Internship Case Report

INTUSSUSCEPTION

Created By:
dr. Dian Zarina Rahmi

Supervisor:
dr. H. Gusnarwin, Sp.B
dr. Eka Novrida Istiana

DATU BERU REGIONAL PUBLIC HOSPITAL

CENTRAL ACEH REGENCY
2016- 2017
 I. INTRODUCTION

Intussusception is a common abdominal emergency in children.

Intussusception is best described as a portion of the intestine which telescopes into a
more distal intestinal segment. It is one of the most common causes of abdominal
obstruction in infants. Intussusception occurs most often in patients between 3 to 12
months of age. There is a male to female predominance of 3:1.1,2
The majority of intussusceptions are idiopathic. An anatomic lead point (a
piece of intestinal tissue which protrudes into the bowel lumen such as a polyp)
occurs in approximately 10% of intussusceptions. This is most often found in
children older than 2 years. Possible lead points include Meckel's diverticulum (most
common), polyps, an inflamed appendix, neoplasm (lymphoma), and ileal
duplications. 2

It is often difficult to diagnose because of the variable presentation of

symptoms in a young infant. Classic presentation involves colicky abdominal pain,
vomiting, palpable mass, and blood per rectum or currant jelly stools (occurring in
20% of patients).2,3
Prognosis is excellent by early treatment. Spontaneous resolution may also
occur and depends on multiple factors, eg, location and length. For example, small
bowel intussusception without a lead point can be asymptomatic and an incidental
finding. Intussusception carries an overall mortality of less than 1%. Recurrence rates
following nonoperative reduction and surgical reduction are approximately 5% and 1-
4%, respectively. The risk of postoperative adhesive small-bowel obstruction
following nonoperative reduction is 0%; after operative reduction, the risk is as high
as 5%.1,10

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 II. CASE REPORT

2.1 IDENTITY OF PATIENT

Name : Baby boy M. A
Sex : Male
Registration Number : 148419
Age : 11 months old
Hospitalized : December 19th , 2016

2.2 ANAMNESIS
The Main Complaint : Bloody and jelly stool
Additional Complaint : abdominal distention, vomiting, fever
History of Present Illness :
An 11 month old baby boy presented to Datu Beru emergency room with chief
complaint of bloody and jelly stool since 1 day before being hospitalized for two
times. The volume of stool each time is ± 40 cc. According to his mother, the
complain started after the patient being massage 4 days ago. And then the abdominal
pain accure gradually and the patient irritable. The abdomen become distended since
1 day before with enlargment of the right side. There is vomiting 3 times, greenish.
Fever in one day. There is no diarrhea, cough, or runny nose. There is no any urinary
complaints. His appetite has been poor since the onset of these symptoms untill now a
day the patient become lethargy and pale.

History of Past Illness : Denied

Family History : Denied
Feeding hystory :
0-3 month : breast feeding + formula milk
3-6 month : breast feeding + formula milk + banana
6 month- now : formula milk + family meals

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2.3 PHYSICAL EXAMINATION
Vital Sign
Consciousness : Alert
Pulse : 138 beats/minute
Respiratory rate : 30 breaths/minute
Temp : 37,8 ° C
Weight : 9 kg

General Status
1. Skin : sianotic (-), icterus (-), pale (-)
2. Head
Eye : Conj. Palpebra Inferior pale (+/+), icteric(-/-), sunken (+/+)
Ears : secret (-/-)
Nose : secret (-/-), nostril breath (-)
Mouth : dry and pale lips (+), no sianotic
Pharynx : Hyperemic (-)
3. Neck : enlargment of limph gland (-)
4. Chest
Inspection
Form : Normochest
Movement : Symmetrical
Breathe Type : Thoraco-Abdominal
Retraction : Suprasternalis (-), intercostalis (-)
Right Chest Left Chest
Stem Fremitus and pain are Stem Fremitus and pain are
Palpation
difficult to asses difficult to asses
Percussion Are not done Are not done
Normal vesicular (+) Normal vesicular (+)
Auscultation
Ronchi (-/-), wheezing (-/-) Ronchi (-/-), wheezing (-/-)

