Intussusception in children. Clinical recommendations. Features of the treatment of intussusception in adults and children Intestinal intussusception

  • The disease begins suddenly. The child becomes restless, cries, screams, presses his legs to his stomach, and refuses to eat. The face turns pale and becomes covered in cold sweat. The child is experiencing severe abdominal pain. Infants refuse the breast and do not take the pacifier. The painful attack lasts about 5 minutes; ends as suddenly as it began. There is a lull for 15-25 minutes. The child calms down and begins to play. But after a while the pain occurs again. Attacks of pain correspond to waves of intestinal peristalsis (wave-like contraction of the intestinal walls), which move a section of intestine into the lumen of another intestine.
  • Against the background of pain syndrome occurs occasional vomiting: first with food debris, then, when the intestinal lumen closes, vomiting becomes fecal in nature.
  • Body temperature most often remains normal or rises to 37.5° C. running forms when inflammation occurs, the temperature can rise to 40° C.
  • At the beginning of the disease, the child's stool is normal. 6 hours after the onset of the first painful attack, an admixture of blood appears in the stools, they acquire characteristic appearance"raspberry" or "currant" jelly. Later allocation bowel movements and gases stop.
  • During an attack, the child tenses his abdominal muscles due to pain, so the abdomen cannot be thoroughly examined. Outside of an attack, most often to the right of the navel, in the area of ​​the right hypochondrium, it is possible to palpate (feel) a tumor-like formation of a soft-elastic consistency: it is not painful. This is the invaginated section of the intestine.
  • A digital examination of the rectum reveals the presence of dark blood and mucus without feces.

Forms

  • Depending on the location of intussusception:
    • small intestinal – insertion of the site small intestine thick;
    • ileocolic intussusception - the introduction of the ileum (lower part of the small intestine) into the colon (main part of the large intestine) through the Bauhinian valve (valve separating the small and large intestine);
    • cecum-colic intussusception - the introduction of the cecum (the initial part of the large intestine) together with the appendix into the colon;
    • colonic intussusception – insertion of the colon into the colon;
    • rare forms of intussusception (isolated insertion of the appendix (appendix)).
  • Depending on the direction of intussusception (a section of intestine that has penetrated into the lumen of another section):
    • descending (isoperistaltic) intussusception: a section of intestine is introduced into lower departments intestines;
    • ascending (antiperistaltic) intussusception, in which a section of the intestine penetrates into the overlying sections of the intestine.

Causes

  • From the anatomical reasons for development of this disease can be distinguished:
    • pathological mobility of the cecum (initial part of the large intestine) and ileum (lower part of the small intestine) intestines;
    • insufficiency of the ileocecal valve (the valve that separates the small and large intestines).
  • Also important is a disorder of the correct rhythm of wave-like contractions of the intestinal wall (peristalsis). They become uncoordinated. This may arise due to inflammatory diseases intestines or changes in diet, for example, due to the introduction of complementary foods to infants.
  • In children older than one year, intussusception is rare and is usually associated with an organic cause (for example, a polyp is a small formation of tissue protruding above the surface of the mucous membrane of a hollow organ; Meckel's diverticulum is a congenital blind protrusion of the wall of the ileum (terminal section of the small intestine), tumor).
  • With the development of intussusception, necrotic (dead) changes occur in the invaginated section of the intestine as a result of compression of the vessels of the mesentery (the fold on which the intestine is suspended). The blood circulation of the internal part of the invaginated intestine suffers to a greater extent. As a result, fluid sweats and erythrocytes (red blood cells) leave the blood vessels. Necrosis of the invaginated intestine subsequently develops.
  • Because of severe swelling and further penetration of the intestinal section, obturation occurs (blockage of the intestinal lumen). Intestinal obstruction occurs.

Diagnostics

  • Analysis of medical history and complaints:
    • sudden onset of intense paroxysmal abdominal pain, which is periodic in nature, repeated after 15-25 minutes;
    • frequent vomiting due to pain: first with food debris, later it becomes fecal in nature;
    • blood in the stool or mucus soaked in blood, reminiscent of “raspberry” or “currant jelly” 6 hours after the onset of the disease;
    • gas and stool retention.
  • General inspection:
    • the face is pale, covered with cold sweat; legs pressed to the stomach;
    • upon palpation (palpation), a soft-elastic, moderately mobile tumor (intussusception) is determined, most often to the right of the navel under the right hypochondrium.
  • A rectal examination reveals the presence of dark blood and mucus without stool.
    • Survey radiography. Expanded loops can be seen on the x-ray small intestine, shadow of intussusception against the background of the intestine, Kloiber's cups as a sign of intestinal obstruction (intestinal loops with horizontal levels of liquid and gas, looking like overturned cups).
    • Ultrasound of organs abdominal cavity.
    • Irrigography with air - x-ray examination of the large intestine. It is the main diagnostic method. Air is introduced using a Richardson apparatus to straighten the intestinal loops, then a radiopaque substance is injected, and an image is taken. The radiopaque substance is distributed in the intestine in such a way that the intussusception is detected in the form of several rings or a corrugated tube.
    • Colonoscopy - endoscopic examination colon. It can be used to detect intussusception, as well as the presence of necrosis of the intestinal wall.
  • Children's consultation is also possible.

