If a healthy baby suddenly has paroxysmal abdominal pain or paroxysmal regular crying, vomiting, blood in the stool and abdominal lumps like salami, you need to go to the hospital in time to ask the doctor to see if it is pediatric acute intussusception, early diagnosis is beneficial to early treatment and long-term healing.
Acute intussusception causes: the cause is still unknown, may be related to the following factors.
1, dietary changes: 4 to 10 months after birth, it is the period of adding complementary foods and increasing the amount of milk, is also the peak of the onset of intussusception. Because the infant intestine can not immediately adapt to the stimulation of the changed food, resulting in intestinal dysfunction, causing intussusception.
2, ileocecal anatomical factors: infancy ileocecal mobility, ileocecal flap excessive hypertrophy, small intestinal tract relatively long, neonatal ileocecal cecum diameter ratio 1:1.43, while the adult is 1:2.5, suggesting that the ileocecal cecum development speed is different. In infants, 90% of the ileocecal flap is lip-like and convex into the cecum, which is more than 1 cm long.
3, viral infection: a series of studies reported that acute intestinal overlap and intestinal adenovirus, rotavirus infection related.
4, intestinal spasm and autonomic dysfunction: due to a variety of food, inflammation, diarrhea, bacterial toxins and other stimulation of the intestinal tract spasm, so that the intestinal peristaltic function rhythm disorder or retrograde peristalsis and cause intestinal overlap. It has also been suggested that due to the delayed sympathetic development in infants and children, the autonomic nervous system activity is dysregulated, which causes intussusception.
According to the nearest part of the sheath and the most distal part of the intestinal segment, intussusception is divided into the following types.
1, small intestine type: including jejuno-jejunal type, ileo-jejunal type and jejuno-ileal type.
2.Ileocecal type: the ileocecal valve is the starting point.
3.Ileo-knot type: the end of the ileum is the starting point, and the appendix is not snapped into the sheath, this type is the most, accounting for about 70%~80%.
4.Colonic type.
5.Complex type or complex type Commonly ileo-ileal type, accounting for about 10%-15% of intestinal condyloma.
6.Multiple types There are two, three or more intussusceptions separated in different areas of the intestinal canal.
Clinical manifestations
1, infant intussusception (within 2 years of age) is common. Mostly primary intussusception with the following clinical features.
(1) Paroxysmal crying and quarrelling: it is common for previously healthy and obese infants to have sudden paroxysmal regular crying that lasts for about 10-20 minutes, accompanied by fidgeting of hands and feet, pallor, refusal to eat, and abnormal painful performance, followed by temporary silence for 5-10 minutes or longer, and so on repeatedly. This kind of paroxysmal crying is consistent with the interval of intestinal peristalsis, as the intestinal peristalsis pushes the sleeve into the intestinal segment forward, the mesentery is pulled, and the sheath of intussusception produces strong contraction and causes severe pain. In the late stage of intussusception combined with intestinal necrosis and peritonitis, the child is depressed and unresponsive. A part of the weaker, or complications of enteritis, dysentery and other diseases, crying is not obvious, but the performance of irritability.
(2) Vomiting: Initially milk and milk lumps or other foods, later turn into bile-like material, and after 1~2 days turn into foul-smelling intestinal contents, suggesting serious condition.
(3) Abdominal masses: If the abdomen is examined in the interval between 2 cries, a salami-like mass with slight movement and light pressure pain can be palpated in the right upper abdomen under the liver; the right lower abdomen generally has a feeling of emptiness; the mass can move along the colon; in severe cases, a cervical-like mass can be palpated in the rectum during anal fingering, which is the head of the trap.
(4) Jam-like blood stool: infants with intestinal overlap occur in more than 80% of the bloody stool. Parents often visit the doctor with blood in the stool as the first symptom, mostly in 6 to 12 hours after the onset of hematochezia, or 3 to 4 hours after the onset of hematochezia, as thin mucus or jelly-like jam-colored blood stool, which can be repeated after a few hours. The reason for the blood in the stool is that when the intestine is trapped, the mesentery is embedded in the intestinal wall and blood circulation is impaired, causing mucosal bleeding, edema and intestinal mucus to mix together and form dark purple jelly-like liquid.
(5) anal finger diagnosis: has important clinical value, some children who come to the clinic early, although there is no blood stool discharge, but through the anal finger diagnosis can be found in the rectum with mucus and blood stool, which is extremely valuable for the diagnosis of intussusception.
(6) General condition: varies according to the early and late consultation, except for pallor and irritability in the early stage, the nutritional status is good. Late stage children may have dehydration, electrolyte disturbance, mental depression, drowsiness, unresponsiveness. When intestinal necrosis occurs, there are signs of peritonitis and toxic shock may appear.
