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Friday, 13 April 2012

PAEDIATRIC SURGERY SERIES : INVAGINASI/ INTUSSUCEPTION (sign, symptoms, diagnosis and management)


I.1 Background

Invagination events often occur in the rainy season in obese children who have flu and diarrhea. invagination is an acute intestinal peristaltic disorders, in which a segment of intestine protrudes into the next segment. Generally the proximal segment into the distal segment. (1) invagination is often found in children and rare in young people and adults.
Invagination in children and infants is still difficult to find compared with invagination in adults. Invagination in children and infants is often found in under 2 years of age and most found at the age of 5-9 months. The cause of invagination in children and infants 70% -90% is unknown; some literature linking the hypertrophied Peyer's patches caused by a virus infection, weather changes or changes in eating patterns. While a large invagination in children and adults the cause is a pathological disorder (Meckel diverticular, polyps, tumors). On the other references say 70% of patients under 1 year (often at the age of 6-7 months). The incidence varies from 1-4 per 1000 live births, and four times more men than women. As well as more common in babies with good nutrition. (1.2)
Invagination cases admitted to hospital as emergency cases. The first action is to overcome the lack of fluid, electrolyte and acid-base balance.

The incidence of intussusception (invagination) adults are very rare, according to figures ever reported was 0.08% of all cases of surgery through the abdomen and 3% of the incidence of intestinal obstruction, other figures reported 1% of all cases of intestinal obstruction, 5% of all cases invagination (children and adults), whereas the numbers that describe the incidence rate by gender and age have not been reported, whereas those involved segment of intestine that Anderson had reported 281 patients occurred in the small intestine (Jejunum, Ileum) 7 patients ileocolica, 12 patients and 36 colocolica cecocolica of 336 cases he reported. in 667 patients describes 53% in the duodenum, jejunum or ileum, 14% lead on ileoseccal pointnya, 16% and 5% included colon appendik veriformis. Nearly 70% of cases of invagination occurs in children age less than 1 year (Bisset et all, 1988) while Orloff get 69% of 1814 cases in infants and children aged less than 1 year (Cohn 1976). Ismail Chairl 1988 gain achieved the highest incidence in children aged between 4 to 9 months. Comparisons between men and women is 2:1 (Kartono, 1986; Cohn 1976; Chairul Ismail! 988).
The highest incidence of inttususepsi are under the age of 2 years (Ellis 1990). Dari1814 Orloof get 69% of cases occur in children younger than 1 year (Cohn 1976). In infants and children, intussusception is the cause of approximately 80-90% of cases of obstruction. Intussusception in adults is less common and is estimated to cause approximately 5% of cases of obstruction (Ellis, 1990) (3)

The small intestine is a complex tube, folds extending from the pylorus to the valve ileosekal. On the living, long small intestine is about 12 feet / about ± 3.6 meters. This gut fill the middle and lower abdominal cavity. Proximalnya tip diameter of about 3.8 cm, but getting to the bottom of their diameters gradually decreased to about 2.5 cm. (4)
Small intestine includes the duodenum, jejunum and ileum. She is responsible for most of the length of the digestive tract mucosa and large surface area is where the absorption of food, water and minerals that allow normal maintenance, growth and development.
Proximal third of the small intestine of jejunum, 2/3 of the following is the ileum. There is no definite boundary between the small intestine. It seems seen a gradual change of bowel wall thickness decreased further to the distal colon. Wide lumen also follows a similar pattern. So that the obstruction is more easily arise in the distal ileum than jejunum proximalis. (1)