Treatment of intussusception

  • Depending on the cause of this pathology, treatment can be conservative (non-surgical) or surgical.
  • As a rule, in infants and when the child is admitted to the clinic early (no later than 12 hours from the first attack), intussusception in most cases resolves with the help of conservative measures.
    • In this case, pump air into colon using a rubber bulb or a special apparatus.
    • Control is carried out nearby x-rays.
    • As air moves through the colon, it straightens sections of the intestine under the influence of pressure.
    • After this procedure, the child is given a liquid barium suspension (a substance that enhances the contrast of the intestines on radiographs) to drink, and then a series of plain X-rays of the abdominal organs is taken at certain intervals, thereby assessing the patency of the intestines.
    • If during the operation signs of necrosis of a section of the intestine are detected, it is removed.
  • Surgical treatment is carried out when the child enters the clinic late.
    • Considering the high probability of necrosis (death) of the wall of the invaginated intestine, an operation is performed - laparotomy (operation with opening the anterior abdominal wall) and manual disintussusception (straightening of intussusception).
    • If necrosis of a section of the intestine is detected, then excision of this section is carried out within healthy tissues with the imposition of an anastomosis (connection of two sections of the intestine).
  • Feeding of children who have undergone disinvagination (straightening of the intussusception) begins 6 hours after the intervention. Infants are given expressed milk 20-30 ml every 1.5-2 hours. After a day, the volume of milk begins to increase.
  • Older children are allowed to drink warm tea 6 hours after disinvagination surgery. From the 2nd day a liquid diet is prescribed; on days 6-7, a regular diet is allowed.
  • Children who have had a dead section of intestine excised are allowed to drink a limited amount of liquid from the second day.

Complications and consequences

  • A complication of this disease is necrosis (death) of a section of the intestine with further development peritonitis - inflammation of the serous (connective tissue) membrane of the abdominal organs. The main signs are: severe abdominal pain, frequent vomiting, retention of stool and gases, muscle tension in the anterior abdominal wall, increased body temperature up to 40° C, increased heart rate.
  • One of frequent complications after the operation there is suppuration of the operated wound. Redness in the wound area, swelling, pain appears, and body temperature rises.

Prevention of intussusception

  • Proper nutrition: timely and correct introduction of complementary foods to infants. The first complementary foods should be introduced between 4 and 6 months of life. Before 4 months, the child’s body is not physiologically prepared to accept new dense foods. And it is undesirable to start later than six months, since problems may arise with adaptation (adaptation of the body to changing external conditions) to food with a denser consistency than milk.
    • The basic rule of complementary feeding is the gradual and consistent introduction of new foods. A new type of complementary food is introduced after complete adaptation to the previous one.
    • Complementary foods should be given before breastfeeding (as opposed to juices, which are given after feeding), starting with 5-10 g and gradually (over 2 weeks) increasing the volume of complementary foods to 150 grams.
    • Complementary feeding dishes should be uniform in consistency, thereby not causing difficulty in swallowing for the child. As you age, you need to move on to thicker, and later, denser foods.
    • When introducing complementary foods, it is necessary to monitor the baby's stool; if it remains normal, then the next day the amount of complementary foods can be increased.
  • Timely detection and treatment of intestinal tumors.
    • Most tumors in children develop without a clear clinical picture and gradually become malignant.
    • Therefore, parents and children's doctors need to pay special attention if:
      • the child suddenly begins to lose weight;
      • his skin color changes (pallor appears, and sometimes a sallow skin color);
      • appetite decreases;
      • body temperature rises;
      • Nausea and abdominal pain begin to bother me.
    • If tumors are detected, timely treatment is necessary, usually surgical.

Additionally

Intussusception is based on elements of strangulation of the mesentery (a fold of mucosa through which the intestine is suspended and through which the vessels pass) of the intestines and obturation (closing of the intestinal lumen by a strangulated section of the intestine or intussusception).
Severe periodic abdominal pain occurs.

– this is the introduction of one section of the intestine into another with the possible development of gastrointestinal obstruction. The main sign of the pathology is sudden intense pain syndrome which lasts about 5 minutes and is repeated every 15-20 minutes. Diagnosis is based on a characteristic clinical picture, palpation of the intussusception during the interictal period, ultrasound data of the abdominal organs and X-ray diagnostics. Treatment can be carried out conservatively (straightening the intussusception using a Richardson balloon) or surgically (laparotomy with elimination of intestinal invasion).

General information

Intussusception is a type of intestinal obstruction consisting in the introduction of one segment of the intestine into the lumen of another. Most often (in 90% of cases) this disease develops in infants, usually at 5-7 months, during the period of introducing complementary foods. The prevalence of the pathology is 3-4 cases per 1000 infants, and boys are more often affected.

Intussusception, which occurs in older children, as well as in adults, always has mechanical prerequisites. Risk factors for the development of pathology are infancy, viral intestinal infections occurring with hypertrophy of Peyer's patches (often observed with rotavirus and adenovirus infections), irrational introduction of complementary foods, male gender, family history, as well as poor living conditions.

Causes

In the majority clinical cases It is not possible to find out the specific cause of the development of intussusception, so the disease is considered idiopathic. All causes of this pathology are conventionally divided into nutritional and mechanical. The leading role in the formation of the disease is given to a violation of the nutritional regime in children: untimely introduction of complementary foods, especially in large volumes, the presence of too thick and coarse food in the diet. The pathology can be a complication of intestinal infections (viral and bacterial), alimentary gastroenteritis, colitis, foreign bodies, intestinal or peritoneal tuberculosis, enteroptosis and other diseases.

Mechanical factors leading to the penetration of one section of the intestine into another are polyps, Meckel's diverticulum, intestinal cysts; ectopic pancreas; intestinal tumors, including lipomas, lymphomas; intestinal form of allergy; motility disorders of various origins; cystic fibrosis; surgical interventions on organs gastrointestinal tract and others.

Pathogenesis

Regardless specific reason pathological syndrome, pathogenesis is always associated with disturbances of intestinal motility. Most gastroenterologists and abdominal surgeons currently tend to agree that the pathophysiological basis of intussusception in childhood is a transient change in peristalsis with the formation of areas of spastic contractions that contribute to the formation of intussusceptions.

