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leading point leading point
Lymphoid hyperplasia
ESENTERY
LEAD POINT
A lead point is a lesion or variation in the intestine that is
trapped by peristalsis and dragged into a distal segment of
the intestine, causing intussusception.
A Meckel diverticulum, polyp, tumor, hematoma, or
vascular malformation can act as a lead point for
intussusception.
The male-to-female ratio is approximately 3:2.
Two thirds of patients are under one year old, the peak
age being between 5-10 months.
Intussusception is the most common cause of intestinal
obstruction in patients aged 5 months-3 years and
accounts for up to 25% of abdominal emergencies in
children up to age 5.
It is rare preterm.
One large Swiss study found an overall incidence of 38,
31 and 26 cases per 100,000 live births in the first,
second and third year of life respectively.
PATHOGENESIS
Occurs most often near the ileocecal junction (ileocolic intussusception), jejuno-
jejunal, jejuno-ileal, or colo-colic.
The intussusceptum, a proximal segment of bowel, telescopes into the
intussuscipiens, a distal segment, dragging the associated mesentery with it.
This leads to the development of venous and lymphatic congestion with
resulting intestinal edema, which lead to ischemia, perforation, and
peritonitis.
Pathological lead point (<10%)
NB: older patients (may have longer history):
Meckel's diverticulum (75%).
Non-pathological lead point (>90%)
Polyps and Peutz-Jeghers syndrome (16%).
Viral 50% - rotavirus, adenovirus and human
herpesvirus 6 (HHV6). Henoch-Schönlein purpura (3%).
Hydrostatic
Pros - No staining of peritoneum
Cons – Could cause rapid fluid shifts if not using iso-osmolar
concentrations
Barium
Pros – Familiar technique
Cons – Perforation, higher chance of peritoneal contamination
Coil spring appearance:
Trapping of barium between the edematous mucosal
folds of the returning limb of intussusceptum & wall of
intussuscepian.
Meniscus sign:
Convex intraluminal mass.
Mortality:
1% with treatment
Fatal if untreated
When a hole or tear in the bowel occurs, it must be treated promptly. If not
treated, intussusception is almost always fatal for infants and young children.
The child will first be stabilized. A tube will be passed into the
stomach through the nose (nasogastric tube). An intravenous (IV)
line will be placed in the arm, and fluids will be given to prevent
dehydration.
Antibiotics may be needed to treat any infection.
Radiological:
Reduction (three tries for three minutes each) if there is no sign
of peritonitis, perforation or shock.
Air enema <120 mm Hg of pressure or barium enema.
The choice of enema is usually left to the radiologist (many now favour
air enema).[7][9]
Laparotomy (reduction/resection) - indications:
Peritonitis
Perforation
Prolonged history (>24 hours)
High likelihood of pathological lead point
Failed enema
Patient should be stabilized and resuscitated with IVF, and the stomach
decompressed with a nasogastric tube. Because there is a risk of perforation
during nonoperative reduction, the surgical team should be notified and steps
should be taken to ensure that the patient is fit for surgery.