Paediatric Acute care Guidelines PMH Emergency Department

Intussusception occurs when a section of bowel invaginates into the lumen of the immediately distal bowel, resulting in infarction and gangrene of the inner bowel. It most commonly occurs at the ileocaecal junction.

Background

  • Peak age 5-10 months (may occur from 3 months to 5 year old)
  • Most common cause of acute intestinal obstruction in children 6-36 months
  • 60% of cases are < 1 year old and 80-90% are < 2 year old

Complications

  • Perforation of bowel, with peritonitis
  • Necrosis of bowel requiring bowel resection
  • Shock and sepsis
  • Re-intussusception after spontaneous or active reduction

Assessment

History

  • Typically, episodes of sudden intense pain with screaming and flexion of the legs, often associated with pallor
    • Episodes last several minutes and recur at 5-20 minute intervals
    • The infant usually looks relatively well between episodes
  • Less commonly, episodes of lethargy, irritability, altered mental status
    • May be mistaken for a child presenting with convulsions or sepsis/meningitis – the child appears floppy and semi-conscious
  • The classical TRIAD of pain, abdominal mass and red currant jelly stool is only seen in < 15% of cases
  • 1/3 of cases present with a history of recent viral illness
  • Recent rotavirus vaccination (there is a small risk of intussusception in infants following the rotavirus vaccination)

Examination

  • The child can present as pale, lethargic and hypovolemic
  • Abdomen may be distended and tender
  • Palpable abdominal mass (sausage shaped) in the right quadrant  
    • The mass can be difficult to palpate
  • Dehydration or shock develop as symptoms progress
  • Vomiting (may become bile-stained if bowel obstruction has occurred)
  • “Red currant jelly” stool (blood and mucous in stool) is a late sign

Investigations

Abdominal X-Ray

  • Mainly to look for signs of bowel obstruction or perforation
  • It may be normal
  • Signs of intussusception are:
    • Paucity of bowel gas on the right side of the abdomen
    • Distended loops of small bowel with air/fluid filled level
    • Look for obscured liver edge, crescent sign and target signs 
    • Free gas if perforated

Ultrasound (USS)

  • Diagnostic investigation of choice – highly sensitive and specific for intussusception (a “target” or “doughnut” sign is classic)

Blood Tests

  • Electrolytes, Urea, Creatinine, Blood gas
  • FBC
  • Cross match if “red currant jelly” stool

Management

Initial management

  • Insert intravenous (IV) cannula and obtain blood tests
  • If shocked, correct using IV boluses of 20 mL/kg of 0.9% saline
  • Nil by mouth
  • If signs of bowel obstruction insert nasogastric tube and leave on free drainage
  • Analgesia:
    • IV morphine 0.05mg/kg to 0.1 mg/kg titrated. See PMH ED Guideline: Analgesia
  • Arrange for an urgent abdominal ultrasound, and urgent surgical review
    • If the abdominal ultrasound is positive:
      • Follow directly by attempted non-operative reduction by means of an air enema unless the Surgeon and Radiologist agree that air reduction is unsafe and operative treatment is required
  • Air enema
    • Contraindications: signs of peritonitis/perforation
    • Antibiotics must be administered prior to the air emema or surgical reduction
      • IV Piperacillin/Tazobactam 100mg/kg (maximum of 4 grams Piperacillin component). See ED Guideline: Antibiotics 
    • ED Nurse +/- Emergency Doctor should accompany child to radiology to administer IV morphine for analgesia prior to attempted reduction
    • Surgical registrar must be in attendance
    • Performed by an experienced radiologist (up to 95% success rate)
  • Surgical reduction is necessary if there are signs of peritonitis / perforation, or if air enema fails to reduce the intussusception
    • Prepare the patient for theatre 

Nursing

  • Baseline observations include heart rate, respiratory rate, temperature and pain score. Blood pressure, oxygen saturations and neurological observations if clinically indicated.
  • Minimum of 1 hourly observations should be recorded whilst in the ED
  • Any significant changes should be reported immediately to the medical team
  • Ensure appropriate medication, monitoring, suction, oxygen and emergency equipment is available for transfer and reduction procedure
  • Fluid input/output is to be monitored and documented

References

PMH ED Guideline: Intussusception. Last Updated January 2015

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