Eating rough food provokes convulsive contractions of the smooth muscles of the intestine with the penetration of its parts, and discoordination of motor skills aggravates the pathological process. Intussusception leads to intestinal obstruction, tissue edema, lymphostasis, and venous stasis develop. Arterial ischemia causes necrotic changes in the intestinal wall and bleeding from the gastrointestinal tract. In the absence of timely adequate treatment intestinal perforation and the development of peritonitis are possible.

Classification

Depending on the cause of development, primary (visible) etiological factor absent) and secondary (there is a previous intestinal lesion: tumor, polyps, etc.) intussusception. According to the localization of the pathological process, small intestinal, large intestinal, small-colic, small intestinal-gastric, as well as intussusception of intestinal loops through fistulous tracts or stomas are distinguished.

Invagination occurring in the direction of peristaltic waves is defined as isoperistaltic, or downward; if penetration occurs in the opposite direction, antiperistaltic or ascending intussusception develops. Intestinal invasion can be single or multiple (there are several intussusceptions), simple (3-cylinder intussusception) or complex (5-, 7-cylinder intussusception).

There are three options for the course of the pathological process. Acute intussusception (occurs in 95% of cases) is a decompensation of intestinal motility resulting from various factors; may result in necrosis of a section of the intestine. The recurrent form often occurs in children due to morphological and functional immaturity of the intestine; can be early (in the first 3 days after straightening) and late (repeated repeatedly in more late dates). Chronic variant the course is characterized by a long existing disease with mild symptoms of intestinal obstruction.

A separate form is abortive or self-repairing intussusception, which occurs with a compensated disorder of intestinal functions, typical symptoms of acute intussusception, and is mainly recorded in patients hospitalized in early dates from the onset of the disease.

Symptoms of intussusception

The main symptom of the disease is severe pain. Abdominal pain at the onset of the disease can be paroxysmal at intervals of ten to thirty minutes. During a painful attack, the child is restless, presses his legs to his stomach, screams, cries, the skin may be pale and covered with cold sweat. The baby may refuse the breast or pacifier. The attack always begins suddenly and stops just as suddenly.

The duration of pain is usually about five minutes, after fifteen to twenty minutes the attacks are repeated (this corresponds to waves of peristaltic contractions of the intestines). During the interictal period, the child behaves normally, plays calmly, but after severe pain he may be inhibited and tired. Characteristic feature intussusception is that the abdomen is soft and slightly painful on palpation (before the onset of necrotic changes).

In some cases, diarrhea and bloating are observed. On initial stages vomiting of food remains is possible, and if intestinal obstruction occurs, vomiting of feces is possible. A few hours after the onset of intussusception, an admixture of blood appears in the stool - the stool takes on the appearance of “raspberry jelly”.

Intussusception in children almost always occurs in an acute form; in adults, a subacute and chronic course can be observed. Acute form usually develops with small intestinal intussusception, since in this case intestinal obstruction quickly forms. The subacute form is more typical for colonic intussusception - due to the larger diameter of the intestine, an obstruction may not form. Colonic intussusception is characterized by less severe symptoms, the pain syndrome is not so intense.

Diagnostics

At typical course Diagnosis of intussusception is not difficult. Consultation with an abdominal surgeon allows you to suspect the disease and determine the characteristic signs. When palpating the abdomen during the interictal period, a soft elastic formation is determined, often localized in the right iliac region, somewhat painful. In the later stages (24 hours after the onset of the disease), palpation of the intussusception is difficult due to the development of intestinal atony. With ileocecal intussusception, Dans' symptom is determined - retraction of the right iliac region. If the intussusception is located low, it may be palpated during rectal examination and even prolapsed.

To visualize the intussusception, an abdominal ultrasound is performed: a hypoechoic formation with a hyperechogenic area in the central part is determined. Can also be applied Doppler ultrasound to assess blood flow in the mesenteric vessels. Plain radiography of the abdominal cavity is less sensitive in detecting intussusception, but is used as a screening method for acute abdominal pain in order to exclude perforation and obstruction.

Radiological signs can be very diverse: abnormal distribution of gases, the presence of fluid levels, dilation of intestinal loops, empty areas of intestine in the intussusception area, as well as ring-shaped alternating areas of darkening and clearing. X-ray with contrast is more informative: an obstacle to the contrast in the form of a semicircle or the distribution of barium in layered rings is determined. To determine the mechanical causes of the development of pathology, computed tomography can be used.

In case of severe intussusception with the formation of intestinal necrosis, symptoms are determined intestinal bleeding, as well as hypovolemia (dry skin, decreased blood pressure, oliguria). At laboratory research no specific signs are found. IN general analysis blood during perforation and peritonitis, leukocytosis is possible, and with hypovolemia - signs of hemoconcentration. The biochemical blood test remains unchanged. In a coprogram (stool analysis), in case of ischemia of an intestinal area, blood and mucus are determined.

Treatment of intussusception

Patients are treated in a hospital. For idiopathic intussusception in children aged 3-36 months, in the case of early hospitalization and the absence of complications, conservative treatment is possible. This is acceptable if no more than ten hours have passed since the onset of the disease. In this case, during diagnostic radiography, therapeutic measures are also carried out: air is pumped into the intestine using a Richardson balloon until the intussusception is completely straightened. Next, a gas outlet pipe is installed to remove air.

After the procedure, observation continues inpatient conditions Department of Abdominal Surgery. A control X-ray contrast study is required. If you apply in a timely manner medical care Conservative treatment is effective in 60% of cases. Within drug treatment Intussusception is treated with antibiotic therapy and infusion therapy.

If more than ten hours have passed from the onset of severe symptoms, as well as in the presence of neutrophilic leukocytosis in the general blood test, ineffectiveness of conservative treatment, signs of severe intestinal bleeding, and dehydration of more than 5%, surgical treatment by laparotomy is performed. The intussusception is eliminated, the viability of the intestine is assessed, and if necessary, part of it is subject to resection.