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5. Heart : In normal limit
6. Abdomen :
Inspection : Distention (+), visible peristaltic (-)
Auscultation : Bowel sound (+) decrease
Palpation : pain (+), Muscular rigidity (-), found a palpable hard 10 cm
sausage shaped mass in the right middle quadrant of the
abdomen
Percussion : dullness on the palpable mass and hypertimpany at the other
region
7. Anogenetalia : in normal limit
8. Extremities : Local Status
SUPERIOR INFERIOR
Extremities
Right Left Right Left
Pale + + + +
Edema - - - -
Icteric - - - -

2.4 DIFFERENTIAL DIAGNOSIS

Mechanical bowel obstruction ec
1. Intussusception
2. Volvulus
3. Abdominal mass

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2.5 SUPPORTING EXAMINATION:
1. Laboratory result
Hematology 19 Des 2016 21 Des 2016 Normal value
Hemoglobin 9,9 g/dl 11,6 g/dl 12,0-14,5 g/dL
Hematocrit 30,8 % 35,4 % 45-55 %
White blod cell 12,07.103/mm3 11,6.103/mm3 4,5-10,5.103/mm3
Platelet 516.103 U/L 437.103 U/L 150-450.103 U/L
Eosinophil 0 0 0-6%
Basophil 1.2 0 0-2%
Neutrophil Segmen 69,1 61 5-70%
Limphocyte 18 30 20-40%
Monocyte 11,7 9 2-8%
Bleeding time 2 1-7
Clothing time 7 5-15
2. Radiology result

Erect abdominal radiograph:

 The dilated of small bowel
 Step ladder/ multiple air fluid
level (+)
 Ground glass appearance in
the lower region

Conclussion : Mechanical bowel

obstruction

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2.6 DIAGNOSIS
Mechanical bowel obstruction ec Intussusception

2.7 MANAGEMENT
Supportif
1. Stop oral intake
2. Nasogastric tube
3. Consult to pediatric amd surgery division

Medication
 O2 ½ - 1 liter/ menit
 Rehydration IVFD RL 80 drips/minute micro
 Maintenance IVFD Kaen 3B 10 drips/minute micro
 Blood transfusion 75 cc PRC intraoperative
 Inj. Ondansentron 1 /4 amp/ 12 hours
 Inj. Metronidazol 200 mg/ 8 hours
 Paracetamol syr 4 x 1 cth
 Zink syr 1x1 cth

Surgery
After laparotomy, found that a
portion of terminal ileum intussuscepts
through the ileocecal valve into the
transversal colon. Milky prosedure does
not repair all of intususception, than
hemycolectomy done. Founded enlarged
mesenteric lymph nodes as a lead point.

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2.8 PROGNOSIS
Qou ad vitam : dubia
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam

2.9 FOLLOW UP
Date Preoperative Post operative The last day care
19-12-2016 20-12-2016 28-12-2016
S Currant jelly stool (+), Currant jelly stool (+) 1 Currant jelly stool (-),
vomiting (+) 1 time, time, the stool become vomiting (-), fever (-),
yellowish, vomiting (-),
fever (+)
O Vital sign/ Vital sign/ Vital sign/
P : 134x/i P : 124x/i P : 126x/i
RR : 32x/i RR : 28x/i RR : 26x/i
T O
: 37.8 C T : 37.4OC T : 36.6OC
PF/ PF/ PF/
 Eyes : pale (+/+),  Eyes : pale (+/+),  Eyes : pale (+/+),
 Mouth: pale lips (+),  Mouth: pale lips (+),  Mouth: pale lips (+),
 Extremitas: pale (+/+)  Extremitas: pale (+/+)  Extremitas: pale (+/+)

S/L a.r Abdomen S/L a.r Abdomen S/L a.r Abdomen

 distention (+)  distention (+)  distention (+)
 bowel sound (+)  bowel sound (+)  bowel sound (+) N
decrease, found a decrease  operation wound is
palpable mass  operation wound dry
is clear

