Transcript Intussusception - Dr. Ahmad Abanamy Hospital

Case Study
Demographic Data
CASE NO:
NAME:
AGE:
SEX:
DIAGNOSIS:
14xxx
Baby H
3 yrs old
Male
Intussusception
Vital Signs:
 BP- 90/60
 HR- 126 bpm
 RR- 26/ min
 T- 38.5 C
 SPO2- 98%
General Assessment
 Patient is conscious, coherent and oriented.
 Cries intermittently and recovers from pain
Skin
 No lesion, moist and good turgor
 Pale in appearance
Head and Neck
No palpable lesion on the head and neck.
Thorax
Trachea in central
Chest movement are equal
Air entry is equal in all areas, no
added sound
Abdomen
No distention, no dilated veins
Guarding present, no rigidity in the
right hypochondrium
Tenderness on the right
hypochondrium
No free fluid on percussion
Bowel sound is present
Genitalia
Circumcised
Testes are bilateral descended and
normal in size
Neurological
 No neurologic defect seen
Past Medical History
The patient has no major
medical problems
No history of surgery
Present Medical History
 Patient’s chief complaints include colicky
abdominal pain associated with fever for 2 days
 Patient was seen by Dr. Jacob and was advised for
ultrasound
 On examination:
Febrile (Temp- 38 C)
RR-20/ min
SPO2- 97 %
WT- 13 kg
PR- 112 bpm
Child cries intermittently and recovers from the pain
Ultrasound done (shows “doughnut- like image”-target
sign)
INTUSSUSCEPTION
Introduction
 Intussusception is a term derived from the Latin intus (within)
and suscipere (to receive). One segment of the bowel
(intussusceptum) invaginates into another (intussuscepien) just
distal to it, much like the piece of a telescope. When this occurs
the bowel wall distends and obstructs the lumen. Peristalsis is
disrupted leading to colicky abdominal pain and vomiting.
Lymphatic and venous obstruction occurs, causing ischemia. In
most children the intussusceptions is ileocaecal, although ileoileocolic and ileo-ileal or colocolic cases can occur.
 The male-to-female ratio is approximately 3:2.
 Two third of patient are under one year old, the peak age being
between 5-10 months old.
 Intussusception is the most common cause of intestinal
obstruction in patient aged 5 months- 3 years and accounts for
up to 25 % of abdominal emergencies in children up to age 5.
Anatomy & Physiology
ETIOLOGY AND
PATHOPHYSIOLOGY
1. The cause can fall into one of the three categories: Idiopathic, Lead
point, or Post operative.
 Idiopathic: this is the most common type, which no identifiable
cause. It is not unusual, however, to obtain a history of a recent
upper respiratory or GI virus. It is hypothesized that
hypertrophy of Peyer’s patches create a thickened segment. It’s
most common in infants.
 Lead point: an identifiable change in the intestinal mucosa can
be discovered, usually during surgical treatment and is most
common in children ages 2-3. Malformations including polyps,
cysts, tumors, Meckel’s diverticulum, and hematomas. Children
with cystic fibrosis are at risk for lead point intussusceptions.
 Postoperative: uncommon but can occur after surgery of the
abdomen and even the chest. It may be due to interrupted
motility from anesthesia or direct handling of the intestine. It
can also occur from placing long tubes into the bowel.
Cont….
2. Invagination results in complete intestinal obstruction.
 Mesentery/ lymphatics/ blood vessels pulled into intestine when
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invagination occurs.
Intestine becomes curved, sausage like; blood supply is cut off.
Bowel begins to swell; hemorrhage may occur.
Necrosis of the involved segment occurs.
If not recognized or treated, bowel death occurs, possibly
resulting in significant loss of intestine, shock and death.
3. Classification of location:
 Ileocecal (most common): when the ileum and the attached
mesentery, lymphatic tissue, and blood vessels invaginates into
the cecum
 Ileocolic: ileum invaginates into colon.
 Colocolic: colon invaginates into colon.
 Ileo-ileo (enteroenteric): small bowel invaginates into small
bowel.
