This is useful for surgery students

2. INTUSSUSCEPTION
DEFINITION :
 One portion of the gut invaginates into the
immediately adjacent loop is intussusception.
 Usually proximal loop invaginates into the distal loop.

4. AETIOLOGY
1. Primary or idiopathic intussusception
2. Secondary intussusception

5. PRIMARY INTUSSUSCEPTION
 Most common
 Children between 6 – 9 months
 Probable causes
 Weaning
 Follows upper respiratory tract infection
 Usually seen in terminal ileum
 Mobile ileum terminating in immobile ceacum
 Excessive lymphoid tissue

6. SECONDARY INTUSSUSCEPTION
1. Polyp
2. Carcinoma
3. Lymphoma
4. Hamartoma
5. Submucous lipoma
6. Appendicular stump
7. Meckel’s diverticulum

7. TYPES
1. Ileocolic / ileocaecal
2. Ileo-ileal
3. Colocolic

9. PATHOLOGY
 Parts of intussusception
1. Intussusceptum – entering or inner tube
2. Intussuscipiens – outer tube

12.  As the intussusception progresses the mesentery of
the entering and returning tubes dragged along with
the gut through the neck of the intussusception.
 Gradually the pull of the mesentery causes the mass of
the intussusception to assume sausage shaped with
concavity towards umbilicus.

13. CLINICAL FEATURES
 Sudden in onset
 paroxysms of colicky abdominal pain
 The child may appear well between paroxysms
initially
 There is early vomiting - rapidly becoming bile-
stained
 Initially passage of stool may be normal,later
there is characteristic “red- currant jelly” stools

14. Redcurrant jelly stool

15. PHYSICAL SIGNS
 There may be a palpable 'sausage-shaped' mass (often
in the right upper quadrant)
 Distension is a late feature
 Empty right iliac fossa(the Sign of dance)
 Rectal examination
 blood stained mucous

18. INVESTIGATIONS
 Plain x-ray abdomen-absent caecal gas shadow
 A barium enema may be used to diagnose the presence of
an ile ocolic intussusception (the claw sign)
 Abdominal ultrasound scan has a high diagnostic
sensitivity in children, demonstrating the typical doughnut
appearance of concentric rings in transverse section

19.  CT scan is currently considered the most sensitive
radiologic method to confirm intussusception, with a
reported diagnostic accuracy of 58–100 per cent.
 The characteristic features of CT scan include a ‘target’
or ‘sausage’- shaped soft-tissue mass with a layering
effect, mesenteric vessels within the bowel lumen are
also typical.

20. TREATMENT
 Preoperative
 Nbm,
 Nasogastric drainage
 Resuscitation with intravenous fluids
 Broad-spectrum antibiotics
 Non-operative reduction can be attempted
using an air or barium enema

21.  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 in the patient
 Perforation of the colon during pneumatic or
hydrostatic reduction is a recognised hazard, but is
rare
 Recurrent intussusception occurs in up to 10 per cent
of patients after non-operative reduction.

22.  Surgery is required when radiological reduction has
failed or is contraindicated.
 Laparotomy (reduction/resection) - indications:
• Perforation
• Peritonitis
• High likelihood of pathological lead point
• Failed enema

23.  Reduction is achieved by
gently compressing the most
distal part of the
intussusception toward its
origin , making surenot to
pull.
 The last part of the reduction
is the most difficult.
 The viability of the whole
bowel should be checked
carefully.

24.  An irreducible intussusception or one complicated
by infarction or a pathological lead point requires
resection and primary anastomosis.

26. VOLVULUS
 Occurs when a segment of the bowel twists around its
mesenteric axis
 Types
 Midgut volvulus
 Sigmoid volvulus
 Caecal volvulus

27.  The rotation causes obstruction to the
lumen (>180° torsion) and if tight enough also causes
vascular occlusion in the mesentery (>360° torsion).
 Bacterial fermentation adds to the distention and
increasing intraluminal pressure impairs capillary
perfusion.
 Mesenteric veins become obstructed as a result of the
mechanical twisting and thrombosis results and
contributes to the ischaemia

28. SIGMOID VOLVULUS
 Male > female
 It is seen most often in elderly patients with chronic
constipation; comorbidities are common and chronic
psychotropic drug use is associated with this condition.