There is a difference between proximal and distal small intestine in the mesentery, which is on the jejunal mesentery fat contained between sheet ends just before the limit of the intestine in the Bering area and buffer the blood vessels visible. If the ileum, fat extends to the intestinal wall so that blood vessels are hard to see. Mesenteric small intestine by a fully serviced. superior mesenteric -15 through 12 branches that make up the "arcades", which led straight to cross mesenteric artery directly into the intestinal wall. (6)
In the intestinal wall into 4 layers:
1. Tunica serosa.
Consists of loose connective tissue covered by mesotel.
2. Tunica muscularis.
Two smooth muscle sheath does not form the tunica muscularis striped intestine. This layer is thickest in the duodenum and decreases towards the distal therein. Outer layer and a layer of longitudinal stratum stratum sirkulare it. Myentericus nerve plexus (Auerbach) and lymph channels are located in between two layers of this muscle. (1.6)
3. Tela submucosa.
Tela submucosa consists of loose connective tissue located between the tunica muscularis and the lamina muscularis mucosa thin layer, which lies under the mucosa. In this space walk braided capillaries and lymph vessels. Also found neuroplexus Meissner.
4. Tunica mucosa.
Tunica mucosa of the small intestine, except duodenum pars superior composed in an overlapping circular folds in the transverse berinterdigitasi. Each fold is covered with protrusions, the villi.
Folds and villi in the jejunum more than in the ileum, so the surface greater responsibility in the intestinal absorption of this.
There are two areas in the submucosa and the specific levels of the small intestine:
1. Plaque Peyer
Plaque Peyer mainly located in the ileum and the distal more. It consists of the aggregation lymphaticus lymphaticus surrounded by a plexus over the surface of the intestine mesenterica.
2. Brunner glands
Brunner glands exist almost entirely in the duodenum, but in the proximal jejunum he found in proximal and decreased with aging.

The large intestine consists of the cecum, colon and rectum, about 1.5 meters in length, extending from the terminal ileum to the anus. Empty at the time of its greatest diameter ± 6.5 cm in the cecum, and was reduced to ± 2.5 cm in the sigmoid. In the cecum and appendix are ileosekal valve attached to the tip of the cecum. Ileosekal valve controlling the flow of kimus of ileum into the cecum and prevent backflow of faecal material from the colon into the small intestine. (4)
The colon is further divided into ascending colon, tranversum, descenden and sigmoid. Place the colon to form a sharp bend in the right abdomen and left hepatic flexure is called the splenic flexure. (4)
Colonic wall consists of four layers, namely:
1. The tunica serosa
Apendises epiploica form, the small pockets that contain fat and protruding from the serosa, except in the rectum.
2. Tunica muscularis
Stratum consists of the outer longitudinal and circular stratum on the inside. Stratum m.Sphincter ani internus circular shape while the stratum forming 3 longitudinal bands called Taenia coli, which is shorter than the colon itself to form colonic folds like a pocket (haustrae).
3. Tela submucosa
Formed by loose connective tissue containing blood vessels and lymph nodes.
4. Tunica mucosa
      Slippery because it had no villi, which has a fold-surface folds (plicae mucosae) crescent-shaped because it did not reach its full circle and is called plicae semilunares lumen.

The colon is clinically divided into left and right hemisphere based on the blood supply it receives. Superior mesenteric artery (memperdarahi right hemisphere; cecum, ascending colon and transverse colon proximal two-thirds) will be branching out into a.ileokolika, a.kolika dextra. Being inferior mesenteric artery (memperdarahi third transverse colon, descenden colon, sigmoid and rectum proximal part) will be branched to the left a.kolika, a.sigmoid, a.hemoroidalis superior. (4)
Venous return from the colon runs parallel to the artery. V.mesenterika superior for ascending and transverse colon. V.mesenterika being inferior to descenden colon, sigmoid and rectum.
The rectum is supplied by the superior a.hemoroidalis (branch of inferior a.mesenterika) and a.hemoroidalis inferior (a branch of the internal a.pudenda). V.hemoroidalis vein flow was the superior and inferior. (4,7)

Lymph flow
In line with the bleeding, among others, the colic glands, glands in the mesentery, the aorta at the base of the gland a.mesenterika superior and inferior. Lymph flow in the rectum, inguinal, internal iliac glands, the colic glands, the glands in the mesentery, and kel.para aorta. (8)

