Intestinal Intussusception

Original Editor - Khloud Shreif

Top Contributors - Khloud Shreif  

Introduction

Intussusception is defined as sliding part of the intestine into an adjacent part, which is common in the small intestine but rare to find in the large intestine. It is more common in children between (6 to 18 months old) who have the classic triad of abdominal pain, bloody stools and palpable abdominal mass, rare to find in adults, and is usually secondary to a disorder, represents about 1%: 5% of intestinal obstructions and is associated with neoplasm in adults, but about 20% of these cases in adults are unknown cause. Patients with prolonged intussusception will increase bowel ischemia and necrosis, requiring surgical resection.

Pathophysiology

In normal condition, the ileum (the last part of the small intestine) moves into the cecum (the first part of the large intestine) because of normal intestinal movement. So in rare abnormal conditions when a section of the ileum or jejunum folds into itself because the intestine’s natural movements pull the upper segment into the lower this intusscception happens. When the part of the intestine gets trapped inside another section, blood flow to that area may be blocked, and without enough oxygen, the intestinal tissue can get damaged (ischemia), this damage can cause the inner lining of the intestine to shed, mixing with blood and mucus creating a stool that looks like red currant jelly. That may happen in about 10% of cases.

The part that moves inside is called the intussusceptum.

The part that receives it is called the intussuscipiens.

Risk Factors

Intussusception cases increase during viral gastroenteritis seasons. For example, The rotavirus vaccine was withdrawn due to its link to the condition. Adenovirus species C is a strong risk factor, while rotavirus and poliovirus are not. Human herpesvirus 6 is also associated with intussusception. Another rare type of intussusception is more common in adults and may be caused by polyps or gastrointestinal tumors. Bacterial infections like Salmonella, E. coli, Shigella, and Campylobacter can also increase the risk, especially within a month of infection.

The majority of cases in about 90% of children are unknown causes and the suspected causes may vary according to the following:

• Infections
• Congenital anatomical abnormalities.
• Altered motility
• Meckel's diverticulum
• Intestinal colon cancer
• Appendicitis
• Hyperplasia of Peyer patches, associated with idiopathic intussusception.
•   Idiopathic
• Bowel adhesions / endometriosis in adults.

Classifications

Intussusception typically occurs when a movable part of the intestine meets a fixed or retroperitoneal section. It is classified into four types based on location:

• Entero-enteral (75%) – This happens in the small intestine and is the most common type.
• Colo-colic (14%) – Occurs within the large intestine.
• Ileocolic (5%) – The terminal ileum (end of the small intestine) slips into the ascending colon. is the most common form in children and is typically managed with nonoperative reduction via pneumatic and/or hydrostatic enemas
• Ileocecal (8%) – The ileocecal valve (where the small intestine meets the colon) acts as the lead point for intussusception.

Symptoms

Symptoms of intussusception may include few not all the symptoms from the following:

In children:

The classic triad of abdominal pain, bloody stools, and palpable abdominal mass

In adults the signs and symptoms are nonspecific:

• Abdominal pain, which may wax and wane
• Vomiting
• Bloating, and bloody stool.
• Other complications may consist of peritonitis or bowel perforation.

Diagnosis

The diagnosis of intussusception varies between children and adults. In children, it usually occurs without a known cause and is generally benign with a good prognosis, it can be quickly diagnosed by recognizing key symptoms, Ultrasound can be used for diagnosis also in children.

Intussusception C.T

A CT scan is the best tool to diagnose intestinal intussusception in adults before surgery with an accuracy of 58% to 100% and helps to determine the location, possible causes, if the intestine is damaged, can also detect metastases, and other abdominal issues.

MRI for better view intestinal wall and blood vessels.

Colonoscopy is used with a patient who has chronic digestive issues or partial bowel blockage to identify masses that might cause intussusception.

Differential Diagnosis

• Abdominal hernia
• Appendicitis
• Blunt abdominal trauma in emergency medicine
• Colic
• Cycling vomiting syndrome
• Emergent treatment of gastroenteritis
• Internal hernia
• Testicular torsion
• Volvulus, loop of the intestine twists around itself making it hard for food and liquids to pass through.

Treatment

Medical Management

The treatment procedure varies according to the age. In children, it is usually resolved by non-surgical methods, using procedures like; pneumatic or hydrostatic enemas with ultrasound-guided which is successful in 85–90% of cases.

However, in adults, surgery (laparotomy or laparoscopy) is the preferred treatment, because of the higher risk of malignancy and if there is a mass. On the other side if the condition was discovered early it can be treated non-surgical with regular follow-up and observation, there are studies found, that the non-surgical procedure in these cases has a success rate of up to 82%.

Physiotherapy Management

Physical therapy intervention post- surgery focuses on preventing post-anesthetic complications (air way obstruction, atelectasis, deep vein thrombosis (DVT), Paralytic Ileus, or nausea and vomiting) improve endurance and strength of abdomen and back muscles by marinating good posture and improving lung capacity , in addition, teaching patient how to take care of the suture site, we can start as soon as the patient is conscious.

• The patient is learned how to splint the suture during cough, sneezing or any activity increase the intraabdominal pressure.
• Pursed lip breathing and diaphragmatic breathing to help patient keep airway clearance and increase lung capacity.
• Start to learn patient how to do static abdominal and back.

Rectal intussusception: this condition site is at the rectum and differ from the rectum it is usually because of staining, and pelvic floor dysfunction. It's symptoms varied from constipation, feeling of heaviness, obstructed defecation, and incomplete evacuation. Biofeedback training, pelvic floor muscle training, high-fiber diet, good hydration, and use of laxatives/enemas are the best suggested treatment protocol before surgery decision.