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Lecture notes, cheat sheets
Pediatric surgery. Acute intussusception (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 13. Acute intestinal intussusception The introduction of a certain section of the intestine into the lumen below (or above) the located area is called invagination. At the same time, at the injection site, the intestine has three cylinders: an external and two internal - intussusception. The top of the intussusceptum is usually called the head, which corresponds to the transition of the inner cylinder to the middle one. An increase in the length of the intussusceptible part of the intestine occurs only due to the screwing of the outer cylinder, the "head" of the intussusceptum remains unchanged. The advancement of the invaginate is accompanied by "tightening" and infringement of the mesentery of the implanted part of the intestine between the inner and middle cylinders (the serous membrane facing each other). In rare cases, "double" intussusceptions are observed, in which the invaginate complex is introduced into the lower intestine, forming 5 cylinders. The introduction of the intestines in children occurs mainly isoperistaltically in the aboral direction. Intussusception, being the most common type of acute intestinal obstruction in children, can occur at any age. In the 1st month of life, it is observed extremely rarely. In infancy between four months and one year of age, intussusception occurs most frequently (80%). The second year of life accounts for about 10% of diagnosed cases of intussusception. The direct cause of intussusception in children of the first year of life is considered to be a change in the dietary regimen characteristic of this age period. Various intestinal diseases (dyspepsia, colitis) are of some importance. In children older than 1 year, mechanical causes of intussusception (polyps, diverticula, tumors of the intestinal wall, stenoses) are relatively often observed. Intussusception can occur at any level of the intestinal tract. Isolated introduction of the large intestine into the large intestine and small intestine into the small intestine is relatively rare, mainly in children over the age of 1 year. Most often, the introduction occurs in the region of the ileocecal angle, which is associated with the anatomical features of this section of the intestine in infancy: greater mobility of the caecum and ileum, the frequent presence of a common mesentery, underdevelopment of the valvular apparatus of the Bauhinian valve, a discrepancy between the diameter of the ileum and its ampulla. Not only the clinical picture, therapeutic measures, but to a certain extent the prognosis of the disease depend on the localization of the primary introduction (the level of formation of the vaginate head) and the nature of further progress. The most acceptable for practical purposes can be considered the classification of X. I. Feldman's intussusceptions: 1) small intestine intussusception (3,5%) - the introduction of the small intestine into the large intestine; 2) ileocolic intussusception (41%) - the introduction of the ileum into the ileum and then into the colon through the Bauginian damper (simple ileocolic intussusception). With further advancement of the intussusceptum, the blind and further located sections of the colon are involved (double, complex ileocolic intussusception); 3) blind colonic invagination (52,7%) - the head of the invaginate is the bottom of the caecum. The appendix and the terminal ileum are passively retracted between the cylinders of the intussusceptum; 4) colonic invagination (2,8%) - the introduction of the colon into the colon; 5) rare forms of intussusception (isolated invasion of the appendix, retrograde intussusception, multiple). Pathological changes in the intestine during invagination depend on the location of the introduction and its duration. Clinical and pathoanatomical studies show that with small intestinal invaginations, necrosis of the intestine usually occurs after 12-24 hours, and with ileocolic invaginations (due to additional incarceration in the area of the Bauhinian valve), necrosis can be expected in the first 6-12 hours. Only with blindness In colonic and colonic invaginations, circulatory disorders develop slowly, and necrosis of the intestinal wall occurs much later. clinical picture The clinical picture of acute intussusception depends on the level of introduction of the intestine, the age of the child and the time that has passed since the onset of the disease. Due to the fact that in children under 1 year of age, intussusception is most often observed in the region of the ileocecal angle (blind-colon and iliac-colon), the clinical picture of these forms in infancy can be considered typical. Small intestinal and large intestine intussusceptions have some features of