Colon diperarafi by the autonomic system regulated but voluntary sphincter externa. Colon are innervated by the parasympathetic system originating from n.splannikus and presakralis plexus and fibers derived from n.vagus. While the rectum are innervated by sympathetic fibers originating from the plexus and the inferior mesenterikus of parasakral system formed from L 2-4 and sympathetic ganglion sympathetic fibers originating from the S 2-4. (8)

II. 2. Invagination

Invagination or intussusception is a situation of acute GI in which a segment of the proximal bowel into the distal part of the general will end up with intestinal strangulation obstruction. (1,4,9,10)
When accompanied by strangulation should keep in mind the possibility of peritonitis after perforation. Invagination is almost always occurs in the terminal ileum.
Sections of intestinal segments into the distal part is called intussusceptum. While the bowel is called intussusceptum containing intususipien.

II.2.2 Etiology
The cause of most of the invagination is not known.
Based on facts collected from the infants with invagination obtained the following matters:
A. Plaque thickening of Peyer result of a process of viral infection of the intestine. Adenovirus was found from the mesenteric lymph nodes at surgery, and also from the culture surface with a higher percentage in children with invagination rather than control. Invagination in children is usually called idiopathic, which is caused by thickening of the plaque Peyeri namely a lymphoid tissue in the wall of the distal ileum, which can stimulate bowel peristaltic in an attempt to remove the mass, causing invagination. (1,2,10)
2. The change of intestinal flora causing a peristaltic meniggi. Flora changes do occur at age 6-9 months with respect to changes in diet in infants. (1,4,7)
3. Whereas in children over the age of 2 years or adults are generally found to trigger the excessive peristaltic movements, such as polyps, diverticular Meckel, lymphoma, hemangioma, and mesenteric hematoma. (1,4,9)
Once the proximal bowel into the distal intestine, by a peristaltic, then the proximal colon it will remain there and even further into the distal intestine.

II.2.3 Pathophysiology
The wide variety of etiologies that result in intussusception in adults is essentially an intestinal motility disorder consists of two parts: one part of the intestine that move freely and the other is fixed to the intestinal / or less freedom than other parts, because the direction of peristalsis is thus part of the oral keanal kelumen entering the intestine is an oral or proximal direction, other circumstances because of a peristaltic disritmik, in special circumstances can be otherwise called retrograde intussusception in patients with post gastrojejunostomi. As a result of intestinal segments into kesegmen other intestinal bowel wall will cause the pinched so will result in decreased blood flow and the final state is going to cause necrosis of the intestinal wall.
Intussusception caused by pathological changes, especially regarding the intussusceptum. Intususepien usually not damaged. Intussusceptum caused by changes in the emphasis of this section due to the contraction of intususepien, and also due to disruption of blood flow as a result of the emphasis and interest of the mesentery. Edema and swelling may occur. The swelling can be so intense that it inhibits the reduction. The existence of dam seepage cause (ozing) mucus and blood into the lumen. Dindidng intestinal ulceration can occur. As a result of strangulation is rare gangrene. Gangrene can result in loss of parts that have prolapsed. Swelling of the intestinal lumen intisuseptum generally closed. But not infrequently the lumen remains patent, so that sometimes complete obstruction did not occur in intussusception (Tumen 1964).
Invagination may lead to an intestinal passage (obstruction) and both total and strangulation partiil (Boyd, 1956). Hiperperistaltik bowel more proximal parts of the car cause the intestine into the lumen of the distal colon. Receiving the distal intestine (intussucipient) is then contracted, there was edema. The result is that the attachment can not return to normal resulting in invagination.
Invagination is a potentially dangerous situation, because not only happen but the sort of strangulation obstruction in which the blood vessels in the mesentery of the proximal part of the intestine into the distal part (intussusceptum) sandwiched between two walls of the intestine, so the chances of having necrotic intussusceptum. Constriction of mesenteric venous return block; subsequent swelling intussusceptum, because mucosal edema and hemorrhage causes blood containing stools, sometimes containing mucus (red currant jelly, red currant jelly). (1,2,9,10)
In the process of strangulation implied by the presence of pain and bleeding per rectum. Pain attacks at first intermittent and then persistent, restless during the attack and is often accompanied by vomiting stimuli. (1,4)
Peak invagination can run up to the tranversum colon, descending, sigmoid, even through the anus and in the case abandoned. This sign should be distinguished from the prolapsed rectum. (1.9). The process of intestinal obstruction has actually been started since invagination occurs, but it takes the appearance of clinical obstruction. Generally after 10-12 hours until the 24 hours of symptoms. (10)

