Introduction
In pediatrics, several conditions could present with abdominal pain hence becoming a medical emergency. Intussusceptions are a pediatric ailment, which could also become a medical emergency if not manage properly on time. Intussusceptions can be described as a disorder, which present with "telescoping or invagination of a proximal portion of intestine into the more distal part and subsequently leading to bowel obstruction" (Irish, 2011). The proximal portion of the intestine is termed the intussusceptum while the distal portion termed intussuscipiens.
This gastrointestinal condition result into inflammation and obstruction. The related concept or factors considered in this case for the diagnosis is the triad of signs and symptoms which are abdominal pain, vomiting and bloody mucoid stools. When that occurs in a child within the age range of 3 month and 6 years, intussusceptions will be suspected. The important aspect of the management is a quick response to prevent the likely complications which include; bowel necrosis, perforation, or death.
Epidemiology
This condition has an incidence rate of 1.5-4 cases per 1000 live births with a male to female predilection ratio of 3 to 2 (Irish, 2011) in the United States. Approximately 66/100000 cases as regards to incidence is found in the United Kingdom. It was also stated to have an increased incidence among the infant within the 9-24 months age group. There is also variation per season in the incidence of the condition with most common occurrence during the spring, summer and middle winter period however, there is no recorded geographical distribution in incidence as regards to the disorder (Irish, 2011).
Etiology
The implicated etiology in intussusceptions is that which is dependent on the affected intestine itself. This is because the intestine is being pulled inward into itself hence resulting hindrance or obstruction to the passage of food. The problem of inward pulling of the intestine can then lead to decreased blood flow to the region, irritation, or inflammation of that part of the intestine. Viral infections has been implicated in the etiology in some situations and also the increase incidence with introduction of vaccination for rotavirus in the United states (Hussain & Ruiz, 2010).lymph nodal enlargement, polyp or tumor has also been implicated in the etiology of the condition (Hussain & Ruiz, 2010). In some cases, gastrointestinal infections or drug reactions has also been implicated as predisposing factors that lead to lymphadenopathy hence an increased chances of intussusceptions (Hussain & Ruiz, 2010).
Pathophysiology
Intussusceptions have intestinal obstruction as a major complication. This obstruction leads to congestion and edema hence impairment in the venous and lymphatic flow causing venous and lymphatic obstruction. The necrosis that has been found to be associated with the condition result when there is ischemia to the part of the intestine due to arterial obstruction. The consequence of the necrosis is that it will lead to fluid sequestration and bleeding from the gastrointestinal tract and subsequent perforation of the tract.
Important signs and symptoms
loud crying by the child, drawing of the knees to the chest while crying, bloody stool, fever, shock, stool mixed with blood and mucus, vomiting, nausea, intermittent pain that tend to resolves temporarily, palpation of the abdomen reveal a sausage shaped mass. In most cases, vital signs are usually normal except in some cases. Pallor may be seen in some instances. The pain usually starts less than 10-12 hours before presentation.
Implication of disease on growth and development
The consequences of the late response to the treatment of the intussusceptions are usually associated with death especially in the developing environment where quality emergency management is not found easily. The child can still experience some effects after treatment. A major changes or consequences noticed with treated patient are development of coronary artery aneurysm (Hussain & Ruiz, 2010).
Laboratory investigations and diagnosis
Provisional diagnosis is made based on the history, associated symptoms, and physical examination. Definitive diagnosis is made based on the diagnostic imaging modalities such as ultrasound or x-ray, which make use of plain radiographs of the chest.
Ultrasound is the main diagnostic tool now because of lack of radiation and increased or high accuracy. The imaging tool will reveal a target-like mass. It has been considered to be 98-100 percent sensitive and 88-100 percent specific although operator dependent in the specificity and sensitive features (Pineda & Hardasmalani, 2009)
Contrast enemas which include the use of barium, water soluble and air enema (Pineda & Hardasmalani, 2009) are of importance in diagnostic procedure involve in the condition although not really considered again as the gold standard for making a definitive diagnosis. This is because of the risk found to be associated with the barium enema, which include shock or bowel perforation (Pineda & Hardasmalani, 2009). The important nursing considerations as regards to the diagnostic procedures for the affected child is that which depend on effective stabilization of the child, adequate hydration and consultation with the surgeon before the investigations are done (Pineda & Hardasmalani, 2009).
Another merit of ultrasound is that it is non-invasive and fast to conduct. The findings on the image shows the presence of 'target lesions' what is considered as doughnut sign when transverse imaging is done or pseudokidney sign when the imaging done is that of longitudinal imaging (Pineda & Hardasmalani, 2009).
In cases of Computed tomography scan, it is not usually indicated because of the cost and radiation exposure. Air enema help in diagnostic process as well as treating the condition and it is associated with less risk of perforation making it more acceptable mode of enema to be used.
Management; Medical/nursing and interdisciplinary intervention
The management involves multidisciplinary approach, which involves the participation of pediatric surgeons, pediatric radiologist, and pediatric nurses. The approach in the treatment involves the first stabilization of the child and then placement of a nasogastric tube to rehydrate the patient. In some situations, the associated bowel obstruction can be treated with the enemas especially the air enema which is known to be associated with lower risk of perforation. In cases where the intussusceptions cannot be reduced by those processes, there is a need for surgical reduction of the bowel tissue and removal any necrotic bowel tissue.
Prognosis
The prognosis is good when the response rate of management is quick. This is because it helps to reduce the incidence of perforation, shock, or death. However, prognosis is poor in areas where response rate is poor.
Health promotion activities, teaching/learning and discharge needs
The health promotional activities or teaching activities that can be initiated by the health care provider is to initiate a program that will educate the public on the condition and what should be done if their kids experience such condition. The importance of urgent presentation at emergency clinic will also be emphasized to help reduce the rate of perforations due to lateness in presentation. The associated discharge need actually depend on the state of presentation. For instance, a child with less than 24hours presentation and was manage within that period can be discharge after being stable within 48 hours. In cases where presentation was quite late, the discharge need will depend mainly on the complete stabilization of the child, which will be determined by the health professionals managing the child.
Conclusion
Intussusception is a condition that usually affects children. Since a child might not be able to express him or herself like an adult. The parent should be aware of prompt report at the emergency clinics in cases of intermittent crying of their children with movement of knees towards the abdomen. It is also very important for the health care provider to always consider promptness in their management of cases of intussusceptions because of the relevance in the prognosis of the condition.
References
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Hussain, R. & Ruiz, G. (2010). Kawasaki Disease presenting with intussusception: a case report. Italian journal of pediatrics.
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Irish, M. & Grewal, H. (2011). Pediatric Intussusception Surgery. Medscape reference.
Retrieved 13 November, 2011 from http://emedicine.medscape.com/article/937730-overview#a0104
Morrison, J. & Jeanmonod, R. (2011). Intussusception Secondary to a Meckel's Diverticulum in an Adolescent. Case report.
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Pineda, C. & Hardasmalani, M. (2009). Pediatric intussusception: A Case Series and Literature Review. The Internet Journal of Pediatrics and Neonatology.
Retrieved 12 November, 2011 from http://www.ispub.com/journal/the-internet-journal-of-pediatrics-and-neonatology/volume-11-number-1/pediatric-intussusception-a-case-series-and-literature-review.html
Shekherdimian, S. & Lee, S. (2011). Management of pediatric intussusception in general hospitals: diagnosis, treatment, and differences based on age. World J Pediatr 2011;7(1):70-73
Retrieved 13 November, 2011 from http://www.wjpch.com/article.asp?article_id=434