Normal Intestine
Pathophysiology
Idiopathic: UNKNOWN
- covers >90% of cases
- viral 50%-rotavirus,
adenovirus, Peyer’s
patch hypertrophy
Lead Point:
-Polyps, cysts, tumors,
diverticulum and
hematomas
Invagination results in
complete intestinal
obstruction.
Decreased blood supply &
eventually cuts off. Intestine
becomes curved, sausage like, and
bowel begins to swell
Post-operative:
Uncommon
-Due to interrupted
motility from the
anesthesia or direct
handling of the
intestine.
Medical and Surgical
treatment/ intervention
done.
• Air/ Barium Enema
• Surgical Reduction
Patient recovers
Necrosis of involved
segment occurs may result
to bowel death, leading to
significant loss of intestine
Shock
DEATH
Signs and Symptoms
 It is usually of sudden onset, and may be more insidious in the older child.
 There are paroxysms (about every 10-20 minutes) of colicky abdominal
pain (>80%) ± crying.
 The child may appear well between paroxysms initially.
 There is early vomiting - rapidly becoming bile-stained.
 Neurological symptoms such as lethargy, hypotonia or sudden alterations of
consciousness can occur.
 There may be a palpable 'sausage-shaped' mass (often in the right upper
quadrant).
 There may be absence of bowel in the right lower quadrant (Dance's sign).
 Dehydration, pallor, shock.
 Irritability, sweating.
 Later, mucoid and bloody 'red currant stools'.
 (Currant jelly stool indicates damage to the intestine and can be a late sign. )
 Late pyrexia.
Diagnostic Test
 CBC - may show neutrophilia.
 U&Es - may reflect dehydration.
 Abdominal X-ray - may show dilated gas-filled proximal bowel,
paucity of gas distally, multiple fluid levels (but may be
normal in the early stages).
 Ultrasound - may show doughnut or target sign,
pseudokidney/sandwich appearance. It is a very effective
modality and many consider it the investigation of choice.
 Bowel enema - barium has been gold standard (crescent sign,
filling defect) but air and water-soluble double-contrast now
available; each has pros and cons - the choice is left to the
individual radiologist.
 CT/MRI scanning - more often used in adults than in children.
Abdominal X-Ray
Abdominal Ultrasound
1. Air Contrast Enema
A small tube is placed in the rectum and air passed
through the tube. The air travels into the intestine and
outlines the bowel on the X-rays. If intussusception is
present it will show the telescoping piece in the
intestine. At the same time the pressure of the air
unfolds the bowel that has been turned inside out and
instantly cures the blockage. Air enema uses <120 mm
Hg of pressure.
2. Barium Enema
Barium is a liquid mixture that is used in placed of air
and works in the same way to fix the blockage.
The radiologist usually decides which test is most
appropriate to perform. Both procedures are very safe
and usually well tolerated by child, although there is
very small risk of infection or bowel perforation (a hole
in intestine). The success rate is over 80%. However,
approximately 5 – 10% of recurrence, which usually
occurs within 72 hours following the procedure.
3. Surgical Intervention
The abdomen is opened and the part that is
telescoped in is squeezed out (rather than pulled out)
manually by the surgeon or if the surgeon is unable to
successfully reduce it or the bowel is damage, the affected
section will be resected. More often, the intussusception
can be reduced by laparoscopy, whereby the segments of
intestine are pulled apart by forceps.
Laparotomy (reduction/resection) - indications:
 Peritonitis
 Perforation
 Prolonged history (>24 hours)
 High likelihood of pathological lead point
 Failed enema
Nursing Intervention:
Pre- operative
•Observe behavior a indicator of pain; the infant may be irritable and very
sensitive to handling or lethargic or unresponsive. Handle very gently.
•Encourage family to participate it comfort measures. Explain cause of pain, and
reassure the parents as to purpose of diagnostic test and treatments.
•Administer medication as prescribed.
•Monitor fluids, and maintain NPO status.
•Restrain infant as necessary for I.V. therapy.
•Monitor intake and output.