Prognosis and prevention

With timely hospitalization of the patient and adequate treatment, the prognosis is favorable. It is possible to develop complications such as recurrence of intussusception, intestinal perforation with the development of peritonitis, the formation of internal hernias and adhesions after surgical treatment. Prevention consists of timely correct introduction complementary feeding (not earlier than 6 months, with the gradual introduction of new dishes and a gradual increase in food volumes, preparation of homogeneous dishes for complementary feeding), treatment of intestinal neoplasms.

This is the most common form of intestinal obstruction in children, especially under two years of age, and is dangerous in its consequences. Intussusception is the acute penetration of one section of the intestine into another, adjacent, with the corresponding part of the mesentery. In this case, compression of the blood vessels of the mesentery occurs, venous stasis with edema, hemorrhage in the wall of the inserted loop, followed by necrosis and gangrene. Introduction during intussusception is most often ileocecal, when part of the narrow ileum is introduced into the wider hypotonic cecum, less often the small intestine into the small and large intestine into the colon.

The cause of intussusception is abnormal increased peristalsis of the intestines, sometimes in infancy with complementary feeding (a portion of undigested solid food), greater mobility of the cecum with a long mesentery, common with the adjacent part of the ileum, less often the presence of any anomalies.

Symptoms:

    sudden acute onset in the midst of full health, for the most part in a well-fed infant;

    seizures sharp pain in a stomach. The child screams shrilly, wriggles, twists his legs, clenches his fists, and has an expression of fear and suffering on his face. Colic is caused by violent peristaltic contractions of the affected parts of the intestine. After the pain subsides, the child lies calmly, with a fearful expression on his face, sometimes falls asleep for a few minutes before the colic recurs;

    state of shock (caused by severe pain), pale gray complexion, dilated pupils, severe anxiety;

    single (or repeated) vomiting, appearing only after the onset of pain;

    refusal to eat. The temperature is mostly normal;

    cessation of passing gas and stool (in the first hour there may still be fecal stool);

    the appearance, if the child strains, instead of stool, a small amount of blood (rarely abundant) or mucus mixed with blood (“currant jelly”).

If, in the clinical picture of intussusception, there is no discharge of blood or mucus with blood, then the child is given an enema (preferably hypertonic), after which blood is shown, or a finger is inserted into the rectum, and blood or mucus with blood is found on the tip of the finger. When palpating the abdomen (with gentle movements of a warm hand) during the intervals between attacks of pain, it is discovered that the abdomen is soft and not swollen. More often in right side a tumor of elastic consistency, sausage-shaped, with slight mobility (during attacks it becomes harder) is palpable. Less often, according to the advancement of the intussusception, the tumor is palpated on the left in the left hypochondrium and the left iliac region. Sometimes you have to resort to lumbar-abdominal palpation with both hands or combine palpation of the abdomen with rectal examination (introduce forefinger right hand into the rectum, and palpate the abdomen from the outside with the left hand). Sometimes the apex of the intussusception may protrude through the anus in the form of a red, fleshy mass.

Variable signs:

    retraction of the right iliac fossa with ileocecal intussusception;

    relaxation of the anal sphincter;

    as the intussusception approaches the rectum, constant straining appears.

In advanced cases of intussusception, significant bloating and increased vomiting, gangrene of part of the intestinal wall, and peritonitis are observed.

Differential diagnosis

IN early stages:

    with simple intestinal colic, in which there is no shock, swelling in the abdomen and bleeding;

    with colitis and dysentery. Colitis and dysentery are characterized by mild pain before defecation. Intermittent vomiting, often pain throughout the large intestines, absence of shock, absence of a tumor in the abdomen, sometimes spastically contracted sigmoid, gradual increase in intestinal phenomena, admixture of feces in the stool, constant tenesmus;

    With acute appendicitis. The latter is excluded by the presence of moderate pain of a more constant nature and tension in the muscles of the abdominal wall, and the absence of signs of obstruction (see acute appendicitis);

    with abdominal purpura (Henoch-Schönlein disease). There is a coincidence of the main symptoms: paroxysmal abdominal pain, vomiting, bleeding from the anus. However, with abdominal purpura the temperature is elevated. Children over 3-5 years of age are most often affected (very rarely in infancy). There are simultaneously skin hemorrhagic, papular or urticarial phenomena, swelling and tenderness of the joints, the stool contains elements of bile, and there may be an admixture of blood in the vomit. It must be borne in mind that abdominal purpura can be complicated by intussusception;

    with prolapse of the rectum and protrusion of the mucous membrane of the anus. Difficulty may arise if a deeply embedded colon (intussusception) has descended into the rectum and began to protrude through the anus. Recognition is aided by careful examination and questioning. In case of rectal prolapse, the area of ​​the protruded mucous membrane of the anus directly passes into the skin, and in the descended intussusception between anus and the mucous membrane of the intussusception there is a groove leading to the rectum. In addition, with rectal prolapse there are no sharply painful attacks and severe general condition;

    with rectal polyp. The discharge of blood from a rectal polyp is usually not accompanied by colic, vomiting, or a disturbance in the general condition.

The diagnosis of intussusception can be confirmed x-ray examination. Do overview shot in an upright position or a picture with the introduction of a barium enema or with the introduction of air (through the anus) using a Richardson balloon. Air causes less intestinal irritation than a barium enema, which must be administered slowly (due to the risk of perforation of the intestinal wall as intussusception progresses) and under the control of an x-ray screen.

With intussusception, a characteristic picture of stopping the barium suspension in the form of a cockade, cup, screw or amputation is obtained, but not with all forms of intussusception.

