1. Case Presentation
Said Al Mazroui

2. On 11/10/09
5 months child presented with 5 days history of loose motion

3. for 3-4 times daily (normal 1-2 times/day)
for 3-4 times daily (normal 1-2 times/day). the diarrhea was associated with low grade fever ( not ducomented )
2 times vomiting only

4. the fever was of low grade in nature, on/off with no sweating, rigors/chills, abdominal pain, respiratory distress, LOC or seizures.
Mother noticed blood in the stool at 11:30pm
h/o increased crying.
perinatal history is not eventful

5. Examination: looks lethargic and dehydrated.
No pallor, jaundice, cyanosis, LN.
HR=140/mint, RR=30/mit, t=36.9 C, O2 sat=98%, BP: 86/ wt:8 kg
Abdomen: soft, no distention , tenderness, no mass.
Other systemic examination: nad.

6. DD ??

7. Plan:
Start I.V.F
Send CBC, U&E, Urine dipstix
Observation

8. UREA AND ELECTROLYTES sodium 136 mmol/l potassium 4.4 mmol/l chloride
Carbon dioxide
22 mmol/l
urea
1.8 mmol/l
creatinine
17 umol/l

9. CBC hemoglobin 11.4 g/dl hematocrit 34 % Mean cell volume 4.58 fl%
Mean cell volume fl
Mean cell hg pg
RBC dist. width
16.5
Platelet count
x10pwr9/1
White cell count
x10pwr9/1
neutophils
x10pwr9/1
lymphocytes
x10pwr9/1

10. Urine dipstick:
ketone 3+

11. After 4 hrs
became playful and active
No crying throughout observation

12. R u happy to d/c ???

13. d/c on ORS
it was fully explained for the parents if the patient developed fever, bloody diarrhoea or vomiting to bring her back to the A&E or nearest local health center

14. On 13/10/09
h/o vomiting x several times, poor oral intake persisting loose watery stools / mixed with blood ? red current jelly stools
No excessive (Inconsolable) crying

15. Examination:
afebrile, tachycardic 158/min, rr 28/min looks mod-sev dehydrated with dry mucus membrane, mild sunken eyeballs and ant fontanelle.
chest: clear sat 100%
P/A: soft, non tender, + bs, no mass

16. Plan

17. US abdomen: (13/10)
There was a donut sign seen in the right mid abdomen suggestive of intusseption. After manipulation is resolved spontaneously. The spleen, liver, GB and both kidneys are normal. No free fluid in the pelvis or abdomen. \ Spontaneous resolution of Colico-colic intusussception

18. Admitted for observation -NPO -start IVF 0
Admitted for observation -NPO -start IVF 0.18 DNS 30 cc/hr -ceftriaxine 170mg IV OD

19. Why she was admitted??

20. Intussuception

21. Definition
telescoping of one segment of bowel into an immediately adjacent segment

22. Classification.
Enterocolic(90%)
Colocolic
Enteroenteric

24. Causes of intussusception
Idiopathic(90%)
Nonidiopathic. (hypertrophied Peyer patches secondary to infection, adenovirus infection, foreign bodies, parasitic infestation polyps, lipomas, Meckel's diverticulum, intestinal duplication, Henoch-Schönlein purpura, lymphomas, (

25. EPIDEMIOLOGY 2 per 1000 live births. male-to-female ratio is 3:1.
Most common between 3-9 month
most common cause of intestinal obstruction between 6 and 36 months of age
Most episodes occur in otherwise healthy and well-nourished children

26. Approximately 60 percent of children are younger than one year old, and 80 percent are younger than two
Intussusception is rare before three months and after six years of age

27. Most patients recover if treated within 24 hours
Most patients recover if treated within 24 hours. Mortality with treatment is 1-3%. If left untreated, this condition is uniformly fatal in 2-5 days. Recurrence is observed in 3-11% of cases. Most recurrences involve intussusceptions that were reduced with contrast enema

28. History Abdominal pain(80-95%) :
The child appears to have intermittent abdominal pain( manifest as episodic bouts of crying) which is colicky, severe and may be accompanied by pallor and drawing up of the legs (guarded position)
Episodes typically occur 2-3 times/hour.
Infant may sleep or may appear lethargic or playful between episodes of pain.

