In an intussusception, the term intussuscipiens refers to:
Ans: C (The outer tube) Ref: Bailey & Love's Short Practice of Surgery, 25th Edition pg. 1191Explanation:Intussuscipiens refers to the sheath or outer tube of intussusceptionIntussusceptionPortion 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.Aetiology and Risk Factors90% of cases are idiopathic.Upper respiratory tract infection or gastroenteritis may precede the condition.Hyperplasia of peyer's patches in the terminal ileum may he the initiating event.Risk Factors in InfantsWeaningLoss of passively acquire maternal immunityCommon viral pathogensRisk Factors in Older ChildrenPathological lead points are common in children more than 2 years of age.After the age of 2 years, a pathological lead point is found in at least one-third of affected children.Meckel's diverticulumPolypDuplicationHenoch-Schonlein purpuraAppendixRisk Factors in AdultsInvariably associated with a lead pointPolyp (e.g. Peutz-Jeghers syndrome)Submucosal lipomaOther tumoursPathologyAn intussusception is composed of three parts:The entering or inner tubeThe returning or middle tubeThe 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 coiocolic.Clinical FeaturesThe classical presentation is with 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 may or may not occur but becomes conspicuous and bile-stained with time.In early stage the passage of stool may be normal, later, blood and mucus are evacuated - the 'red currant jelly* stool.Physical ExaminationChild 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 maybe 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.ImagingPlain Abdominal X-rayEvidence of small or targe 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-operativelv.Resuscitation with intravenous fluidsBroad-spectrum antibioticsNaso-gastric drainageNon-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 perforationKnown pathological lead pointShock.Problems with Non-Operative Reduction:Strangulated bowel and pathological lead points are unlikely to reduce.Perforation of the colon - rare.Recurrent intussusception occurs in upto 10%.Surgical ManagementIndicated when radiological reduction has failed or is contraindicated.
The inner tube
The middle tube
The outer tube
The entire complex of intussusception
Intestinal Obstruction