Right-Hemicolectomy Specimen (External View) Showing the Ileocecal Intussusception.
The cecum (C) and ileocecal valve have invaginated into the ascending colon (AC).
The dashed lines indicate the appendix. I denotes the terminal ileum.(13)

Intussusception divided into 4 types:
A. Enteric: small intestine into the small intestine (6.7%)
2. Ileosekal: valvula ileosekalis experience invagination prolapse into the cecum and ileum pulled in behind him. Valvula are the apex of the intussusception. (39%)
3. Kolokolika: colon to a colon. (4.7%)
4. Ileokoloika: ileal prolapse through the valvula ileosekalis to the colon. (31.5%)

Signs & Symptoms:
• The attacks of pain / kholik (pain associated with passase of intussusception).
• Vomiting (stenosis pylori: Watery and sour, small bowel obstruction: Color greenish, colonic obstruction: a long onset vomiting)
• The exit of blood through the rectum,
• The presence of a palpable in the abdomen.
TRIAD invagination:
• Children's sudden episodic pain, crying and pick-foot (Craping pain), when a further continuous pain
• Vomiting green (gastric fluid)
• stool feces mixed mucus (mucosal damage) or blood (in layers) à currant jelly stool
Clinical Examination
Most babies are in good health, good nutrition. There may be several days before the upper airway inflammation. (1,2,4,9)
In the typical cases, severe colicky pain that arises suddenly, is intermittent. Sudden infant crying like endure pain for a while, then silence, then play or sleep. Often accompanied by vomiting stimuli. Vomiting in the form of drinks or food intake.
A few hours later (between 6-8 hours after the first attack) baby fresh blood with bowel movement and mucus. (1) Furthermore, only blood and mucus defecation. While the symptoms and signs of obstruction is not visible, on abdominal examination a mass may be palpable. When a palpable mass in the right or left of it touching on the lower right abdomen continued to empty. This situation is referred to as "Dance's Sign". (1,9,10)
Digital rectal examination there is a stool with fresh blood and mucus on the gloves. Towards the 24 hours since the attacks of pain, which was blocked intestine can become partially blocked totalis, such as a bulging abdomen with visible contours and peristaltic bowel. Vomiting was green, because they contain or have fecal bile. (2) intra-abdominal mass palpable hard again.
Digital rectal examination may be palpable invaginatum end, such as touching on the lower portion, known as pseudoportio. Gloves are only blood and mucus, there is no longer the stool. Continuous discharge will cause dehydration if not treated immediately will cause shock and possible rise in body temperature.
In children suffering from malnutrition, pain symptoms are not severe, the symptoms of chronic obstructive walking & intussusceptum may prolapse through the anus.

Radiological examination
 On a plain photo abdomen, blockage by solids in invaginatum can show the invagination.
 Barium enema will show the filling defect or a bowl at the end of the barium, because the flow is blocked by invagination. Barium enema can also be used for therapy.
 Ultrasonography is now also beginning to be used to show abnormalities invagination. (1)

Caption:. Note intussusception in the left upper quadrant on this plain film of an infant with pain vomiting. Courtesy of Dr. Kelly Marshall, Children's Healthcare of Atlanta at Scottish Rite. 

