypical and are easily misdiagnosed and missed in clinical practice. The course of the disease develops slowly, manifesting as chronic, intermittent, incomplete obstruction, with symptoms appearing for several days, months to more than 1 year, and finally may gradually develop into acute complete obstruction, initially with recurrent symptoms of intestinal inflammation and intestinal dysfunction, abdominal pain with nausea and vomiting, a small amount of mucus and blood in the stool, or completely normal, abdominal masses may appear or harden during painful episodes, and may be seen intestinal type, and return to the original state during the interval of pain, if the set is reset by itself, the abdominal mass can disappear completely.
III. Examination.
(1) air enema examination: air enema examination of intestinal entrapment, is developed on the basis of successful rectification with water pressure irrigation, because air enema is by means of translucent gas, the set into the part lined with a high density of soft tissue mass shadow, not only to confirm the diagnosis early, and the role of rectification, and therefore has dual clinical significance, to air enema to do colonic injection, the pressure is usually 60-90mmHg, under fluoroscopy The air is injected slowly from the anus, and the air is injected into the intestinal cavity easily at the beginning, and then suddenly stops when it reaches the head of the sleeve, because the head of the sleeve protrudes into the inflatable colon, and the front of the air column forms an obvious cup-shaped shadow.
(2) Ultrasound examination: the ultrasound of the sleeve area shows a substantial mass, and the transverse section shows the “concentric circles” sign formed by the multi-layered intestinal wall, and the longitudinal section shows the “sleeve” sign, and the intestinal movement near the sleeve is reduced, and the dynamic observation shows no or very little peristalsis, and the intestinal The contents of the intestine are stationary. The rate of diagnosis by ultrasound in our hospital is over 95%.
(3) MRI or nuclide scan: MR or nuclide examination is recommended to exclude organic lesions if intussusception occurs repeatedly in older children.
(4) laparoscopic investigation: it is both a diagnostic and therapeutic method to determine the type of intussusception, the presence of intra-abdominal fluid, the blood flow of the intestinal wall, the presence of intestinal perforation, necrosis, etc. under direct vision. At present, laparoscopic exploration is often used only after the failure of air enema.
IV. Treatment
1, general treatment: after the clear diagnosis of intestinal entrapment, that should be given a diet ban, gastrointestinal decompression, intravenous fluids and other supportive and anti-infective treatment.
2, air (barium) enema or B ultrasound under water pressure enema: for early pediatric intussusception preferred treatment, the success rate of our hospital reached 90% or more.
Application indications: intussusception within 24-48h, general condition is still good, no signs of peritonitis, no significant dehydration and shock symptoms.
Complications: intestinal perforation is the most critical complication.
3.Surgical repair method
Indications: ①Onset more than 48h, or within 48h serious condition suspected signs of intestinal necrosis. (2) Those who failed to rectify the colon with gas injection (or barium). ③Multiple recurrences suspected of organic lesions, surgical revision can both clarify the diagnosis and have a therapeutic effect. ④Small intestine type of pile-up.
V. Prevention
Regardless of what kind of reset method, the recurrence rate of intussusception is about the same, generally in 5%~10%. Therefore, it is necessary to strengthen preventive measures at ordinary times.
1, usually to avoid children’s abdomen cold, add clothing at the right time, to prevent climate change caused by intestinal dysfunction.
2, to prevent intestinal tract infection, hygiene, prevent disease from the mouth.
3, such as the occurrence of intussusception, after the successful reset, the first 3 days as far as possible liquid or semi-liquid diet, avoid eating allergy-prone food, can be appropriate to eat some probiotics to regulate the intestinal tract.