A Mechanical bowel Post Hemycolectomy Post Hemycolectomy

obstruction ec Dextra POD I ec Dextra POD VII ec
Intussusception Intussusception Ileocolic Intussusception Ileocolic
P Th/ Th/ Th/
 O2 ½ - 1 liter/ menit  fasting – start diet per  IVFD KAEN 3B 10
 Rehydration IVFD RL NGT gradually drops/minute
80 drips/minute micro  IVFD KAEN 3B 10  IVFD Aminofusin Ped
 Maintenance IVFD drops/minute 10 drops/ 8 hours

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 Kaen 3B 10  IVFD Aminofusin Ped  Inj. Cefotaxime 300 mg/
drips/minute micro 10 drops/ 8 hours 12 hours
 Inj. Ondansentron /4  Inj. Cefotaxime 300
1  Inj. Metronidazol 200
amp/ 12 hours mg/ 12 hours mg/8 hours
 Inj. Metronidazol 200  Inj. Metronidazol 200  Inj. Antrain ½ amp/ 12
mg/ 8 hours mg/8 hours hours
 Paracetamol syr 4 x 1  Inj. Antrain ½ amp/ 12  Inj. Ondansentron 1 /4
cth hours amp/ 12 hours
 Zink syr 1x1 cth  Inj. Ondansentron 1 /4  Inj. Fenobarbital 10 mg
amp/ 12 hours  Inj. Ranitidin 1 /4 amp/
P/  Inj. Fenobarbital 10 mg 12 hours
- Check routin blood,  Inj. Ranitidin 1 /4 amp/
ct/bt, blood group 12 hours Discharge medication
- Erect abdominal  Cefadroxyl 2 x 1 cth
radiograph (mechanical  Metronidazole 3 x ½ cth
bowel obtruction)  Paracetamol 3x 1 cth

P/
 Aff drain, wound care
 Control after 5 days

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 III. DISCUSSION

An 11 month old baby boy presented to Datu Beru emergency room with chief
complaint of bloody and jelly stool since 1 day before being hospitalized for two
times. The volume of stool each time is ± 40 cc. According to his mother, the
complain started after the patient being massage 4 days ago. And then the abdominal
pain accure gradually and the patient irritable. The abdomen become distended since
1 day before with enlargment of the right side. There is vomiting 3 times, greenish.
Fever in one day. There is no diarrhea, cough, or runny nose. There is no any urinary
complaints. His appetite has been poor since the onset of these symptoms untill now a
day the patient become lethargy and pale.
Two thirds of children with intussusception are less than 1 year old, most
commonly affecting infants 5 to 10 months of age. Intussusception can occur in
adults but is rare, accounting for 16% of the cases. Approximately two thirds of the
case are male.1
Children with intussusception often present with various nonspecific symptoms.
The classic triad of intussusception are a young child with crampy, intermittent (also
known as colicky) abdominal pain associated with “currant jelly” stools and a
palpable mass on physical examination have been shown to be present in fewer than a
quarter of children. 2

The mesentery is pulled along with the intussusceptum (leading invaginating

segment) into the intussuscipiens (receiving segment). The intussusceptum is
propelled distally through peristalsis causing the pain intermittent. The mesenteric
vessels are compressed leading to venous obstruction. If the intussusception and
obstruction reaches high pressures, arterial flow also can be inhibited, causing
necrosis. Ischemic mucosa sloughs off, causing heme-positive currant jelly stools..
The patient may develop vomiting (90% of cases). The emesis may become bilious
because of the obstruction.1, 2

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 The patient present with lethargy and pallor. Heart regular rhythm and normal
rate. Lungs are clear with good aeration. His abdomen is distended, with hypoactive
bowel sounds, and a palpable mass in the right upper quadrant.
The etiology of this lethargic presentation is not known, but it tends to occur in
younger infants. Some hypothesize that this is due to release of endogenous opioids
or endotoxins released from ischemic bowel. In some patients, a mass may be
palpable in the right upper quadrant. It is often described as sausage-shaped. A
sausage-like mass in the right upper quadrant and emptiness (the absence of bowel) in
the right lower quadrant is clinically indicative of an intussusception. First and
foremost, Ileo-colic intususception is more commonly (90%) located in the right
upper quadran or epigastric region of the abdomen; whereas transient small bowel
intususception is (91%) located in the right lower quadran or periumbilical region. 3