symptoms that require separate coverage. Retrograde and multiple invaginations are manifested by symptoms of the usual introduction of the corresponding localization. Analysis of the clinical picture of the disease in many cases makes it possible to establish not only the diagnosis of invagination, but also to suggest the form of administration. To a certain extent, X-ray methods of research contribute to this. Clinical picture of cecum-colon and ileo-colon intussusception. The disease begins acutely, among full health. Suddenly, the child begins to worry sharply, screaming convulsively with legs. The face becomes pale, sometimes covered with cold sweat. Older children grab their stomachs with their hands, tend to take a knee-elbow position. The child does not calm down in the mother's arms, refuses to breastfeed. An attack of pain is usually short-lived (3-7 minutes). accompanied by vomiting and stops as suddenly as it started. The child immediately calms down, his behavior becomes normal; sucks mother's breast, interested in toys. After a few minutes (5-10, sometimes 15-20), the attack of pain is repeated with the same force. Again, the child begins to twist his legs, scream, worry sharply, toss and turn in bed or in the arms of his parents. The vomiting is repeated. The "light" intervals between contractions gradually become longer, but the general condition of the child progressively worsens. He becomes lethargic, adynamic, loses interest in the environment, refuses food. Recurring attacks gradually lose their severity, are not accompanied by a sharp motor restlessness. The occurrence of pain depends on the infringement and tension of the mesentery, a sharp spasm of the intestine in the area of intussusception. A periodic increase in peristalsis, followed by a weakening of the motor function of the intestine (a response to a sudden pain irritation), explains the cramping nature of the pain. Their intensity depends on the force of compression by the invaginate cylinders of the implanted mesentery and the degree of its tension. As edema and circulatory disorders increase, pain sensations decrease due to the onset of neurological changes and limitation of invaginate advancement in the aboral direction. In the first hours of the disease, the child may have an independent fecal stool. Often, a normal stool is obtained after an enema, which is given to the child before the doctor's examination by the parents. However, after a chair, the nature of the attacks does not change. A few hours after the onset of the disease, the child has a stool with a large amount of dark blood without feces, but with the obligatory presence of mucus. Sometimes the discharge from the rectum has the character of a bloody jelly-like mucous mass. In some cases, the presence of blood is determined only after an enema. It should be noted that the release of blood with mucus from the anus is one of the most important signs of intussusception. Typical anamnestic data allow suspecting intussusception with a certain reason. No less valuable information for diagnosis is obtained by the doctor during the examination of the child. The general condition upon admission to the clinic in the first hours of the disease is usually assessed by the surgeon on duty as moderate (28%) or severe (66%). The skin and visible mucous membranes are somewhat pale or normal in color. The tongue is moist, slightly coated with white coating. The pulse is frequent (100-120 beats per minute), satisfactory filling. Body temperature is normal or subfebrile. The stomach is of the correct shape, not bloated. Visible peristalsis is usually not observed. Palpation of the abdomen is painless, the tension of the muscles of the anterior abdominal wall is not determined. One of the earliest and most persistent symptoms of intussusception is the presence of a tumor-like formation in the abdominal cavity, which is palpable along the colon (corresponding to the progress of the intussusception), more often in the right hypochondrium. The intussusceptum is palpated as an elongated smooth roller, soft elastic consistency moderately mobile. In most cases, palpation or displacement of the intussusceptum is accompanied by minor pain sensations (short-term anxiety of the child, resistance to examination) or causes a recurrence of an attack of sharp pains. With the restless behavior of the child, it is extremely difficult to obtain the correct diagnostic data when examining the abdomen. In such cases, it is necessary to find a way to calm the child. You can wait a while until the attack of pain passes and the patient falls asleep. In rare cases (more often with inept examination) it is necessary to resort to short-term anesthesia or to relax the muscles of the abdominal wall by introducing short-acting muscle relaxants. It should be remembered that only an experienced anesthesiologist can