肠套叠（乔中伟）课件

肠套叠诊断和非手术治疗 瑞金医院放射科研究生 上海儿科医院放射科 乔中伟 2005.6.22 INTUSSUSCEPTION Latin intus within + susception- INVAGINATION ; especially: the slipping of a length of intestine into an adjacent portion usually producing PATHOLOGY Intussusception occurs when one portion of the bowel slides into the next. When this occurs, it creates an obstruction in the bowel, with the walls of the intestines pressing against one another. This, in turn, leads to swelling, inflammation, and decreased blood flow to the intestines involved. Types of Intussusception Most cases Intussusception are ileocolic. Ileo-ileo and ileo-ileocolic are accounting for no more than 10 12%. These types are more difficult to diagnose and tend to be delayed; consequently complications such as bowel necrosis and perforation are more common. Types of Intussusception Dr.Rafinesque classified intussusception into four types; hyperacute, acute, subacute, chronic (i.e., patients surviving for more than 14 days). Other types A very type is Back and forth, antegrade and retrograde telescoping of the bowel with multiple layers of intestine. Epidemiology Intussusception: the most common cause of intestinal obstruction in children between the ages of 3 months and 6 years Occurs most often in children between 5 and 10 months of age (80% occur before a child is 24 months old) Affects between one and four infants out of 1,000 Is three to four times more common in boys than in girls Causes of Intussusception (1) In infants, the causes of intussusception are unknown, although there are some theories about why it occurs. Because intussusception is seen most often in spring and fall, this seems to suggest a possible connection to the kinds of viruses that children catch during these seasons, including upper respiratory infections. Causes of Intussusception (2) In some cases, intussusception may follow a recent bout of gastroenteritis. Gastrointestinal infections may cause swelling of the lymph tissue that lines the intestine. Causes of Intussusception (2) Recently, there has also been some investigation into the rotavirus vaccine and its possible connection to intussusception, although the number of reported cases of intussusception among babies who received the vaccine is quite small. According to the U.S. Centers for Disease Control and Prevention (CDC), it has not been established that the vaccine causes intussusception, but the CDC and the U.S. Food and Drug Administration ( FDA) have suspended the vaccine until theyre able to gather more information. Babies who received the rotavirus vaccine before its suspension have no increased risk of developing intussusception now. Causes of Intussusception (3) Intussusception is most common around the age that infants are being introduced to solid foods. It has been suggested that the introduction of new foods may also cause some swelling of the lymph tissue in the intestines, increasing the chance of developing an instussusception. Causes of Intussusception (4) Usually when an adult or a child older than 3 develops an intussusception, its often the result of enlarged lymph nodes, a tumor, or a polyp in the intestine. Clinical Findings（1） Children with an intussusception have intense abdominal pain, which often begins so suddenly that it causes loud, anguished crying and causes the child to draw the knees up to the chest. The pain is usually intermittent, but recurs and becomes stronger. As the pain subsides, a child may stop crying and seem fine. Clinical Findings （） Other common symptoms include: abdominal distension or a palpable abdominal mass (50 60%) currant jelly stool (60%) ：passing stools mixed with blood and mucus vomiting ：vomiting up bile, often golden- brown to greenish in color Clinical Findings （） As the illness progresses, a child will become progressively weaker and may develop a fever and appear to go into shock. Symptoms of shock include lethargy (i.e., drowziness or sluggishness), rapid heartbeat, weak pulse, low blood pressure, and rapidshallow breathing. Physical Examination and Medical History You can feel the part of the intestine thats involved, which is swollen and tender and often is described as a “sausage-shaped mass,“ or palpable emptiness in the right lower quadrant. vomiting (time, frequency) bloody or currant jelly stool bloody or currant jelly stool Other Medical History ask the parent about any concerns and symptoms their child has, the childs past health, their familys health, any medications the child is taking, any allergies the child may have, and other issues. Imaging Investigation An abdominal X-ray, which may or may not show an obstruction. An ultrasound examination may also help make the diagnosis. A barium or air enema is often used to both diagnose and treat a suspected intussusception. Attention! If the child appears very ill, suggesting damage to the intestine, even SHOCK! The surgeon may opt to take the child immediately to the operating room to correct the bowel obstruction. Plain Abdomen Film A soft tissue mass Dilated bowel loops or small bowel obstruction Pneumoperitoneum with Intussusception and bowel perforation. Barium enema Contraindications 1. peritonitis 2. pneumoperitoneum when seen in a plain abdomen film The abnormalities seen in a barium enema are: 1. obstruction of the barium at the site of intussusception 2. a cup-shaped filling defect at the site of obstruction 3. coiled spring appearance Air Enema Reduction （1） Dr. GU L. Shanghai Children Hospital Intussusception reduction in children by rectal insufflation of air. AJR 150: 1345- 1348, 1988 Success rate of reduction:70 90% Air Enema Reduction （2） Under Fluoroscopic control Foley bulb Inflating the balloon of Foley bulb to near the diameter of the rectum, and pulling it down as a plunger against the sealed anus. Air Enema Reduction: 60 100 mm Hg, not exceed 120 mm Hg. Discussion （1） Barium, aqueous and air reduction These procedures are very safe and usually well tolerated by the child The radiologist usually decides which test is most appropriate to perform Monitor: fluoroscopic or ultrasonic . Discussion （2） There is a very small risk of infection or bowel perforation (1-3%) . Theres a 4% 10% risk of recurrence, which usually occurs within 72 hours following the proced