2.Children with intussusception
The clinical symptoms of intussusception in children are atypical compared with those of intussusception in infants. The onset of the disease is relatively slow, mostly incomplete intestinal obstruction, intestinal necrosis occurs relatively late. Children also have paroxysmal abdominal pain, but the interval between episodes is longer than that of infants, and vomiting is less common. Only about 40% of children with intussusception have blood in the stool, and blood in the stool often appears only a few days after the intussusception, or only a little blood on the finger sleeve during anal examination. In children who are more cooperative, the abdomen is often palpable with a waxy mass. Rarely, severe dehydration and shock are present.
Diagnostic differentiation
The diagnosis is established when the child presents with paroxysmal crying and restlessness, vomiting, jam-like blood in the stool, and a bologna-like mass is palpated on abdominal examination. However, in about 10%-15% of clinical cases, they lack the typical manifestations of acute intussusception when they come to the hospital, or only have one or two of the symptoms. At this time, we should carefully check whether a mass can be palpated in the abdomen, whether there is a feeling of emptiness in the right lower abdomen, and observe whether there is jam-like mucus stool on the finger sleeve for further confirmation. If necessary, do abdominal ultrasound and other auxiliary examinations to assist in the diagnosis.
Auxiliary examinations
1.Abdominal ultrasound
It is the preferred examination method, which can assist in clinical diagnosis through the characteristic images of intussusception.
Ultrasound examination of intussusception sonogram features.
(1) mixed abdominal mass, a little exudate can be detected in the periphery.
(2) The cross-sectional view shows “concentric circles”, with the outer circle showing homogeneous hypoechoic echoes of the distal intestinal wall, the middle and inner two circular inhomogeneous hypoechoic bands, which are the proximal intestinal edema and necrosis of the entrapped intestine, and the inner inhomogeneous slightly strong echoes of the intestinal contents and exudate of the entrapped segment (Figure 1A).
(3) The longitudinal section showed the “sleeve sign”, which is a symmetrical multi-layered parallel structure with high and low echogenicity (Figure 1B).
(4) The intestinal wall was thickened and hypoechoic, and secondary signs of intestinal obstruction such as dilatation of the intestinal canal, gas and fluid accumulation, and enhanced peristalsis of the contents were seen above the sleeve.
(5) Color Doppler flow imaging (CDFI) can detect abundant blood flow signals in the edematous intestinal wall of intussusception within 24 h after the onset of the disease (Figure 1D).
However, since intussusception is usually accompanied by intestinal obstruction after the onset of intussusception, it is affected by the accumulation of gas in the intestinal cavity, so this examination is somewhat limited.
2.Air enema
Before the air enema, a full frontal and lateral fluoroscopy of the abdomen is performed to observe the intestinal inflation and distribution. After air injection, a dense soft tissue mass in a semicircular shape is seen at the tip of the sleeve, protruding into the colon, and a distinct cup shadow is formed at the front of the gas, and sometimes some of the gas is seen entering the sheath to form different degrees of pincer shadows. The diagnosis is clear while repositioning treatment can also be performed with pressure.
Differential diagnosis
When the clinical symptoms and signs of acute intestinal loop are atypical, pay attention to differentiate from the following diseases.
1.Bacterial dysentery
Differentiation points: bacillary dysentery is mostly seen in summer, often with a history of unclean diet; high fever can appear at an early stage, with a temperature of 39°C or higher; mucopurulent stool with urgency and heaviness, and a large number of pus cells are seen in the stool routine. But occasionally, when bacillary diarrhea diarrhea, because of intestinal peristaltic disorder, can cause intussusception.
2.Acute necrotizing small bowel infection
Differentiation points: mainly diarrhea, stool is washed water-like or red jam-like, with special fishy odor; high fever, frequent vomiting, obvious abdominal distension, severe vomiting coffee-like material; general condition deteriorates faster than intestinal loop, severe dehydration, skin pattern and coma and other shock symptoms.
3.Allergic purpura
Children with abdominal purpura have paroxysmal abdominal pain and vomiting, with diarrhea or blood in stool, dark red, sometimes thickened due to edema and bleeding of intestinal canal, and masses can be palpated in the right lower abdomen. Note whether the child has a hemorrhagic rash on both lower extremities, knee and ankle pain, etc. Some cases may have hematuria. It has been reported that 25% of abdominal purpura can be accompanied by intussusception, at this time, ultrasound or air enema should be done to assist in the diagnosis.
4.Meckel’s diverticulum bleeding
Differentiation point: Meckel’s diverticulum ulcer bleeding occurs suddenly. The amount of blood in the stool is often a lot, and shock can occur in severe cases; there is no abdominal pain or only mild abdominal pain when bleeding. However, Meckel’s diverticulum can also cause intussusception, and it is difficult to distinguish it from primary intussusception, which is mostly found during surgery.
