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CASE PRESENTATION ON INTUSSUSCEPTION

CASE PRESENTATION ON INTUSSUSCEPTION

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 DEMOGRAPHIC PROFILE

Name                           : ********

Age/Sex                      :1.6YEARS                                          

HOSP. No                      : *******

Ward/Bed No              : *******

DOA                           :*******                                

Religion                       : *******

Nationality                  : *******

Address                       : ******

Informant                    : Mother

Reliability                    : Fair

Diagnosis                    : Ileo-Colic Intussusception

Surgery Done              : Exploratory laparotomy + Manual reduction of intussusception

CHIEF COMPLAINTS

  • Recurrent abdominal pain * 3 days
  • Non-bilious vomiting and non-passage of stool * 3days

HISTORY OF PESENT ILLNESS

Child was apparently well 3 days ago when he developed abdominal pain which was non-colicky in nature. Associated with non-bilious vomiting and non-passage of stool. No h/o fever, jaundice, melena.

O/E P/A: Soft, non-tender, no lump present.

So, brought to paediatrics casualty on 04/02/18 and diagnosed on USG as Ileocolic intussusception

PAST HISTORY

H/O 1 surgery in the past

No significant medical history

FAMILY HISTORY

  • Non-consanguineous marriage                                                  
  • Product of spontaneous conception       
  • No h/o similar illness in the family                                                         

OBSTETRICAL HISTORY

G2P2L2A0

T1 : SPC/UPT diagnosed. No h/o post conceptional folate intake. No h/o fever with rashes. No h/o radiation exposure. No h/o teratogenic drug intake.

T2/T3 : Regular iron and calcium supplementation taken. Quickening at 5 month. Received 2 doses of TT. No h/o deranged blood sugar or high BP records.

Intrapartum history

Baby was full term and cried immediately after birth. Birth weight was 2.5 kg.

Postnatal history – uneventful

DEVELOPMENTAL HISTORY

Appropriate milestones present

Cannot walk, stand without support

IMMUNISATION HISTORY

Immunised as per age

SOCIOECONOMIC STATUS

Middle class family, staying at own house.

Electricity & water- government supply

Sanitation facilities – Indian type toilet in the house

PERSONAL HISTORY

Hygiene- clean hair and scalp. Hygiene maintained

Dietary pattern-appetite decreased.

Elimination pattern- passes urine 6-7 times daily. Not passing stool for 2 days

Sleep – 12-14 hours daily, good sleep.

No h/o known allergies

VITAL SIGNS

Vitals: Temperature- 98of. Respiratory rate- 32/min. Heart rate- 100 bpm.

PHYSICAL EXAMINATION

Weight- 8.8 kg                        Length- 74.5 cm

On examination:  conscious, active alert, afebrile. No pallor, icterus, cyanosis, respiratory difficulty, edema

Head – grossly normal

Chest 

CVS – S1, S2 normally audible, no murmurs present

Respiratory system– chest moving symmetrically, b/l air entry equal. No added sounds

Abdomen – Scar of previous surgery present.

Soft, non-tender, no distension at present, no organomegaly,

Per rectal – Faecalomas present

Genitalia– normally placed urethral meatus, vagina and anus.

INVESTIGATIONS

  1. X RAY

Dilated small bowel loops with multiple AF level

Ileo-colic intussusception + sub acute intestinal obstruction

  • Histopathology report

Mesenteric lymph node (1cm in diameter) shows features of reactive lymphoid hyperplasia

  • ULTRASOUND ABDOMEN

Multiple dilated small bowel loops are seen with interloop fluid seen.

Investigation 04/02
HB 10.4
PCV 36
TLC 9400
Platelets 2,69,000
Na/K 141/4.9mEq/L
Urea/Cr 12/0.3mg%

INTUSSUSCEPTION

Definition

Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This “telescoping” often blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that’s affected, which can lead to a tear in the bowel (perforation), infection and death of bowel tissue.

Intussusception is the most common cause of intestinal obstruction in children younger than 3. The cause of most cases of intussusception in children is unknown. Though rare in adults, most cases of adult intussusception are the result of an underlying medical condition, such as a tumour.

In children, the intestines can usually be pushed back into position with an X-ray procedure. In adults, surgery is often required to correct the problem

Symptoms

The first sign of intussusception in an otherwise healthy infant may be sudden, loud crying caused by abdominal pain. Infants who have abdominal pain may pull their knees to their chests when they cry.