use relaxants for the diagnosis of intussusception. An auxiliary symptom, which is determined by palpation of the abdomen in almost half of infants with cecum-colon and ileo-colon intussusception, is the desolation of the right iliac region due to displacement of the caecum during its implementation. All children with suspected intussusception should have a digital examination through the rectum. This simple technique often helps the diagnosis, allowing you to detect some of the signs characteristic of intussusception. If the child has an obstruction, then the doctor may sometimes note a noticeable relaxation of the sphincter when inserting a finger into the rectum. This symptom is not permanent, but it should be taken into account in the examination complex. For invagination, the absence of feces in the rectal ampulla (empty ampule) is quite characteristic. With a low location of the intussusceptum, the head of the implanted intestine can be detected with a fingertip. Sometimes, with a bimanual examination, it is possible to palpate a "tumor" that is not determined by simple palpation of the abdomen through the abdominal wall. At the end of the examination, it is very important to look for rectal spotting that stains the finger or appears after it is removed from the anus. The presence of dark blood and mucus without feces can be considered one of the most reliable symptoms of intussusception obtained when examining the rectum with a finger. The clinical picture performed is typical for early manifestations of intussusception (the first 6-12 hours). If the diagnosis is not made during this period, then in some children the severity of the symptoms of obstruction begins to smooth out (stage III). The behavior of patients changes, they worry less, their cry becomes weak, and the phenomena of intoxication and dehydration increase. Body temperature rises to subfebrile levels. The tongue is dry and covered with a brown coating. There comes an apparent subsidence of the phenomena of obstruction. By the end of the 2nd - beginning of the 4th day of illness, the behavior of the infant bears little resemblance to that noted in the initial stages of intussusception. Sharp periodic anxiety is replaced by complete indifference to the environment. The phenomena of intoxication are increasing. Body temperature rises, pulse is frequent, weak filling. Signs of peritonitis and intestinal paresis appear. The abdomen is swollen, tense, there is no stool, gases do not pass away. By digital examination through the rectum, you can obtain symptoms characteristic of intussusception (flaccid sphincter, empty rectal ampulla, palpation of the head of the intussusception, discharge of blood and mucus behind the removed finger). Plain radiographs of the abdominal cavity show multiple horizontal levels - Kloiber's cups. The diagnosis of intussusception during a late initial examination is usually extremely difficult. The clinical picture of small intestinal intussusception has some features depending on the severity of neurotrophic disorders in the intestine. The first signs of beginning implantation in infants will be severe anxiety and, as a rule, a high-pitched, loud cry. Older children complain of sharp pain. The child's face turns pale and vomits, usually repeatedly. The duration of anxiety and screaming varies (10–20 min). Then the patient calms down somewhat, but the typical “light” period does not occur, the child does not take the pacifier, refuses the mother’s breast, older children note a subsidence, but not the disappearance of pain. After a short period of time, a sharp anxiety arises again, the child screams, takes a forced position. Vomiting is repeated, vomit is colored with bile, has an unpleasant fecal odor. Pain attacks after a few hours from the onset of the disease become less prolonged and intense, but the general condition of the patient progressively worsens. The pulse is frequent, weak filling, arterial pressure decreases. The child becomes lethargic, adynamic, groans at times, the body temperature rises to 37,5-38 C. The skin is pale, with a grayish tinge. The stool remains normal for a long time, bloody discharge from the rectum appears after 12-24 hours or later. The abdomen is not swollen, soft. On palpation, the intussusceptum is palpated with certain difficulties, since its location is unstable (usually in the navel), it is mobile and usually of relatively small size. Examination of the abdominal cavity is complicated by persistent pain in the abdomen, in connection with which the child resists examination, actively strains the abdominal press. To identify intussusception in doubtful cases, one should resort to short-term anesthesia. A digital examination through the rectum provides less information than when inserted into the ileocecal angle. Only the desolation of the rectal ampulla and some relaxation of