5. Ascaris intestinal obstruction
Differentiation points: mostly seen in young children and children, paroxysmal abdominal pain, may have a history of vomiting, stool roundworms; abdominal masses are mostly around the umbilicus in the shape of strips or flour masses, can be deformed by pressure; clinical rarely have blood in stool; children have a history of improper deworming before the onset; abdominal ultrasound shows the image of roundworms in the intestinal lumen.
Disease treatment
There are two types of treatment for pediatric acute intussusception: non-surgical treatment and surgical treatment. In the non-surgical treatment, there are air enema, barium enema and water pressure enema reset therapy under ultrasound, among which air enema reset has been widely used for a long time.
Non-surgical treatment
1, indications and contraindications.
Indications: air enema can be used to reset the patient with a duration of less than 48 hours, good general condition, no obvious dehydration and electrolyte disorders, no obvious abdominal distension and peritonitis, and the reset pressure is generally controlled at 60~100mmHg, and the pressure of intussusception and diagnostic enema for infants under 3 months of age generally does not exceed 80mmHg.
Contraindications.
(1) Those with a disease duration of more than 2 days, poor general condition, such as severe dehydration, depression, hyperthermia or shock and other symptoms.
(2) High degree of abdominal distension, marked abdominal pressure, muscle tension, and suspected peritonitis.
(3) Repeated intussusception, when secondary intussusception is highly suspected or has been diagnosed
(4) Small intestine type intussusception.
Air enema repositioning of intussusception: A colonic gas injector with automatic pressure control is used and a Foley tube is inserted in the anus. After the anal injection of gas, various images of the colonic mass are seen, gradually receding toward the ileocecal region until it disappears completely, at which time the sound of gas over water can be heard and the central abdomen is suddenly elevated and the reticular or circular inflatable ileum is visible, indicating that the colonic has been reset. Air enema reset rate can reach more than 95%.
After the enema confirms that the intestinal loop has been completely reset, the following observations should be made.
(1) A large amount of foul-smelling mucus and blood and yellow fecal water is discharged after removal of the balloon anal tube.
(2) The child falls asleep quickly without any bouts of crying and vomiting.
(3) The abdomen is flat and soft, and the original mass is no longer palpable.
(4) Oral administration of activated charcoal 0.5~1g, with black charcoal powder excreted from the anus in 6~8 hours.
2.Complications of air enema reset.
Serious complications are colon perforation, the phenomenon of abdominal cavity “flash” under fluoroscopy, that is, the air suddenly appears to fill the entire abdominal cavity, standing position to see the diaphragm free gas. No gas is expelled from the anus when the anal tube is removed. The child has difficulty breathing, rapid heartbeat, pale face, and sudden deterioration of the condition. The gas should be discharged from the abdominal cavity immediately by stabbing with a sterile needle in the middle of the glabella and umbilicus.
Surgical treatment
Indications for surgery.
(1) Cases in which non-surgical therapy is contraindicated.
(2) Cases in which the application of nonoperative therapy for repositioning has failed.
(3) Small bowel entrapment.
(4) Secondary intussusception.
(5) Surgical repositioning of intussusception
Before surgery, dehydration and electrolyte disturbance should be corrected, water fasting, gastrointestinal decompression, antipyretic, oxygenation, blood preparation and other measures should be used if necessary. In cases of intestinal necrosis, resection and anastomosis of the necrotic intestinal segment should be performed.
Precautions
Whether air enema reset or surgical reset, there is a 10% chance of recurrence of intussusception in the near future, so parents should take their children to the hospital promptly if they find that their children have paroxysmal crying, vomiting and restlessness again.
Sonographic features of intussusception on ultrasonography.
(1) Mixed abdominal mass, with a little exudate detectable in the periphery.
(2) The cross-section is “concentric circles”, the outer circle is homogeneous hypoechoic, the distal intestinal wall echogenicity, the middle and inner 2
The outer circle diameter of the sleeve site was 25-51 mm, with an average of (36.0±11.2) mm; the central circle diameter was 10-37 mm, with an average of (25.0±2.7) mm.
(3) The longitudinal section showed the “sleeve sign”, which is a symmetrical multi-layered parallel structure with high and low echogenicity (Figure 1B); the typical “sleeve sign” diameter of 63 cases was 20-70 mm, with an average of (50.0±10.0) mm.
(4) The intestinal wall was thickened and hypoechoic, and secondary signs of intestinal obstruction such as dilatation of the intestinal canal, gas and fluid accumulation, and enhanced peristalsis of the contents were seen above the sleeve, and enlarged lymph nodes were detected in the mass and surrounding mesentery (Figure 1C).
(5) Color Doppler flow imaging (CDFI) can detect abundant blood flow signals in the edematous intestinal wall of intussusception within 24 h after the onset of the disease (Figure 1D).
However, since intussusception is usually followed by intestinal obstruction, it can be affected by the accumulation of gas in the intestinal lumen and therefore limited by this examination.