Treatment

When a diagnosis of intussusception is made, as well as if it is suspected, immediate hospitalization is necessary. The main treatment is emergency surgery. The advantage of surgical treatment: elimination of intussusception under direct visual control and the ability to identify and eliminate causative factor diseases. In the early stages, disinvagination is performed. At a later admission, the affected part of the intestine is resected. The method of bloodless straightening of intussusception using a barium enema or introducing air into the large intestine can be used only when children are admitted to the hospital no later than 24 hours from the onset of the disease and if small intestinal intussusception is excluded. At the same time, the effectiveness of disinvagination can be proven not only by straightening the intussusception, but by the passage of gases and stool, and feeling good child. The disadvantage of bloodless intussusception is that children are exposed to repeated radiation.

Children admitted in shock must be brought out of shock before surgery. After surgery you should take necessary measures to replace fluid loss and combat hyperthermia.

Strangulated inguinal hernia

A strangulated inguinal hernia is one of the most acute surgical diseases in early childhood. Abdominal hernia - exit from the abdominal cavity of the viscera, covered with parietal peritoneum, into the outer sections of the abdominal wall ( external hernia) or into a pocket in the abdominal cavity (internal hernia). An inguinal hernia is often oblique, on the right. It becomes noticeable in the first weeks and months in the form of a protrusion of the groin area. Increases with anxiety, crying of the child. Reduces on its own or with light pressure with a rumbling sound.

The most dangerous complication any hernia is a strangulation, characterized by sudden compression of the released viscera in the hernial ring. Blood circulation and function of the strangulated organ (mainly intestinal loops) are disrupted. Without appropriate treatment, necrosis of the intestinal segment and peritonitis quickly occurs. Elastic entrapment occurs when there is a sharp increase in intra-abdominal pressure. When the hernial ring expands, nearby intestinal loops penetrate through it. After termination abdominals The hernial ring, due to its elasticity, narrows again and compresses the prolapsed intestinal loops.

Less commonly, fecal strangulation occurs due to the accumulation of a significant amount of feces in the intestinal loops of the hernial sac and subsequent compression of the efferent intestinal loop along with the mesentery. Sometimes fecal and elastic strangulation is combined.

Causes of strangulation: straining during defecation, during a severe coughing attack, often in the absence of a clear reason.

Symptoms:

    sudden onset of pain. The child continuously screams shrilly, kicks his legs, and strains. At times the pain subsides and the child calms down;

    nausea and vomiting are constant early symptoms. Sometimes vomiting with a fecal odor (when the loops of the small intestine are pinched);

    non-passage of gases and feces (non-permanent symptom);

    gradual increase in bloating;

    the presence of an irreducible tumor at the external opening of the inguinal canal. The tumor fills the area of ​​the spermatic cord to the scrotum or the entire scrotum (when examining a child, especially with abdominal pain, you should never limit yourself to examining only the abdomen and not pay attention to the groin area);

    the tumor is tense, dense, smooth, painful when touched. When transilluminated, a darkening is obtained, greatest in the central part;

    the skin surface of the tumor is initially unchanged, but later, with the development of inflammatory phenomena, it becomes red and hot;

    in the absence of necessary therapeutic measures further development occurs common symptoms obstruction with a collaltoid state, necrosis of intestinal loops and peritonitis.

The diagnosis is not difficult if a tense, painful swelling is visible at the site of an easily reducible inguinal hernia. The following cases pose difficulties for diagnosis:

    if the child’s inguinal hernia was not noticeable before;

    with infringement in the internal inguinal canal. When examining with a finger inserted into the external opening of the inguinal canal of the affected side, a sharply painful dense formation is palpated deep in the canal;

    in the absence of painful hernial protrusion due to sudden and very strong compression of the strangulated organ.

Instead of swelling and effusion in the hernial sac, necrosis of the strangulated organ quickly develops. A higher location of pain and swelling serves as a basis for misdiagnosing acute appendicitis.

Differential diagnosis:

    for small hernias with acute inguinal lymphadenitis. Inflamed The lymph nodes are significantly painful, the skin over them is hot, swollen, reddish. The temperature is elevated, there is no vomiting, stool is not retained;

    with a spermatic cord cyst with a small strangulated hernia located at the external opening of the inguinal canal. Features: when light passes through, the cyst becomes translucent, and the strangulated hernia darkens, mobility and painlessness of the cyst, and absence of vomiting are noted;

    with orchitis ( acute inflammation testicle) and epididymitis (inflammation of the epididymis, which is a complication of some infectious diseases). With these diseases, there is a sharp pain in the testicle, elevated temperature and localization of the tumor in the scrotum;

    with torsion of the spermatic cord of an undescended testicle, which is characterized by localization of swelling and sharp pain on the same side of the abdomen on which the testicle is missing in the scrotum.

An unclear picture is given by isolated strangulation in the hernial sac of the appendix or Meckel's diverticulum. The initial symptoms in this case are: an increase in the hernial tumor and pain, the hernia is not tense, there is no vomiting, intestinal patency is preserved, since the Meckel's diverticulum and the appendix are intestinal appendages. Only after 2-3 days do the usual signs of strangulation appear, and if the appendix is ​​strangulated, signs of appendicitis appear. At the same time, a detailed examination reveals identifying features: the presence of a double elastic cord, doubling the spermatic cord and descending below the latter; in this case, a hernia is often visible, small in volume and not compacted.