the sphincter can serve as indirect signs of obstruction. Intussusceptum (even with bimanual examination) is not determined. After the finger removed from the rectum, some stool without blood is usually excreted. Only in the later stages can you get dark ("high") blood with an admixture of mucus. Clinical picture of colonic intussusception. The introduction of the large intestine into the small intestine is manifested by less pronounced clinical signs than with other types of invagination. Especially erased symptomatology is observed in older children, who rarely show a typical set of signs of intussusception. In an infant, the disease begins with a mild short-term anxiety. The general condition remains unchanged, pain attacks are relatively rare, there may be a single vomiting. Parents do not always pay due attention to the change in the behavior of the child, and only early (in the first hours from the onset of pain attacks) the appearance of blood in the stool makes you see a doctor. In older children, the onset of the disease may be different. When examining a patient, it is always possible to feel the invaginate, which is localized in the left upper quadrant of the abdomen or the left iliac region. Finger examination through the rectum often allows you to determine the head of the intussusceptum. A significant amount of raspberry-colored mucus and liquid blood is released behind the extracted finger. Fecal masses, as a rule, do not exist. In rare cases of the introduction of the distal colon, the head of the intussusceptum falls out through the anus. The mucous membrane of the prolapsed intestine is cyanotic, somewhat edematous, with areas of hemorrhage. Isolated intussusception of the appendix in clinical manifestations resembles acute appendicitis. The disease occurs mainly in children older than 4-5 years. Typical main signs of intussusception are either absent or not clearly expressed. Isolated invagination of the appendix is manifested by pain in the right iliac region, which at first is usually not very intense. Pain attacks are replaced by short-term relief of pain. However, the child cannot always accurately characterize these "light" intervals, and the doctor does not attach due importance to them. If in the first hours, with a targeted survey, it is possible to establish paroxysmal pain, then after a few hours, they become permanent. At this time, the child's behavior changes, he refuses food, stops outdoor games that are usual for this age. The general condition remains satisfactory for a long time. Body temperature is normal. Vomiting is more often single. The stool is normal, urination is painless. The tongue is moist, clean, or slightly coated with white. The pulse is rapid, satisfactory filling. The abdomen is of the correct form, participates in the act of breathing, on palpation it is soft in all departments, somewhat painful in the right iliac region. Some patients have a slight tension of the rectus abdominis muscles on the right, which becomes more distinct in the later stages from the onset of the disease. Shchetkin-Blumberg's symptom in older children in some cases is mildly positive. Palpation of the lumbar regions is painless. A digital examination through the rectum does not reveal symptoms characteristic of intussusception. There is no bloody discharge from the rectum. Data from laboratory studies in children with intussusception usually do not represent significant features. X-ray methods of research Non-contrast survey radiography of the abdominal cavity does not provide significant assistance in establishing the diagnosis of intussusception and reveals only some indirect signs of obstruction (absence of gas in the large intestine, a homogeneous shadow due to intussusceptum, several loops of the small intestine swollen with gas with the presence of single horizontal levels of fluid). However, a similar x-ray picture in children, especially infancy, can be observed in other diseases. More valuable data for the diagnosis of intussusception is provided by a contrast study of the colon with the introduction of air. An indication for this method of research is a doubt in the diagnosis or the need to clarify the type of invagination, but only in cases where the use of a conservative method of treatment is acceptable (in infants and only in the first 12 hours from the onset of the disease). Differential diagnosis Differential diagnosis has to be carried out with diseases accompanied by bouts of abdominal pain, vomiting, bloody discharge from the rectum, the presence of a tumor-like formation in the abdominal cavity. Various combinations of these symptoms at the first examination of a child with intussusception are often mistakenly interpreted by a pediatrician as a manifestation of dysentery, dyspepsia, appendicitis and other acute diseases. This is primarily due to insufficient