Intussusception: Management

by Kevin Pei, MD

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    00:01 Although some patients may require surgery, particularly with signs of ischemia or perforation, the vast majority of patients respond quite well to non-operative reduction.

    00:12 There are a couple of options.

    00:15 There's therapeutic enemas.

    00:17 This is a hydrostatic reduction where a column of barium is inserted into the rectum at a certain height.

    00:23 This height is optimized to both reduce the intussusception, but also to minimize the risk of perforation.

    00:30 This can be performed hydrostatically with either contrast barium or water-soluble contrast.

    00:36 Similarly, pneumatic or air enemas have increasing use in patients with reduction of intussusception.

    00:44 There's no need for barium in this situation.

    00:47 Both have fairly good success.

    00:50 Please also keep in mind, this is not as useful if it's not ileocolic.

    00:56 In any other portions of the intestines, pneumatic or therapeutic hydrostatic enemas may not be able to reduce the proximal of the section.

    01:03 It is worth mentioning that in 10% of cases, intussusception recurs after reduction.

    01:08 Now, in this situation where patients do not reduce intussusception with the enemas therapy, there are some indications for surgery.

    01:22 For example, if the patient develops peritonitis, remember, in babies, they may not be able to present with classic findings of peritonitis as in adults.

    01:32 Everything generally just hurts.

    01:34 But if you find that there is discoloration of the skin, this may be a sign of peritonitis.

    01:40 Next, pneumoperitoneum.

    01:43 This suggests likely perforated.

    01:45 Although you don't know where the perforation is, this is an absolute indication for surgery.

    01:51 And lastly, as is in the case with most kids, progressive clinical deterioration.

    01:56 As a reminder, if a clinical scenario is presented to you and the patient has suspicion for ischemia or clinical deterioration, I strongly recommend that you go to the operating room.

    02:08 In the operating room, this is how we take care of intussusceptions.

    02:14 Generally, it's recommended that you push the invaginated segment out rather than pulling it out.

    02:21 This reduces the perforation risk.

    02:23 It’s common physics.

    02:25 If you're successful or not successful, management is a little bit different.

    02:31 If you're able to reduce intussusception in children by simply pushing out the invaginated segment and the segments appear viable, then complete the procedure by doing an appendectomy.

    02:45 However, if you are not easily able to reduce intussusception, it’s probably safer to perform a segmental resection.

    02:54 Let's review some very important clinical pearls and high-yield information.

    02:59 In patients who do not succeed an enema reduction, they can be repeated.

    03:05 Additionally, if a patient initially succeeds with enema reduction and re-intussuscepts, they’re also a candidate for enema reduction as long as these patients do not demonstrate any signs or indications for surgery that we've discussed.

    03:22 And for your examination, remember, lead points are rare in children.

    03:28 Lymph nodes, however, is the most common lead point, usually following upper respiratory infection.

    03:34 However, if an intussusception is presented in an adult patient, think about cancer as most patients - adult patients with intussusception have a lead point to explain why they develop a non-idiopathic non-ileocolic intussusception.

    03:53 Let's talk about Meckel's Diverticulum This is a small congenital diverticular of the small intestines that often finds its way onto tests.

    04:01 It is often described as following the rules of 2's meaning it occurs in 2% of the population, but only 2% of those patients develop symptoms.

    04:10 Usually it is two inches in length, normally located within two feet of the ileocecal valve.

    04:17 And commonly symptomatic in children less than two years of age.

    04:20 The symptoms include abdominal pain, bowel obstruction, bleeding and intussuspection if the diverticular inverts into the bowel lumen.

    04:29 Thank you very much for joining me on this discussion of intussusception.

    About the Lecture

    The lecture Intussusception: Management by Kevin Pei, MD is from the course Special Surgery.

    Included Quiz Questions

    1. Ileocolic
    2. Ileoileal
    3. Ileo-ileo-colic
    4. Colocolic
    5. Retrograde
    1. Absence of sepsis
    2. Peritonitis
    3. Perforated intestines
    4. Pneumoperitoneum suggesting vascular compromise
    5. Unstable patient

    Author of lecture Intussusception: Management

     Kevin Pei, MD

    Kevin Pei, MD

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