Treatment

Urgent hospitalization is required surgery department. Due to the great elasticity of tissue in children and the instability of spasm, a strangulated hernia sometimes reduces itself. In children admitted to the department in the first 12 hours after strangulation, especially in those who are weak and malnourished or in the first 6 months of life, if the conservative method of reduction is successful, it is recommended to temporarily postpone the operation for several days so that the local tissue reaction disappears. The conservative method of reducing a strangulated hernia is as follows: after subcutaneous injection A 1% solution of Omnopon in a dosage of 0.1 ml per 1 year of a child’s life is placed in a warm bath for 10-20 minutes. Then they take you out of the bath and, holding your legs, lower you upside down. If the hernia cannot be reduced, the child is placed in bed with the foot end of the bed raised. Children usually fall asleep and self-reduction of the hernia may occur. If these measures are ineffective, surgery is indicated in the next few hours. Emergency surgery is necessary for all children admitted to the department later than 12 hours after strangulation, also for all girls, regardless of the time of admission and strangulation (in girls, strangulated rotated appendages quickly swell and become necrotic). Before surgery, all necessary measures must be taken to eliminate the collapsed state, dehydration and intoxication.

Other forms of obstruction

Obstruction due to coprostasis. Mechanical ileus is often encountered in children, caused by blockage of the intestinal lumen with dense feces (coprostasis) due to intestinal lethargy (except for megacolon - Hirschsprung's disease, when the etiology is different). Dense feces are palpated not only in the left half of the abdomen, but also on the right in the blind and ascending colon. Incomplete patency can be replaced by complete patency with the development of the entire symptom complex of obstruction.

Treatment

Repeated enemas with water, preferably siphon ones. Enema with Vaseline or vegetable oil. Subsequently, appropriate nutrition, 5-15 ml orally Vaseline oil 1-2 times a day. At night, glycerin suppositories or the introduction of petroleum jelly into the rectum. If coprostasis recurs, examination in a hospital setting using fluoroscopy of the intestinal canal.

    Helminthic obstruction.

Blockage of the intestinal lumen by roundworm balls is often observed in children due to a significant percentage of infection with roundworms, the narrowness of the intestinal lumen, and poor development of the muscular layer of the intestinal wall. Ascariasis causes a mechanical form of obstruction (blockage with a ball of roundworms) and a mixed form (blockage of the lumen and spasm of the intestinal wall, less often implantation and volvulus).

Treatment in hospital. High enemas, novocaine blockade perirenal, abdominal massage, anthelmintic treatment. The ineffectiveness of these measures is an indication for urgent surgery.

Strangulation ileus occurs due to compression of the intestines by strands of inflammatory origin (adhesions), Meckelian diverticulum, vermiform appendix, volvulus, due to an unusually long mesentery. The symptoms are the same as with other forms of obstruction.

Among the forms of dynamic ileus in children, intestinal paresis occurs in postoperative period and paresis of the intestines during a febrile illness with symptoms of bloating, vomiting and stool retention (with pneumonia, a severe form of an infectious disease).

Treatment. Hypertensive enemas, injection into a vein 5-10 ml 10% sodium chloride, injections of proserin.

Intussusception is the insertion of one section of the intestine (loop, usually) into another. As a result, the process of food passage is disrupted, i.e. intestinal obstruction develops (the so-called “volvulus”). The inflammatory process begins almost immediately, and suppuration occurs a little later. Without appropriate treatment, the process ends fatally.

Most often the process occurs at the level of the cecum, as well as in the area of ​​the ileocecal angle. The latter happens in 90% of cases, and the name is specified to ileocecal intussusception.

Causes of intussusception

Most often observed in children, due to the weakness of the developing intestinal wall and frequent inflammatory processes digestive system. Intussusception in children holds second place after in the list of surgical pathologies of childhood.

The general statistics are as follows: 2-3 cases per 1000 children, and 2/3 of these episodes occur in children aged 4 to 10 months. Boys get sick a little more often, due to their higher activity levels (and tendency to eat weird things).

Highlight following reasons of this state:

  • change in diet, inadequate introduction of complementary foods. This category also includes everything that can provoke excessive intestinal peristalsis (contractility). “Dancing intestines” leads to the fact that a loop of one intestine simply “flies” into another. In adults this state does not lead to intussusception, because the intestinal wall is much denser and thicker. However, in combination with other factors, excessive peristalsis can harm even adults;
  • benign intestinal neoplasms. This is, as a rule, an “adult” cause of intussusception - bulk tumor gradually changes the structure of the tissue underneath and can be a source of chronic inflammation. The intestinal wall gradually weakens, and under some conditions succumbs to external pressure;
  • adenovirus infection of the mucous membrane, complicated by lymphadenopathy. Mucous in in this case weakened by the inflammatory process, and if interested regional lymph nodes the likelihood of intussusception becomes even greater;
  • systemic connective tissue diseases in newborns: systemic red, mixed disease connective tissue and other similar processes imply initial defects in the intestinal wall. This is due to a disruption in the synthesis of certain proteins, mucopolysaccharides and other components necessary for normal life;
  • congenital pathology of the ileocecal valve;
  • abdominal injuries. This includes both penetrating abdominal wounds and blunt trauma. In the first case, the intestinal wall is damaged directly. After the surgeon applies stitches, a connective tissue. As a rule, it is in such areas of the intestine that intussusception occurs. At blunt trauma Microtraumas and mucosal cracks may occur. If an inflammatory process occurs, the intestinal wall is weakened, which can lead to intussusception;
  • excessive, pathological mobility of the ileum and cecum. This genetic defect, is an additional risk factor for intussusception.

Symptoms of the disease in children

Heat- symptom of intussusception

The clinical picture of the disease varies depending on the age of the child, duration inflammatory process and related diseases.

In infants, intussusception begins acutely. Suddenly the child begins to scream, fight, and jerk his legs. Episodes of fainting are possible. The skin turns pale, cold sweat may appear, and vomiting is common. It is impossible to calm a child in this state - there is a clinic " acute abdomen».

The pain comes in attacks, this is due to intestinal contractility. Attack intestinal colic lasts an average of 15 seconds, then the pain completely disappears. The child begins to play and may fall asleep. The frequency of pain is from 5 to 20 minutes. Gradually, periods of remission are lengthening, but this does not mean anything good.