knowledge of the variants of the clinical picture and the characteristics of the course of invagination, as well as an incomplete examination of the patient. Less often, children are diagnosed with intussusception or other surgical conditions that have similar symptomatology. In infants, intussusception is most often mistaken for dysentery. In such cases, a carefully collected anamnesis, a correct assessment of the child's behavior and objective examination data almost completely exclude the possibility of diagnostic errors. For dysentery, such an acute onset of the disease that occurs in the midst of complete health is uncharacteristic and is accompanied by severe bouts of abdominal pain, followed by "light" intervals, which is typical for intussusception. Differentiating these diseases, it is necessary to carefully examine the discharge from the rectum. Dysentery is characterized by the presence of liquid feces and mucus, mixed with lumps of pus, with streaks or blood clots. With intussusception, liquid dark blood with mucus (sometimes in large quantities) is released from the anus, but without feces. A cylindrical (sausage-shaped) formation palpable in the abdominal cavity confirms the diagnosis of implantation. Examination with a finger through the rectum often reveals some spasm of the sphincter in dysentery. With intussusception, you can feel the "head" of the intussusceptum with your fingertip. In rare cases of difficult diagnosis, the use of additional research methods is indicated: palpation of the abdominal cavity under anesthesia, contrast X-ray examination of the colon with air. Abdominal syndrome in Henoch-Schonlein disease often has manifestations similar to intussusception: sudden attacks of abdominal pain, vomiting, and bloody stools. An erroneous diagnosis of intussusception, entailing a vain laparotomy, significantly worsens the prognosis in Henoch-Schonlein disease. Even more severe consequences are caused by the unrecognized introduction of the intestines, which is observed in hemorrhagic vasculitis. The abdominal syndrome of Shenlein-Genoch disease is characterized by inconstancy and instability of symptoms, while with intussusception they persist and grow. A clinical feature of uncomplicated forms of abdominal purpura can be considered a discrepancy between the severity of the general condition of the patient and local signs of the disease. Children may vomit with blood, which is uncommon for intussusception. Intestinal bleeding in Henoch-Schonlein disease occurs along with fecal stools, while intussusception is characterized by the presence of blood and a large amount of mucus. The age of the patients should also be taken into account. Intussusception in Henoch-Schonlein disease is most often observed in children after 3 years of age. The main objective symptom of invagination is the presence of a mobile and painful sausage-like tumor in the abdominal cavity. To detect it in restless patients, palpation of the abdomen under short-term anesthesia should be performed. In older children, intussusception often has to be differentiated from acute appendicitis. This occurs when the most typical symptoms of implantation are absent at the onset of the disease. Symptoms of intussusception in older children are usually less pronounced than in typical cases in infants, however, consistent clinical examination reveals characteristic signs of the introduction of the intestines. In contrast to appendicitis during invagination, abdominal pain is cramping in nature with "light" intervals. Signs of intestinal obstruction (stool retention, gases) are also not characteristic of appendicitis. With intussusception, the abdomen is always soft, while tension in the abdominal wall is the most constant symptom of acute appendicitis. Only with a late admission of the patient, when a child with intussusception develops the phenomena of peritonitis, the differential diagnosis is practically impossible, and the true cause of the catastrophe in the abdominal cavity is clarified during an urgent laparotomy. Isolated invagination of the appendix is accompanied by a clinical picture similar to that observed in acute appendicitis, which usually leads to misdiagnosis. Cramping pain attacks with short-term intervals of pain relief often occur with appendicitis, and the introduction of the process may be accompanied by local pain on palpation and tension of the rectus muscles of the abdominal wall in the right iliac region; the final diagnosis in such cases is established during the operation. The most difficult differential diagnosis of intussusception with peptic ulcer of Meckel's diverticulum or intestinal hemangioma. In these diseases, intestinal bleeding is the first and main symptom. Unlike intussusception, bleeding is not preceded by pain attacks, the child remains calm. Older children do not complain about pain. Bleeding