The pain of intussusception comes and goes, usually every 15 to 20 minutes at first. These painful episodes last longer and happen more often as time passes.

Other frequent signs and symptoms of intussusception include:

  • Stool mixed with blood and mucus (sometimes referred to as “currant jelly” stool because of its appearance)
  • Vomiting
  • A lump in the abdomen
  • Lethargy
  • Diarrhoea
  • Fever

Not everyone has all of the symptoms. Some infants have no obvious pain, and some children don’t pass blood or have a lump in the abdomen. Some older children have pain but no other symptoms.

Causes

In the vast majority of cases of intussusception in children, the cause is unknown. Because intussusception seems to occur more often in the fall and winter and because many children with the problem also have flu-like symptoms, some suspect a virus may play a role in the condition. Sometimes, a lead point can be identified as the cause of the condition — most frequently the lead point is a Meckel’s diverticulum (a pouch in the lining of the small intestine).

Adults

In adults, intussusception is usually the result of a medical condition or procedure, including:

  • A polyp or tumour
  • Scar-like tissue in the intestine (adhesions)
  • Weight-loss surgery (gastric bypass) or other surgery on the intestinal tract
  • Inflammation due to diseases such as Crohn’s disease

Risk factors

Risk factors for intussusception include:

  • Age. Children — especially young children — are much more likely to develop intussusception than adults are. It’s the most common cause of bowel obstruction in children between the ages of 6 months and 3 years.
  • Sex. Intussusception more often affects boys.
  • Abnormal intestinal formation at birth. Intestinal malrotation is a condition in which the intestine doesn’t develop or rotate correctly, and it increases the risk for intussusception.
  • A prior history of intussusception. Once you’ve had intussusception, you’re at increased risk of developing it again.
  • A family history. Siblings of someone who’s had an intussusception are at a much higher risk of the disorder.

Complications

Intussusception can cut off the blood supply to the affected portion of the intestine. If left untreated, lack of blood causes tissue of the intestinal wall to die. Tissue death can lead to a tear (perforation) in the intestinal wall, which can cause an infection of the lining of the abdominal cavity (peritonitis).

Peritonitis is a life-threatening condition that requires immediate medical attention. Signs and symptoms of peritonitis include:

  • Abdominal pain
  • Abdominal swelling
  • Fever

Peritonitis may cause your child to go into shock. Signs and symptoms of shock include:

  • Cool, clammy skin that may be pale or gray
  • A weak and rapid pulse
  • Abnormal breathing that may be either slow and shallow or very rapid
  • Anxiety or agitation
  • Profound listlessness

A child who is in shock may be conscious or unconscious. If you suspect your child is in shock, seek emergency medical care right away.

Tests and diagnosis

child’s doctor will start by getting a history of the symptoms of the problem. He or she may be able to feel a sausage-shaped lump in the abdomen. To confirm the diagnosis, your doctor may order:

  • Ultrasound or other abdominal imaging. An ultrasound, X-ray or computerized tomography (CT) scan may reveal intestinal obstruction caused by intussusception. Imaging will typically show a “bull’s-eye,” representing the intestine coiled within the intestine. Abdominal imaging also can show if the intestine has been torn (perforated).
  • Air or barium enema. An air or barium enema is basically enhanced imaging of the colon. During the procedure, the doctor will insert air or liquid barium into the colon through the rectum.

In addition, an air or barium enema can actually fix intussusception 90 percent of the time in children, and no further treatment is needed. A barium enema can’t be used if the intestine is torn.

Treatment

child’s doctor will start by getting a history of the symptoms of the problem. He or she may be able to feel a sausage-shaped lump in the abdomen. To confirm the diagnosis, your doctor may order:

  • Ultrasound or other abdominal imaging. An ultrasound, X-ray or computerized tomography (CT) scan may reveal intestinal obstruction caused by intussusception. Imaging will typically show a “bull’s-eye,” representing the intestine coiled within the intestine. Abdominal imaging also can show if the intestine has been torn (perforated).
  • Air or barium enema. An air or barium enema is basically enhanced imaging of the colon. During the procedure, the doctor will insert air or liquid barium into the colon through the rectum.

In addition, an air or barium enema can actually fix intussusception 90 percent of the time in children, and no further treatment is needed. A barium enema can’t be used if the intestine is torn.

Treatment of intussusception typically happens as a medical emergency. Emergency medical care is required to avoid severe dehydration and shock, as well as prevent infection that can occur when a portion of intestine dies due to lack of blood.

