Intussuception is frequently associated with: (2014 Feb D. REPEAT)
Ans: C (Sub mucosal lipoma) Ref: Bailey and Love's Short Practice of Surgery. 25th edition Chapter 66, Intestinal Obstruction pg:1191-1212 and Donald A, Antonioli, "Gastro-intestinal Autonomic Nerve Tumors, expanding the spectrum of gastrointestinal stromal tumors", Arch Pathol Lab Med 1989; 113; 831-833Explanation:Intussusception consists of telescoping of a bop of bowel inside itself. It may or may not originate from a lead point, which is usually a swelling of the mucosa or submucosa (eg: Inf lammed Peyer's patch, mucosal adenoma, submucosal lipoma)." Ref: Clinical Surgery, Alfred Cuschieri, 2nd editionIntussusceptionPortion of the gut becomes invaginated within an immediately adjacent segment.Usually the proximal segment gets invaginated into the distal.Most commonly in children.Peak incidence - 5 to 10 months of age.Primary or secondary to intestinal pathology, e.g., polyp.Ileocolic is the most common variety.Aetiology and Risk Factors:90% of cases are idiopathic.Upper respiratory tract infection or gastroenteritis may precede the condition.Hyperplasia of Payer's patches in the terminal ileum may be the initiating event.Risk Factors in Infants:Weaning.Loss of passively acquire maternal immunity.Common viral pathogens.Risk Factors in Older Children:Pathological lead points are common in children more than 2 years of age.o Meckel's diverticulum.o Polyp,o Duplication.o Henoch -Schonlein purpura.o Appendix.o Submucosal Gl lipoma {Most Common in ileum, are single submucosal, intramural lesion), o Leiomyoma.Risk Factors in Adults:Invariably associated with a lead point.Polyp (e.g. Peutz-Jeghers syndrome).Submucosal lipoma.Other tumours.PathologyAn intussusception is composed of three parts:The entering or inner tube.The returning or middle tube.The sheath or outer tube (intussuscipiens).* The part that advances is the apex, the mass is the intussusceptions and the neck is the junction of the entering layer with the mass.An intussusception is a strangulating obstruction as the blood supply of the inner layer is usually impaired.The degree of ischaemia is dependent on the tightness of the invagination, which is usually greatest as it passes through the ileocaecal valve.Most common intussusception in children is ileocolic.Most common intussusception in adults is colocolic.Clinical Features:Episodes of screaming and drawing up of the legs in a previously well male infant.The attacks last for a few minutes and recur repeatedly.During attacks the child appears pale, whereas between episodes he may be listless.Initially vomiting which becomes bile-stained later.In early stage the passage of stool may be normal, later, blood and mucus are evacuated - the 'red currant jelly' stool.Physical Examination:Child should be examined between episodes of colic.Classically, the abdomen is not initially distended.Lump that hardens on palpation is present in 60% of cases.Emptiness in the right iliac fossa--the sign of Dance.Rectal examination--blood stained mucus may be found on the finger.Occasionally, in extensive intussusception, the apex may be palpable or even protrude from the anus.Progressive dehydration and abdominal distension from small bowel obstruction ensues without treatment, followed by peritonitis secondary to gangrene.Rarely, natural cure may occur as a result of sloughing of the intussusceptions.Imaging:Plain Abdominal X-rayEvidence of small or large bowel obstruction with an absent caecal gas shadow in ileocolic cases.A soft tissue opacity is often present.Barium EnemaClaw sign in ileocolic intussusception.Does not demonstrate small bowel intussusception.UltrasoundDoughnut appearance of concentric rings in transverse section.Computerised Tomography (CT)Used in equivocal cases.TreatmentIn infants with ileocolic intussusception non-operative reduction is tried first.More than 70% of intussusceptions can be reduced non- operatively.Resuscitation with intravenous fluids.Broad-spectrum antibiotics.Naso-gastric drainage.Non-Operative ReductionNon-operative reduction is attempted using an air or barium enema.Successful reduction can only be accepted if there is free reflux of air or barium into the small bowel, together with resolution of symptoms and signs.Contraindications for Non-Operative ReductionSigns of peritonitis or perforation.Known pathological lead point.Shock.Problems with Non-Operative Reduction:Strangulated bowel and pathological lead points are unlikely to reduce.Perforation of the colon -- rare.Recurrent intussusception occurs in up to 10%.Surgical ManagementIndicated when radiological reduction has failed or is contraindicated.
Subserosal lipoma
Intramural lipoma
Sub mucosal lipoma
Subfascial lipoma
Intestinal Obstruction