is usually so significant that symptoms of acute anemia are soon revealed, not observed during intussusception. The secreted blood from ulcers of Meckel's diverticulum or hemangiomas does not contain mucus, which is characteristic of intussusception. Palpation in the abdominal cavity does not reveal a sausage-like tumor, which can almost always be felt during intussusception (in doubtful cases or when the child is worried, palpation is performed under short-term anesthesia). X-ray examination is of little help in differential diagnosis. Colon polyposis is often accompanied by massive bleeding. However, the pain syndrome in such children is not observed, the stool remains fecal, with an admixture of scarlet or darker blood with clots; marked anemia. Finger examination through the rectum, sigmoidoscopy and irrigography clarify the diagnosis. Blockage of the intestinal lumen by a ball of ascaris or a tumor is relatively difficult to distinguish from intussusception. The absence of bleeding through the rectum makes it possible to some extent to doubt the presence of the introduction of the intestines, however, with small intestinal intussusception, blood in the stool may be absent for a long time. The shape and consistency of the tumor palpable in the abdominal cavity have some difference - during intussusception it is oblong, smooth, moderately mobile. A twisted cyst of the abdominal cavity, in contrast to invagination, is accompanied by non-intensive pains of a permanent nature. There are no pronounced symptoms of intestinal obstruction (gas passes, normal stools). In the first hours of the disease, the cyst can be felt through the abdominal wall. It differs from intussusceptum in its rounded shape and sharp soreness. In later periods, the phenomena of peritonitis develop, the abdomen becomes inaccessible for palpation, which creates serious difficulties for differential diagnosis. An erroneous diagnosis in such cases does not cause serious consequences - both diseases equally need urgent surgical intervention. Treatment The main principle of treatment of invagination of the intestines is possibly early disinvagination. Surgical tactics and methods of therapeutic measures depend on the localization and form of implementation, the timing of admission and the age of the child. There are two main methods of disinvagination - conservative and operative. Each of these non-competing methods has strict indications and contraindications, depending on which tactics of individual choice of treatment method are carried out. Conservative treatment of intussusception is relatively simpler and more atraumatic than the surgical method. It is based on the principle of mechanical action on the intussusception of liquid or air introduced under pressure into the colon. There are a significant number of reports in the literature about the successful use of high enemas with barium suspension, carried out under the control of an X-ray screen. However, the use of this technique is relatively difficult, and the ability to clarify the form of intussusception is limited and it is difficult to determine the fluid pressure that has arisen in the intestine. In this regard, recently, for the conservative treatment of invagination, mainly dosed air injection into the colon is used. The method recommended by the authors saves the child from laparotomy and possible postoperative complications, reduces the time spent in the hospital. However, as observations and literature data show, conservative treatment should be limited by several factors. 1. Technically, small intestinal intussusception cannot be straightened. The impact of air injected through the rectum (or a suspension of barium sulphate) does not apply with sufficient force to the invaginate located in the small intestine. 2. Ileocolic implantation due to infringement in the Bauhinian valve of the intussusceptum and its edema is not dealt with by conservative measures even at the earliest dates of the child's admission to the clinic. The establishment of this form of invagination is possible only with a sufficiently qualified X-ray examination of the colon with the introduction of air during attempts at conservative treatment. 3. Conservative straightening is dangerous after 12 hours from the onset of the disease or with an unclear history, since necrosis of the intestine in the region of the intussusceptum head is possible. A false impression about the spreading of the introduction can lead in such cases to serious consequences. Later terms of conservative treatment (up to 24 hours) are acceptable in cases of accurate diagnosis of cecum-colon or colonic intussusception. 