Picture 2.1 A palpable sausage mass due to an intususception

With a prolonged intussusception, perfusion to the intestine may be

compromised, which can then lead to bowel necrosis, perforation, and shock. Blood
may be found on rectal examination after perforation and mucosal bleeding. If the
intussusception has been present for a longer period of time, the abdomen may be
distended and there may be findings of peritonitis. 2
Laboratory of the patient in this case indicate there is anemia and leukocytosis.
According to studies that there are no spesific laboratory studies that aid with the

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spesific diagnosis of intususception. But as the process progresses there may be
assosiated electrolyte abnormalities due to dehydration, anemia, and/or leukocytosis. 3
The erect abdominal radiograph of this patient shows multiple air fluid level
that indicate mechanical bowel obstruction. Some of Abdominal Radiographs are
used as diagnostic modalities in intususception. Plain abdominal films (supine frontal
and left lateral decubitus) are the first imaging studies used in the ED. However, they
lack sensitivity (45%) and may give many false negatives. Classic intussusception
radiological signs are: Absence of air in the ascending colon (RUQ and RLQ). Soft
tissue density in the upper abdomen (up to 60% of patients). Small bowel obstruction
signs: small bowel dilation, air fluid levels.4
Ultrasound is highly accurate for the diagnosis of intussusception, especially
ileo-colic with a reported sensitivity of 98% to 100%. Ultrasound is preferred because
it is fast, non-invasive, and eliminates the growing concern of cumulative radiation.
Classic findings include: the target lesion or and the pseudokidney sign on
longitudinal imaging. CT scans can distinguish intussusception secondary to a lead
point versus no lead point, therefore decreasing the incidence of unnecessary
surgery.5

Picture 2.2 The doughnut sign on Picture 2.3 The pseudokidney sign
Ear transverse imaging
on longitudinal imaging

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 Early diagnosis and management are essential for achieving successful
outcomes in infants with intussusception. Once the diagnosis is entertained, surgical
personnel should be notified, an intravenous (IV) line inserted, and IV hydration
started. A nasogastric tube should be inserted and placed to suction. If there is marked
distention or a dilated bowel loop, an abdominal radiograph should be obtained.
Antibiotics should be administered if there is clinical suspicion of peritonitis or
infection (sepsis) or if the white blood cell (WBC) count is markedly elevated. 1
In this case, after laparotomy, found that a portion of terminal ileum
intussuscepts through the ileocecal valve into the transversal colon. Milky prosedure
did not repair all of intususception, than hemycolectomy did.
Frequently, the terminal ileum telescopes into the colon but colo-colic and ileo-
ileal variants can also occur. Idiopathic intussusception typically occurs at the ileo-
colic junction and often affects infants and toddlers. Enteroenteral intussusception
often occurs in older children. Intussusception is affiliated with Henoch-Schonlein
purpura, cystic fibrosis, hematologic dyscrasias, postoperative changes, or lead
points. Most pediatric small bowel intussusceptions resolve spontaneously and only
require observation.1, 2

Lead points are found in 2% to 12% of children, as age increases, so does the
occurrence of a lead point, and the chance of a non-surgical reduction becomes less
common. Examples of lead points are Meckel's diverticulum, enlarged mesenteric
lymph nodes, benign or malignant tumors, mesenteric cysts, and submucosal
hematomas associated with HSP. Other possible causes are change from breast to
cow’s milk feeding, viral inducers including rotavirus, rotavirus vaccine, Intestinal
lymphoid hyperplasia, and common upper respiratory illnesses. 6
Contrast enemas (barium, water-soluble and air) are diagnostic and therapeutic
techniques, with reduction rates of 70 to 90%. Barium enema is no longer considered
the gold standard for non-surgical treatment, though its use is still extensive. 7 This
test should be considered only after stabilizing the child, adequate hydration, and
consultation with a pediatric surgeon. The only current absolute contraindication for
barium enema is full bowel necrosis. 8