29. classic red currant jelly stool is a late sign (60%)
Vomiting (75%)
is usually a prominent feature
Initially nonbilious but may progress to bilious
Bowel motions
blood and/or mucus
classic red currant jelly stool is a late sign (60%)
.( so bilios vom is a late )

32. Diarrhea is quite common and can lead to a misdiagnosis of gastroenteritis .(can be an early sign of intussusception )
Lethargy is a relatively common presenting symptom with intussusception
There may be a preceding respiratory or diarrheal illness

33. Classic triad(21% all three, 72% have two)
1-Intermittent abd. Pain(80-95%)
2-Bilious vomiting(75%)
3-Currant-jelly stool(60%)

34. Examination
Abdomen:
Abdominal mass(65%) - sausage shaped mass in RUQ or mid-abdomen variably tender
Abdomen may be soft, non-tender or distended and tender
( This is hard to detect and is best palpated when the infant is quiet between spasms of colic. )
( dependeing in cmplet virsus incomplet obs or presense pf pertonitis)

35. Peristaltic wave may be present.
Absence of bowel contents in RLQ ( Dance sign)
PR: may revealed blood or mass. (PR unnecessary if good evidence of intussusception).
(u may palpate spex of intracss., u should be able to defrinniitae betweenit and rectal prolapse

36. Investigations Blood tests FBC, U&E Blood group and cross -match
Blood glucose
Cbc for leukocytosis, ue for dehydration

37. Plain abdominal Xray
Performed to exclude perforation or bowel obstruction
A normal AXR does not exclude intussusception
radiographic signs of intussusception are subtle
Signs of intussusception on a plain Xray include :

38. 1-Target sign - two concentric circular radiolucent lines usually in the right upper quadrant
2-Crescent sign : intussusceptum protruding into a gas filled pocket, which often results in a crescent shaped gas pocket.
3-Signs of obstruction.
( dilated small bowel, fluid levels, minilmal fecal content of colon

39. .

40. Sensitive and specific.
Ultrasound scan :
Useful if there is a suggestive history but no mass palpable or signs on plain AXR
Sensitive and specific.
Its use is limited by diagnostic and therapeutic use of air enema
Donut sign: hyperechoic core surrounded by hypoechoic rim

42. This intervention is both diagnostic and therapeutic
Hydrostatic reduction( air or barium)
This intervention is both diagnostic and therapeutic
Diagnostic investigation of choice if high level of suspicion
Sucuss rate is 80-90%, recrrence is 10%(most within 24 hr post reduction)

44. Complications: Intestinal hemorrhage
Intestinal obstruction and dehydration.
Bowel infarction leading to bowel resection
Bowel perforation
Peritonitis
Sepsis and shock
recurrence

45. Prognosis
Prognosis is excellent if diagnosed and treated early; otherwise, severe complications and death may occur.

46. Differential diagnosis
Gastroenteritis
Enterocolitis
Infantile colic
Incarcerated inguinal hernia
meckel’s diverticulum
HSP
others: polyps, appendicitis

47. Management Initial stabilization: Secure IV access
Most children will require fluid resuscitation with normal saline 20mls/kg IV
Keep nil orally
nasogastric decompression
Surgical consultation.
It is very important that this condition is diagnosed and treated early

48. recrrence is 10%(most within 24 hr post reduction)
Hydrostatic reduction
Sucuss rate is 80% in <24h of intrassusception. Only 32% if >24h.,
recrrence is 10%(most within 24 hr post reduction)
CI: peritonitis, perforation, shock
Complications: perforation, reduction of necrotic bowel.

49. Surgical reduction: indicated in:
1-suspected bowel gangrene or perforation.
2 -failure of hydrostatic reduction
3-multible recurrence.

50. Clinical pearls
Intussusception is the most common cause of intestinal obstruction between 3 months and 2 years of age.
high index of suspicion is essential
60% of Intussusception are initially misdiagnosed( GE is commonly confused with it)
( please remember)

51. Colicky abdominal pain is the major symptom
Bilious vomitous and currant jelly stool are late finding
Profound Lethargy can be the sole presenting symptom (up to 10%) , which makes the diagnosis challenging
Morbidity and mortality increased with delayed diagnosis.

52. THANX