4. Conservative treatment is ineffective in the presence of mechanical causes that cause invagination (polyps, diverticula). Straightening achieved conservatively in such cases will inevitably be complicated by a relapse of the disease. Due to the fact that mechanical causes occur mainly in children older than 1 year, and the presence of a polyp or diverticulum can be established only when examining the intestine during surgery, we consider conservative treatment of intussusception contraindicated at this age. 5. Recurrence of intussusception of any form and localization should not be dealt with conservatively, since even in infants, re-implantation is usually associated with the presence of mechanical causes, the prompt elimination of which is necessary to prevent a new recurrence of the disease. Thus, conservative treatment of intussusception is indicated in infants with early admission to the hospital (up to 12 hours from the onset of the disease) and the localization of the intussusceptum head in the colon. The use of a conservative method is permissible only in a specialized pediatric surgical hospital and only by a surgeon who has sufficient experience in clinical and radiological diagnosis and surgical treatment of intussusception in children. Conservative treatment of intussusception by injecting air into the colon. 30-40 minutes before the intervention, the patient is injected subcutaneously with a solution of promedol and atropine at the age dosage. Straightening of intussusception produced in the x-ray room. Restless children are given short-term mask anesthesia with nitrous oxide. The child is placed horizontally on the table of the X-ray machine and air is introduced into the colon. Clinically, the straightening of invagination is accompanied by a noticeable improvement in the general condition of the patient. The child ceases to worry, willingly takes the mother's breast, quickly falls asleep. On palpation of the abdomen, the intussusceptum is not determined. The chair appears in 5-12 hours. Partial expansion is characterized by: 1) preservation of the invaginate shadow on the radiograph with its movement in the oral direction; 2) a change in the contours and shape of the shadow of the invaginate; 3) air filling of the caecum, but the absence of gas in the small intestine. In such cases, the child continues to worry, refuses food. Palpation can sometimes determine the intussusceptum, the size of which becomes smaller and the localization is different (closer to the iliac region). An unsuccessful attempt at disinvagination is radiologically detected by the presence of a shadow of an invaginate of the original size and shape, located in the same place. The contours of the colon are not completely filled with air, gas in the small intestine is not traced. The clinical picture after an unsuccessful attempt at conservative straightening of the intussusceptum does not change compared to that before the start of treatment. In case of an unsuccessful attempt or partial straightening of the intussusception, the child must be immediately transferred to the operating room and proceed with surgical intervention. The management of the patient after conservative straightening of intussusception does not require special therapeutic measures. The patient is placed in the recovery room for observation. The slightest changes in behavior (anxiety, crying, vomiting) require a careful examination of the child by a surgeon (possible recurrence of the disease or a reviewed partial expansion of the intussusception). An hour later, they begin to give the patient water, if there is no vomiting, they prescribe the usual diet for his age. Children are discharged home after a conservatively straightened intussusception in 1-2 days. Parents are warned about the need to immediately consult a doctor if the child's anxiety appears. Preoperative preparation should be short-term and intensive, individually planned for each patient. In rare cases, if the general condition is satisfactory, one should limit oneself to general surgical measures - gastric lavage, drug preparation for anesthesia. If upon admission the child exhibits severe intoxication, dehydration, and peritonitis, then preparation for surgery is carried out within 2-3 hours, aiming to improve the general condition. To do this, a venesection is performed and intravenous administration of 10% glucose solutions and hemodesis begins. At the same time, antipyretics are prescribed (at body temperature above 38 C). The operation is performed under endotracheal anesthesia with controlled breathing and protective blood transfusion. Postoperative treatment. The patient is placed in an intensive care unit, cardiac medications, broad-spectrum antibiotics, and oxygen therapy are prescribed. All children undergo prolonged epidural anesthesia for 4-5 days to prevent and treat intestinal paresis. Anti-adhesion physiotherapy is prescribed. The intravenous drip infusion apparatus is left for 1 day, and if parenteral nutrition is necessary, for longer periods. To detect relatively frequent