VOLGOGRAD STATE MEDICAL UNIVERSITY

VOLGOGRAD STATE MEDICAL UNIVERSITY

Department of Pediatrics surgery

Small bowel intussusception in children

Prepared by :

Tiong shyun ping, group 41

FACULTY OF GENERAL MEDICINE

Intussusception is one of the most common causes of acute abdomen in the early childhood. Ileocolic type accounts for most of the bowel invagination cases. ^[1] Small bowel intussusception (SBI) is much less frequently diagnosed, and it is usually associated with a lead point^[2]^,^[3] or it occurs postoperatively.^[4] An unreduced intussusception can potentially cause bowel obstruction and mesenteric vascular compromise leading to bowel ischaemia/necrosis. An early diagnosis and treatment of this condition is very important. However, careful interpretation of ultrasound (US) with or without CT scan has disclosed many SBIs that were transient and were reduced spontaneously without any intervention.^[5]^,^[6]^,^[7]^,^[8]^,^[9]

Intussusception is one of the most common emergencies in infants and children. In more than 80% of the cases ileocecal region is involved. SBI is found in less than 10% of cases.^[1] SBI is generally found in patients with age ranging between 2−20 years, with a median age of 10 years.^[1]^,[2],[3] Strouse et al.^[5] found SBI involving jejunum in 54% cases, mid small bowel in 18% cases, and ileum in 29% cases.

Pathological entities which can lead to SBI are: infections, polyps, lymphomas, malabsorption syndrome, Meckel's diverticulum, duplication cyst, cystic fibrosis, intraluminal hematoma, and adhesions. ^[2]^,^[3]^,^[5] It is also found to occur in postoperative period.^[4] However, now idiopathic SBIs are increasingly found. Factors predisposing to idiopathic SBI are: 1) swelling of the small bowel wall, 2) abnormal gastrointestinal motility, and 3) scar or adhesions of the bowel from previous insult i.e., surgery, chemotherapy, or radiotherapy.^[6],[7] The common association of mesenteric lymphadenopathy and ileocolic intussusception supports the above spectulation.

Typical presentation of cyclical abdominal pain, abdominal mass, and blood in stools is not found in patients with SBI.^[2]^,^[3]^,^[5]^,^[6]^,^[7] In the present case series, case 1 had atypical presentation, while case 2 presented with typical signs and symptoms. Diagnosis is generally based on clinical suspicion and radiological evaluation. SBIs are also found incidentally in asymptomatic patients or symptomatic patients evaluated for other reasons.^[5]^,^[6]^,^[7] The radiological diagnosis of SBI is based on its typical finding of target sign or pseudokidney sign on left upper quadrant of the abdomen on ultrasonography (USG).

With increasing use of CT scans and MRI, increased number of asymptomatic or idiopathic SBI has been identified, which are transient and does not require surgical intervention. Doi et al.^[8] described this phenomenon as benign SBI. According to them, SBI reduces naturally in many cases (benign SBI), but may be associated with intestinal ischaemia (SBI disease) or progresses to large bowel intussusception (ileo-ileo-colic). Typical findings of benign SBI associated with spontaneous reduction on US are: a) small outer diameter (<2.5 cm), b) short segmental invagination (<3 cm), c) peristaltic wall motion, and d) absence of any visible pathological lead point.^[5]^,^[7]^,^[9] The incidence of pathological lead point in patients with SBI is low according to Kornecki et al.^[6] However, Ko et al[2] found lead point in 56% of the patients with SBI requiring surgical exploration. There are reports of spontaneous reduction of SBI even in presence of lead points, i.e., in patients with polyp, perpura. In the case 1, the repeat scan revealed real time reduction of the intussusception and so the child was successfully managed conservatively. However, case 2 had peristent intussusception on US and was operated, though intraoperatively, it was found to have reduced spontaneously. Laparoscopy techniques might have been a useful option to avoid laparotomy in this situation. Radiological findings of free fluid in the abdomen, bowel obstruction and trapped fluid between the intussuscepted bowels are associated with reduced chances of spontaneous reduction.^[7] The criterion for successful reduction is mainly based on the symptomatic improvement of the patient. The repeat US findings will corroborate with the clinical improvement in the patient.

Kornecki et al.[6] recommend that if the US findings are typical for benign SBI and child is stable or asymptomatic, the patient can be managed conservatively and should be monitored by subsequent imaging at 45 minutes interval to confirm the spontaneous reduction. The authors further recommend that even if the reduction does not occur and the child remains asymptomatic, it is reasonable to follow these children with appropriate clinical monitoring without necessarily doing repeat US scans. This period will be double edged sword and has to be balanced by the surgeon and is largely subjective. We believe that by the mentioned criteria the surgeon can achieve this balance on timing of intervention. Optimal timing will achieve favourable results. However, patients with recurrent or multiple intussusceptions and those with persistent symptoms should undergo surgical exploration.^[7]^,^[8]^,^[9] Ko et al.[2] has reported three patients with idiopathic ileoileal intussusception developing delayed peforation after 6, 32, and 99 days. So it is important to closely follow-up the patients with SBI for several months.

The sonographic features of small-bowel intussusception are similar to those of ileocolic intussusception, including a doughnut sign of alternating hypoechoic and hyperechoic rings and a crescent-in-doughnut sign of a hyperechoic crescent layered around a central mass [2, 14]. Focal lead points such as Meckel's diverticulum, duplication cysts, and jejunal feeding tubes are sometimes well depicted on sonography [15]. Sonography, however, has low sensitivity for certain causes of intussusception, such as intraluminal polyps, and is not always reliable for differentiation of benign lymphoid hyperplasia and lymphoma

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