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 Air enema’s use has increased due to its lower perforation risk, less radiation
exposure, faster and better reduction rate. One study compared air vs. contrast enema
reporting success rates of 76% and 63% respectively. Intussusception recurrence rates
for air versus liquid enema are reported to be similar, approximately 10%.7, 8
If the intussusception is reduced successfully by enema, some may discharge
the patient home from the emergency department after observing the patient.
However, most feel that the patient should be observed in the hospital for 24 hours. If
the intussusception is not reduced by an enema, or if there is intestinal perforation,
shock, or peritonitis present, the patient is sent for surgical reduction. An intravenous
line, a nasogastric tube, and consultation with a surgeon should be considered. 2, 8

The abdomen and bowel are typically explored through a transverse incision in
the right lower quadrant (RLQ), though some advocate a right transverse
supraumbilical or even an upper midline incision. After inspection for signs of
perforation, the intussusception is identified and delivered into the wound. First, an
attempt is made at manual reduction by retrograde milking of the intussusceptum.
Although gentle pulling may aid in reduction, avoid vigorous pulling apart of the
intussuscepted segment of bowel.7
If manual reduction is unsuccessful, or pathologic lead point is present, or if
perforation has occurred, segmental bowel resection is necessary. After resection, a
primary anastomosis may be performed. After successful manual reduction, the
involved bowel segment may appear edematous, hyperemic, or ischemic, but such
findings do not necessarily mandate resection. 8
Prognosis is excellent by early treatment. Spontaneous resolution may also
occur and depends on multiple factors, eg, location and length. For example, small
bowel intussusception without a lead point can be asymptomatic and an incidental
finding. Intussusception carries an overall mortality of less than 1%. Recurrence rates
following nonoperative reduction and surgical reduction are approximately 5% and 1-
4%, respectively.9 The risk of postoperative adhesive small-bowel obstruction
following nonoperative reduction is 0%; after operative reduction, the risk is as high
as 5%.10

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 BIBLIOGRAPHY

1. Moore SW, Kirsten M, Muller EW, Numanoglu A, Chitnis M, Le Grange E,

Banieghbal B, Hadley GP: Retrospective surveillance of intussusception in
South Africa, 1998–2003. J Infect Dis 2010,202(S1):S156-S161

2. Ignacio, R. Chapter 39 : Intususception. In Ashcraft’s Pediatric Surgery. Fifth

Edition. Saunders 2009. 508-516

3. Park NH, Park SI, Park CS, Lee EJ, Kim MS, Ryu JA, Bae JM: Ultrasonographic
findings of small bowel intussusception, focusing on differentiation from
ileocolic intussusception. Br J Radiol 2007, 80: 798–802.

4. Applegate KE. Intussusception in children: Imaging Choices. Semin Roentgenol.

2008 Jan;43(1):15-21.

5. Kim YH, Blake MA, Harisinghani MG, Archer-Arroyo K, Hahn PF, Pitman MB,
Mueller PR: Adult intestinal intussusception: CT appearances and identification
of a causative lead point. RadioGraphics 2006, 26: 733–744

6. Fischer TK, Bihrmann K, Perch M, et al. Intussusception in early childhood: a

cohort study of 1.7 million children. Pediatrics. 2004; 114: 782-5

7. Beasley S. Intussusception. Pediatr Radiol. 2004;34:302-304

8. Banapour P, Sydorak RM, Shaul D. Surgical approach to intussusception in older

children: Influence of lead points. J Pediatr Surg. 2015 Apr. 50(4):647-50

9. Gray MP, Li SH, Hoffmann RG, et al; Recurrence rates after intussusception
enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(1):110-9.

10. Michael S.I. Pediatric Intussusception Surgery Treatment & Management.

International Pediatric Endosurgery Group. 2015

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