A plain film of the abdomen (Panel A) disclosed multiple airfilled lucencies in the right upper quadrant that were suggestive of the presence of pneumatosis coli. A computed tomographic scan revealed air within the wall of the ascending colon and the typical target lesion of a colonic intussusceptions (arrow in Panel B). (13)

II.3 repositioning of hydrostatic
Invagination cases hospitalized as emergency cases. The first actions are:
A. General state of absolute corrective action needs to be done before taking any action.
2. To decompress the stomach sonde installation and prevent aspiration.
3. Rehydration. Be careful of dehydration signs are sometimes not clearly visible because the baby is well nourished and in fact often obese.
4. Tranquilizers to painkillers.
5. After a good general condition following surgery, when it clearly has visible signs of intestinal obstruction. Or repositioning of the action when there are no contraindications.

Basic treatment of intestinal invagination is repositioned into other intestinal lumen. Repositioning can be achieved with a barium enema, or by surgically repositioning pneumostatik. (1,2,9)
a. Hydrostatic reduction
This method is by inserting barium through the anus using a catheter with a certain pressure. Was first proposed by Ladd success in 1913 and repeated its success by Hirschsprung in 1976. Repositioning followed by barium X-ray. At first look-shaped shadow moving cupping barium at the site of invagination. With the hydrostatic pressure of ¾ - 1 meter of water, barium is pushed to arah.proksimal. hydrostatic pressure should not be over 1 meter of water and don'ts manual sequencing or emphasis in the stomach when done reposisis hydrostatic
Treatment is considered successful if the barium has reached the terminal ileum. At that time, gut passage back to normal, given per os norit will exit through the rectum. Along with the re-examination of the contrast agent can be seen coiled spring appearance. The picture is caused by the remnants of barium on the former site of invagination along haustra At present barium enema is used for diagnostic procedures, about 75% successful reduction of invagination. (1) Provision of adequate little sedative before the procedure is very much help the successful enema reduction This hydrostatic. (14)
A. there are no symptoms and signs of peritoneal stimulation
2. not toxic nor high obstruction
3. no dehydration
4. invagination of symptoms less than 48 hours
contra indications:,
A. Excessive abdominal distension,
2. Recurrent invagination
3. invagination symptoms more than 48 hours,
4. Peritonitis

o Put an oral discontinued, the patient was given intravenous fluids and repositioning of the bowel selanjutkan done.
o Depending on the circumstances of the patient, repositioning is done by surgery or barium enema. At surgery, repositioned manually and the results are immediately known.
o Repositioning followed by barium X-ray, at first seemed a shadow of barium moving cupping shaped invaginations at the site. With the hydrostatic pressure of 3/4 meter of water, pushed toward the proximal barium.
o Treatment is considered successful if the barium has reached the terminal ileum. At that time, gut passage back to normal, given per os norit will exit through the rectum.
o Along with the re-examination of the contrast agent can be seen coiled spring appearance. The picture is caused by the remnants of barium on the former site of invagination along haustra.
o Since 1876, the barium enema has been used for the treatment of invagination and the results are satisfactory. Only slightly despite the possibility of bowel perforation have experienced gangrene, as long as the hydrostatic pressure does not exceed 1 meter.
o Similarly, the treatment duration is shorter than the barium repositioning surgery. In contrast with the reduction in the operating manual it is more traumatic, so it's easier bowel rupture occurs.
o With the advantages mentioned earlier, in Scandinavia repositioning of barium is more widely used. Survival rate of 55%, respectively 81% less at age 1 year and 15% at about age 3 months.
o Sometimes repositioning of barium did not work, for example at least 3 months of age and ileo-ileal invagination. Shadow contrast in the form of cupping does not reach the terminal ileum requiring surgery.
o The operation is done early without barium therapy in case of perforation, peritonitis and signs of obstruction. This situation is usually the invagination that had lasted 48 hours.
o Similarly, in cases of relapse. Invagination over 11% after repositioning of barium and 3% in the surgery without bowel resection. Resection usually performed if the blood flow did not recover after warmed with physiological solution.
o Intestinal invagination which had appeared bluish. At the 2x treatment, surgery is done without barium enema (3).