If symptoms of intussusception appear in a child, do not relax; if the symptoms of colic soften, the pinched intestine simply loses normal contractility. This indicates the transition of the process to a more severe phase.

For the first 6 hours, bowel movements occur normally. After this, the intestines begin to bleed, mucus and blood are released. There will be no more feces.

After 12 hours, signs of a massive inflammatory process appear:

  • appears constant pain– the strangulated intestine becomes inflamed;
  • the child’s anxiety gives way to lethargy and apathy (intoxication);
  • in half of the cases of intussusception in children, you can feel a “knot” in the abdomen, this is, in fact, intussusception, i.e. area of ​​inflamed intestine;
  • bleeding from the rectum is observed;
  • bloating may appear;
  • vomiting often occurs;
  • if intussusception is accompanied by ruptures and effusion of contents into the peritoneum, the clinical picture of peritonitis begins. This outcome is inevitable if you do not seek help from surgeons.

Complications of intussusception, as a rule, develop within 24-36 hours from the onset of the disease.

Boys sometimes develop colonic intussusception after the age of 3 years. It is caused by an intestinal infection, and is much milder than the small intestinal form. The pain is much weaker, but intestinal bleeding is more pronounced. The infiltrate can be felt on the left side of the abdomen.

Diagnostics


Examination of the child is one of the ways to diagnose the problem.

The doctor conducts a survey and examination. In principle, for surgeons, the symptoms of an acute abdomen are enough to confirm the need for intervention, so simply taking the baby to the doctor is enough. If the situation allows, some of the following examinations are urgently performed:

  • plain radiograph of the abdominal organs. This simple test can detect signs of intestinal obstruction;
  • Ultrasound provides information about the infiltrate, i.e. thickening of the intestine in the peri-umbilical region - the so-called. target sign and pseudokidney sign;
  • irrigography is used if colonic obstruction is suspected;
  • a computed tomogram is prescribed if there are doubts or inaccuracies in the examination of the child;
  • A blood test can determine the presence of intestinal bleeding and the extent of inflammation ( leukocyte formula, ).

If blood enters the intestine above the volvulus, then there may not be significant bleeding from the rectum. In this case, the child risks losing a lot of blood. If pronounced - surgical intervention must be done immediately.

Treatment of intussusception

If intussusception occurred less than 6 hours from the first intestinal colic, then intussusception can be treated relatively painlessly, without surgery, and the outcome of the situation will be positive.

They use the pneumoirrigoscopy method - air is pumped into the intestine with a special device, the intestine straightens and pushes out the intussusception. This is possible only in the early stages of the process, when there are still no adhesions and infringement of the implanted area.

In other cases, surgery is performed. If part of the intestine is already dead, it is removed. If there are signs of peritonitis, a full cycle of treatment for this complication is carried out. In any case, after the operation, fairly strict antibiotics will be prescribed (levofloxacin, tienam, meronem, etc.), since it is necessary to protect against the development of sepsis.

If you find that the doctor prescribes a drug for your child that is not indicated for children, in this case you should not demand its cancellation. The benefit/complication ratio in this case forces the doctor to use everything in the arsenal, including “adult drugs.”

Traditional methods of treatment in this case are ineffective and cause complications and death of many children. Intussusception does not correct itself, and delay leads to complications.

Prevention in children


The rules of complementary feeding should never be neglected!

Preventive measures should be taken by the child’s parents, plus a local pediatrician or family doctor. It is necessary to strictly follow the complementary feeding schedule and not make unnecessary experiments. In addition, complementary foods should not be introduced during the ARVI epidemic or within 10 days after vaccinations.

Solid foods should also be withheld during frequent episodes. intestinal disorders. In general, if a child does not eat regularly, is often sick, or has pathologically loose intestines, there is no point in taking risks with complementary foods. Juices are especially dangerous in terms of the risk of intussusception.

You need to understand that an overfed child is also at risk - increased intra-abdominal pressure affects the intestinal walls, making them more pliable. In a hungry child, intestinal motility increases due to waves of contractility.

Thus: a healthy, well-fed, but not overfed child with timely (not early) complementary foods has a much lower risk of suffering from intussusception. Adults need to closely monitor the condition of the intestinal mucosa, and receive prompt treatment for chronic inflammatory diseases, polyps and benign (and even more so malignant) tumors.

Video about intussusception in children

The content of the article

Intussusception- a mixed form of mechanical intestinal obstruction that occurs during telescopic insertion of the proximal part of the intestine into the lumen of the distal part of the intestine.

Historical background of intussusceptions

Intussusception was first described by Barbette in 1674. In 1834, Wilson performed the first successful surgical treatment of intussusception. In 1876, Hirschprung proposed the technique of hydrostatic spread of intussusception and, after observing 107 cases, reported a 35% mortality rate in 1905. Prevalence Intussusception occurs with a frequency of 1.5-4 cases per every 1000 live newborns, most often at the age of 9-24 months. There is seasonality in the occurrence of intussusception - most often it occurs in spring, summer and mid-winter, coinciding with peaks in the occurrence of seasonal gastroenteritis and infections respiratory tract. Intussusception after intestinal surgery occurs in 1% of cases.

Etiology of intussusception

In most cases unknown. Factors contributing to the occurrence of intussusception include: poor diet, intestinal diseases, lymphadenopathy as a result of adenoviral infection, abdominal trauma, polyps or intestinal tumors, Meckel's diverticulum. Anatomical reasons for the development of intussusceptions include: pathological mobility of the cecum and ileum, malformations of the ileocecal valve.