Initial care

When your child arrives at the hospital, the doctors will first stabilize his or her medical condition. This includes:

  • Giving your child fluids through an intravenous (IV) line
  • Helping the intestines decompress by putting a tube through the child’s nose and into the stomach (nasogastric tube)

Correcting the intussusception

To treat the problem, your doctor may recommend:

  • A barium or air enema. This is both a diagnostic procedure and a treatment. If an enema works, further treatment is usually not necessary. This treatment is highly effective in children, but rarely used in adults.

Intussusception recurs as often as 10 percent of the time and the treatment will have to be repeated.

  • Surgery. If the intestine is torn, if an enema is unsuccessful in correcting the problem or if a lead point is the cause, surgery is necessary. The surgeon will free the portion of the intestine that is trapped, clear the obstruction and, if necessary, remove any of the intestinal tissue that has died. Surgery is the main treatment for adults and for people who are acutely ill.

In some cases, intussusception may be temporary and go away without treatment.

Nursing Management

  1. Monitor I.V. fluids and intake and output to guide in fluid balance.
  2. Be alert for respiratory distress due to abdominal distention.
  3. Monitor vital signs, urine output, pain, distention, and general behaviour preoperatively and postoperatively.
  4. Observe infant’s behaviour as indicator of pain; may be irritable and very sensitive to handling or lethargic or unresponsive. Handle the infant gently.
  5. Explain cause of pain to parents, and reassure them about purpose of diagnostic tests and treatments.
  6. Administer analgesic as prescribed.
  7. Maintain NPO status as ordered.
  8. Insert nasogastric tube if ordered to decompress stomach.
  9. Continually reassess condition because increased pain and bloody stools may indicate perforation.
  10. After reduction by hydrostatic enema, monitor vital signs and general condition – especially abdominal tenderness, bowel sounds, lethargy, and tolerance to fluids – to watch recurrence.
  11. Encourage follow up care.
  12. Provide anticipatory guidance for developmental age of child.

ACUTE PAIN

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

Assess location, characteristics, onset, duration, frequency, location, and severity of pain; Observe for verbal and nonverbal cues. Provides data about the description of pain which can be used as a guideline for analgesic therapy.
Encourage use of relaxation techniques. Promotes rest and refocus attention thus decreases discomfort.
Apply ice compress as indicated. Relieves pain and decreases edema.
Administer analgesic as ordered. Lessens pain and promotes rest which reduces stimuli and pain.
Educate parents that medications will prevent pain and restlessness and allow for healing. Provides information about the need for pain medications for child’s comfort.

ANXIETY

Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

Nursing Interventions Rationale
Assess source and level of anxiety and
need for information that will relieve anxiety.
Provides information about anxiety level and need to relieve it; concerns include the type of procedure after surgery.
Encourage verbalization of concerns and allow time for parents and child to ask
questions about condition, procedures, recovery.
Provides an opportunity to vent feelings and fears and secure environment.
Encourage parents to stay with the child
during hospitalizations and to assist in care.
Allows parents to participate in the care of the child and continue the parental role.
Provide parents an opportunity to make decisions on care and common routines. Allows for control over situations and maintains familiar routines for care.
Answer questions calmly and honestly;
use pictures, drawings, and models for information.
Promotes better understanding, trust and a calm, supportive environment.
Teach parents about postoperative care
restraints maybe in place; medications will be administered to control pain and promote sedation.
Provides information about postoperative care and what to expect following surgery.
Teach parents relaxation techniques. Decreases anxiety and promotes ability to provide calm and parental care.
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RISK FOR INFECTION

At increased risk for being invaded by pathogenic organisms.

Nursing Interventions Rationale
Assess wound for redness, swelling,
drainage on dressing.
Provides information on the presence of infection or impaired healing.
Apply sterile technique during dressing changes. Prevents contamination by introducing organisms into sterile wound or cavity.
Immobilize arms and legs with restraints, remove periodically; use a bed cradle following surgery. Prevents accidental removal of catheter or contamination of wound if surgical correction is done for a more severe defect.
Inform parents to avoid allowing the child
to straddle toys, play in a sandbox, swim, or engage in rough activities until advised by the physician.
Prevents trauma to or dislodging of sutures or infection.
Teach parents to sponge bathe the child and use loose-fitting clothing. Promotes cleanliness and comfort without constriction.
Educate parents in signs and symptoms of infection. Provides information about the need to report immediately for early management.
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