•Be alert for respiratory distress because of abdominal distention. Watch for
grunting or shallow and rapid respirations if in shock like state.
•Insert NGT if ordered to decompress stomach.
- Irrigate at frequent intervals.
- Note drainage and return from irrigation.
•Maintain NPO status as ordered.
- Wet lips, and perform mouth care.
- Give infant pacifier to suck.
•Continually reassess condition because increased pain and bloody stool may
indicate perforation.
Post- operative
 Monitor vital signs and general condition, notify
healthcare provider of any changes or unexpected
trend.
 Assess temperature and administer antipyretics and
other cooling measures. Fever is usually present from
absorption of bacteria through the damaged
intestinal wall.
 Assess for abdominal tenderness, bowel sounds, and
distention of abdomen. Maintaining suction as
ordered.
 Assess pain and level of consciousness.
 When able to take fluids, assess tolerance carefully
and advance intake slowly.
Complications
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Missed diagnosis
Ischemia of the intussusceptum/intussuscipiens
Necrosis
Hemorrhage
Perforation
Infection and peritonitis
Failure of enema reduction
Chronic intussusception - rare cause of failure to
thrive
PRIORITIZATION OF NURSING PROBLEMS
Nursing Diagnosis:
 Acute Pain related to paroxysmal abdominal colic
 Risk for Ineffective Breathing Pattern related to
abdominal distention
 Risk for Decreased Fluid Volume related to vomiting
 Anxiety related to present hospitalization
 Knowledge Deficit related to unfamiliarity to course of
present illness
Assessment
Nursing
Diagnosis
Planning
Interventions
Subjective:
“I’ am experiencing
on and off
abdominal pain.”
Pain Related
to paroxysmal
abdominal
colic
Relief of pain
after 2 hours of
administration
of analgesic
while awaiting
for the
investigation
report.
Proper breathing
technique
demonstrated like
breathing through
mouth in perfect
rhythm
Objective:
•Child cries
intermittently (1530 minutes
interval)
•Lethargic
•Facial grimace
•Pale in appearance
•Irritable
•Vital signs:
Temp- 38 C
PR- 126 bpm
RR- 26/ min
Rationale
To improve
respiratory
difficulties.
Assessed the
stability of the
patient through
monitoring vital
signs.
Inserted IV
cannula and start
IV fluid as
ordered.
Administered
analgesic as
ordered.
Laboratory test
and diagnostic
procedure done.
E.g CBC/
Abdomen
Evaluation
After 2 hours of
nursing
intervention,
client will be
relieved from the
abdominal pain as
manifested by:


To maintain
proper
hydration.
To alleviate the
abdominal pain.
To arrive at
probable
diagnosis.
Patient is
more relax &
comfortable.
Vital signs:
T- 37.2 C
PR- 108 bpm
RR- 21/ min
 Explain that recurrences are rare and
usually occurs within 36 hours after
reduction. Review signs and symptoms with
parents.
 Review activity restrictions with parents
(eg, positioning on back or side, quiet play,
and avoidance of water sports until wound
heals).
 Encourage follow up care.
 Provide anticipatory guidance for
developmental age of child.
Intussusception is considered as one of the most common causes
of bowel obstruction in infant and toddlers. In this case most patients
may have deceiving healthy appearance, usually well nourished and
generally above average in physical development. This fats and healthy
appearance is apt to mislead us in the early hours of patient’s illness, we
must not be reluctant as it may progress rapidly and makes child
desperately ill. Any presence of unusual signs and symptoms must be
reported immediately, so proper treatments and intervention may be
given to prevent further complication.
Early detection and immediate seek for medical assistance may
lead to a better prognosis and for patient’s fast recovery.
Bibliography:
 Nelson Textbook of Pediatrics 19th Edition, by Kleigman,
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Stanton, St. Geme, Schor and Behrman.
Lippincott Manual of Nursing Practice 9th Edition, by
Lippincott, Williams and Wilkins
www.patient.co.uk › Professional Reference
en.wikipedia.org/wiki/Intussusception_(medical_disorder)
emedicine.medscape.com/article/930708-overview