Pathogenesis of intussusception

Intussusception occurs when there is a sudden discoordination of intestinal peristalsis. Initially, when the ripples of the implanted intestine are strangulated, strangulation intestinal obstruction occurs. Incarceration of the ripples leads to obstruction of lymphatic and venous drainage, edema of the embedded intestine and the release of red blood cells from the bloodstream through diapedesis. Mixing with mucus, the bloody transudate is intensively produced and forms stool in the form of “raspberry (currant) jelly.” Increased intestinal edema leads to disruption of arterial blood supply and the occurrence of intestinal gangrene. Gangrene begins at the head of the intussusception and spreads backward. Later, strangulation is joined by obstructive intestinal obstruction when the lumen of the intestinal tube of the intussusceptum is closed. The child develops dehydration due to vomiting. Ischemia and necrosis of the intestine lead to intestinal perforation and the development of sepsis. Necrosis of a significant length of the intestine can lead to the development of “short intestine” syndrome. In the intussusception there are 3 cylinders (external, middle, internal) and the head of the intussusception.

Classification of intussusceptions

According to the clinical course, they are distinguished:
1. Acute intussusception (98.8%).
2. Chronic intussusception - the occurrence of an adhesive process in the intussusception (as a result of the development of inflammation) in the absence of complete occlusion of the intestinal lumen (0.7%).
3. Recurrent intussusception (0.5%).
By localization(according to V.P. Portnoy):
I. intussusception in the area of ​​the ileocecal angle - 91, 3%):
a) slip-rim form - the wall of the cecum is inserted into the ascending colon, the ileum is passively retracted without passing through the ileocecal valve;
b) pubo-ileo-colic form - penetration of the ileum into the ileum, then through the ileocecal valve into the colon:
simple form- the cecum does not go deep into the intussusception;
complex form - the cecum and other parts of the colon deepen into the intussusception to form part of the middle cylinder.
c) ileo-valvular-colic form - the part of the ileum at the ileocecal valve extends into the large intestine, involving the colon.
II. Small-intestinal form - 6.5%.
III. Colonic form - 2.25%.

Intussusception Clinic

The appearance of a child suffering from intussusception is quite deceptive. Usually this child is well fed and is not given to the sick. In contrast, intussusception is less common in children who are thin or have poor nutrition. Clinical manifestations Intussusceptions are usually as follows:
1. Sudden occurrence of intense (up to painful shock) paroxysmal abdominal pain of a periodic (frequency of 5-30 minutes) nature. During an attack of pain, the child turns pale, screams and pulls his legs towards his stomach. These episodes of pain last for several seconds, during which time the child appears calm or even sleepy.
2. Vomiting, first with leftover food.
3. Blood in the stool or mucus soaked in blood (“raspberry” or “currant jelly”), without feces, 4-6 hours after the onset of the disease.
4. A soft-elastic, moderately mobile tumor - intussusception, which can be felt by palpation of the abdomen.
5. Absence of the cecum in the right iliac region - symptom satisfied
6. Retention of gases and stool.
7. During a rectal examination, you can sometimes notice or palpate the head of the intussusception and detect blood in the stool.

Diagnosis of intussusception

1. General and biochemical tests blood - do not have definite signs of intussusception, but depending on the duration of the disease and associated vomiting and blood loss, they may reflect dehydration, anemia and / or leukocytosis.
2. Plain radiography - does not always provide data for diagnosis, but quite often the radiograph shows dilated loops of the small intestine, a shadow of intussusception against the background of the intestine, Kloiber cups as a sign of intestinal obstruction).
3. Ultrasound - with two-dimensional echography - echo-negative and echo-positive areas of the image, which alternate in the form of concentric rings with transverse ultrasound), or a symptom of “pseudo-mirror” with longitudinal ultrasound). Ultrasound is better used as a diagnostic tool to exclude the diagnosis of intussusception.
4. Computed tomography - often used for differential diagnosis of diseases accompanied by abdominal pain. Although this method is not used to diagnose intussusception, it can be detected accidentally when analyzing computed tomography data).
5. Irrigography with air as the main diagnostic method (symptoms of “claw of cancer”, “cockades”). Air pressure should not exceed 50-60 mmHg. Art. Air is introduced using a Richardson apparatus. In the absence of signs of perforation or peritonitis, it is possible to perform contrast irigoraphy with water-soluble contrast (urografin, verografinn, Triombrast)).
6. Colonoscopy reveals the condition of the head of the intussusception - necrosis of the head is possible. Differential diagnosis carried out with acute dysentery, toxic dyspepsia, acute appendicitis, peptic ulcer of Meckel's diverticulum, acute cholecystitis and pancreatitis, polyps of the gastrointestinal tract, prolapse of the rectal mucosa.

Treatment of intussusceptions

Conservative

The technique of through blowing under anesthesia using the Richardson apparatus is used. The air pressure in the rectum should not exceed 120 mm Hg. Control of intussusception expansion by palpation and with the help of a nasogastric tube, through which air escapes into a glass of liquid. Relapses of intussusception after conservative treatment are about 5%. Contraindications to conservative treatment:
1. Ileo-ileo-colic form of intussusception.
2. Bleeding from the rectum.
3. Small bowel obstruction on radiograph.
4. More than 18 hours from the onset of the disease.
5. In children older than 1 year or younger than C months.
6. Dehydration more than 5%.
7. Recurrent intussusceptions.
9. Necrosis of the head of the intussusception, detected during colonoscopy.

Operational

Preoperative preparation for 2-3 hours is required. Methods of surgical treatment - laparoscopic and laparotomy. During laparotomy, depending on the condition of the intussusception, the following is performed:
1. Disintussusception with “videojuvannya” of intussusception.
2. Disinvagination followed by intestinal resection and anastomosis.
3. Simultaneous resection of the intussusception without straightening it.
4. Resection of intussusception through the intestine.
Recurrence of intussusception after surgical treatment is about 1-4%. Mortality less than 1%.
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