29.  Aetiology
• LONG,DILATED,REDUNDANT,THICK WALLED
sigmoid colon hanging on a LONG mesentery and
with the two limbs closely tethered
• the attachment of the mesocolon to the posterior wall
is also NARROW
• Colonic dysmotility
• Dilation of the sigmoid colon may be due to
overloading with feaces as a result of chronic
constipation and increased ,bulky high residue diet,
aganglionic megacolon or acquired megacolon

31. PATHOPHYSIOLOGY
 Rotation nearly always
occurs in the
anticlockwise direction
 Closed loop obstruction
of the sigmoid with
secondary simple
occlusion of the bowel
proximal to the sigmoid

32. PATHOPHYSIOLOGY
 Rapid distention of the sigmoid with gas from rapid
bacterial putrefaction
 The bowel becomes thickened and edematous if blood
supply is cut off and gangrene sets in
 Translocation of bacteria ,peritonitis ,septic shock and
death

33. CLINICAL FEATURES
 The symptoms are of large bowel obstruction.
 Presentation varies in severity and acuteness, with younger patients
appearing to develop the more acute form.
 Abdominal distension is an early and progressive sign, which may be
associated with hiccough and retching.
 Constipation is absolute.
 In the elderly, a more chronic form may be seen.
 General condition is usually good except when gangrene sets in

34. Clinical Examination
 Distension of abdomen
 There may be emptiness of the left iliac fossa
 Severe tenderness ,rebound tenderness, guarding,
rigidity, fever and tachycardia, hypotension points
towards the presence of a gangrenous segment
 DRE - empty rectum

35. INVESTGATIONS
 Plain x-ray abdomen
 Bent inner tube sign
 Omega loop sign

36.  Contrast x-ray
 Twisted birds
beak sign
 Ace of spade
deformity

37. MANAGEMENT
 The ultimate goal of management is to achieve
detorsion and prevent recurrence
 This starts with an evaluation of the general condition
of the patient for evidence of gangrene , perforation or
peritonitis

38. RESUSCITATION
 Intravenous fluids
 Intravenous antibiotics
 Urinary catheter
 Nasogastric tube
 Serial monitoring
 Supplemental O2 as respiratory embarrassment may
ensue
 Transfuse if indicated

39. NON -OPERATIVE Endoscopic
detorsion
 Patient is stable with no feature of gangrene
 Patient is prepared for exploration with consent signed
 Rigid or flexible Sigmoidoscopy is done and the apex
of the volvulus is identified as a spiraling of the
mucosa

40.  Well lubricted Rectal tube is gently wriggled through
the apex with a let out of gas
 Rectal tube is left in for a few days and a repeat x-ray
taken to ensure that decompression has occurred.
 Successful deflation, as long as ischaemic bowel is
excluded, will resolve the acute problem

41. Surgery
Laparotomy
• Derotation
• Resection and hartmann procedure
• Resection end to end anastomosis
• A Paul–Mikulicz procedure is useful, particularly if
there is suspicion of impending gangrene

46. Meckel’s diverticulum
 Meckel's diverticulum,
 a true congenital
diverticulum,
 is a small bulge in the small
intestine present at birth.
 It is a vestigial remnant of the
omphalomesenteric duct
(also called the vitelline duct
or yolk stalk), and
 is the most frequent
malformation of the
gastrointestinal tract

47. Mecke diverticulum
 Meckel's diverticulum is
 located in the distal ileum,
 usually within about 60–100 cm (2 feet) of the ileocecal
valve.
 It is typically 3–5 cm long,
 runs antimesenterically and
 has its own blood supply
 It is vulnerable to infection and obstruction in the same way
as the appendix

48. Rule of 2
 the rule of 2s:
 2% (of the population).
 2 feet (from the ileocecal valve).
 2 inches (in length).
 2% are symptomatic.
 2 types of common ectopic tissue (gastric and pancreatic).
 2 years is the most common age at clinical presentation.
 2 times more boys are affected.

49. Clinical features
 Majority are asymptomatic
 Haemorrhage- If gastric mucosa is present, peptic
ulceration can occur and present as painless maroon
rectal bleeding or melaena
 Intussusception- Meckel’s can be the lead point for
ileoileal or ileocolic intussusception.

50. Clinical features
 Intestinal obstruction- A band between the apex of the
diverticulum and the umbilicus (also part of the
vitellointestinal duct) may cause obstruction directly
or by a volvulus around it.
 Littere’s hernia- Meckel’s can also present as an
indirect hernia
 Diverticulitis-Occasionally, Meckel's diverticulitis may
present with the features of acute appendicitis.

51. Diagnosis
 Incidentally found
 A technetium-99m (99mTc) pertechnetate scan detects
gastric mucosa and is the investigation of choice to
diagnose Meckel's diverticula.

52. Treatment
 Treatment is surgical.
 In patients with bleeding, strangulation of bowel, bowel
perforation or bowel obstruction,
 treatment involves surgical resection of both the Meckel's
diverticulum itself
 along with the adjacent bowel segment.
 In patients without any of the afore mentioned
complications,
 treatment involves surgical resection of the Meckel's
diverticulum only.