III.4 REDUCTION MANUAL (milking) and bowel resection
Patients with unstable circumstances, found an increase in temperature, leukocyte numbers, experience prolonged symptoms or have further found that marked abdominal distension, bloody stools, severe intestinal disorders systematically to arise shock or peritonitis, the patient is immediately prepared for an operation laparotomy with transverse incision interspina If found abnormalities have undergone necrosis, and reduction of unnecessary resection be done and done (Ellis, 1990).
Other treatment:
1. Pre-operative
Handling of intussusception in adults are generally the same as the handlers in other cases of intestinal obstruction such as the general state of repair and correction of electrolyte rehydration has occurred when the electrolyte deficit
2. Durante Operative
Resection of the involved segment of bowel anastosmose to ensure resection leads pointnya limit generally is 10cm from the edge - the edge of the involved segment of intestine, another opinion on the proximal side of a minimum of 30 cm from the lesion, then do anastosmose end to end or side to side.
Operation will not be done on the general state of an ugly baby. The new baby can be anesthetized and operated on when we are sure of blood to the tissue perfusion is good. If the disease process was thought to be more than 24 hours or the baby has a fever the broad-spectrum antibiotics are required.
Surgery can be performed if tissue perfusion is sufficient that can be measured clinically from the production of urine, which is 0.5 to 1 ml / kg / h through the catheter. Other criteria are body temperature less than 38 º C, the pulse is less than 120 times per minute, breathing no more than 40 times / minute, improved skin turgor, and most importantly a good conscience. Akral which had been cold so warm again. Usually by administering fluids for 50% of the requirement (for correction and normal needs), tissue perfusion can already be achieved. Surgery and anesthesia are done at the time of inadequate tissue perfusion will lead to accumulation of metabolism that results should be removed from the body, and this will lead to poor tissue oxygenation, which can result in irreversible cell damage, and when it comes to vital organs will cause death .
When it tries to reposition the operating manual of the encourages invaginatum anal ileo-caecal angle towards, drive carefully done without the pull of the proximal part.
Surgical repositioning achieved through laparotomy. After the abdominal wall was opened, the next action depends on the existing findings. Repositioning is done manually squeezed as squeezing milking cow's milk is called, is done smoothly and slowly with the patient, and interspersed with a break some time to allow blood to flow forth the effort to reduce edema, thus simplifying the next milking. Never pull the intestine into another bowel, but is squeezed from the other party. If leakage occurs before or after milking intestine is performed with resection of the bowel, then anastomosa end to end. If we succeed with the milking, then most experts do not perform fixation of the cecum.
If there is a fairly extensive intestinal damage, danbanyak part of the intestine was removed. So in this case can not be done end to end anastomosis, colostomy should make digestive process is still running. (16)
If found to be the cause of the trigger factor such as diverticulum or duplication is necessary to resection. In patients who are managed by way of milking generally been able to leave the hospital the day of the 4th and 5th postoperative.
3. Post-Surgery
• Avoid Dehydration
• Maintain the stability of the electrolyte
• Supervision will be inflammatory and infectious
• Provision of analgesics that do not have the effect of disrupting intestinal motility


The use of barium enema in the treatment of disease by using the principle of hydrostatic invagination has been used since 1876, using a catheter through the anus with a certain pressure, is expected to improve the situation of having intussusepsi colon. Reduction with barium enema is only done when there is no great distension, signs of peritonitis, and high fever. Picture will appear cupping and coiled spring that disappeared along with terisinya ileum by barium. With barium enema reduction was successful when the barium fills pretty much looked the window ileum or colon.
In addition to barium enema, air enema there is a method, how the two methods are similar. If this method worked, your baby can drink and be home in a few days. If this method does not work is necessary to the operation. Intestinal invagination tends to clog and stop the blood flow to the intestines, making it necessary to do emergency surgery


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