hyperthermia, the child’s body temperature is measured every 2 hours. An increase in temperature above 38 °C is an indication for antipyretic measures. Feeding of patients in whom the operation ended with disinvagination begins 6 hours after the intervention. Breastfed children are prescribed expressed human milk 15-20 ml every 2 hours. After a day, in the absence of vomiting and improvement in general condition, 10-15 ml of milk is added to each feeding, bringing to the 4-5th day to a normal amount corresponding to the mass body and age of the child. These days, the missing amount of fluid is administered intravenously. If vomiting occurs after the first feeding, then the child is prescribed parenteral nutrition for a day, gastric lavage every 3-4 hours, and only after that fractional feeding begins again. Older children 6-8 hours after the disinvagination operation are allowed to drink warm tea or glucose in the amount of 30-50 ml, prescribing parenteral nutrition at the same time. From the 2nd day, if there is no vomiting, a liquid diet is used, transferring to the postoperative table after 2-3 days, and the usual diet is allowed from the 6-7th day. For children who underwent resection of the intestine, parenteral nutrition is carried out for three days, allowing them to drink a limited amount of liquid from the second day. Then a liquid postoperative table is prescribed and the diet is continued for up to two weeks. With an uncomplicated postoperative period, the child is discharged on the 12-14th day. Complications in the postoperative period are observed relatively often. Most of them are associated with late admission of children to the hospital or erroneous surgeon tactics. Hyperthermia appears in the first hours after surgery due to the adsorption of toxic products from the invaginated segment of the intestine. Timely preventive measures taken before surgery and at the beginning of the temperature increase, the correct set of pharmacological and physical cooling measures make it possible to eliminate this serious complication in almost all cases. Intestinal paresis, which occurs due to extensive circulatory disorders of the invaginated intestine, intoxication and, in some cases, peritonitis, was observed in 1/3 of the operated patients. In advanced cases, when the child has severe intestinal paresis, systematic suction of stagnant contents from the stomach is necessary. Enterostomy with intestinal paresis experts consider contraindicated. Suppuration of the postoperative wound. The introduction of a rubber graduate into the subcutaneous tissue during surgery for 1-2 days usually limits the possibility of extensive suppuration. However, in some cases, inflammation of the wound develops, despite the ongoing conservative measures. Appear: edema, hyperemia of the skin, the general condition of the child worsens, the body temperature rises. In such cases, part of the skin sutures is removed and a suction bandage is applied. After the inflammation subsides, the edges of the wound are pulled together with strips of adhesive tape. Healing occurs by secondary intention. In some cases, suppuration of the postoperative wound can lead to bowel eventration. The main measures to prevent this complication are the fight against intestinal paresis, antibiotic therapy and physiotherapy. The resulting eventration is an indication for urgent surgery under general anesthesia. Peritonitis in the postoperative period occurs due to the failure of the anastomotic sutures or necrosis of the intestinal wall with an incorrect assessment of its viability during disinvagination. The general condition of the child progressively worsens, the body temperature rises, vomiting occurs, the pulse becomes frequent, the tongue is lined, dry. Exsicosis and intoxication develop. Increased intestinal paresis. In blood the considerable leukocytosis with shift to the left comes to light. The abdomen is tense, sharply painful on palpation. The diagnosis of peritonitis is an indication for a second laparotomy. In a severe general condition, a short-term intensive preoperative preparation is prescribed (transfusion of liquids, blood, antipyretics). Surgical intervention is performed under endotracheal anesthesia and protective blood transfusion. In the postoperative period, broad-spectrum antibiotics are prescribed (parenterally and through irrigators into the abdominal cavity), physiotherapy, systematic gastric lavage, and prolonged epidural anesthesia. Authors: Drozdov A.A., Drozdova M.V. << Back: Recurrent congenital intestinal obstruction (Circular intestinal stenosis. Ledd syndrome. Internal abdominal hernias. Compression of the intestinal lumen by cystic formations) >> Forward: Adhesive intestinal obstruction (Early adhesive intestinal obstruction. Late adhesive intestinal obstruction)
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