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Intussusception (in-tuh-suh-SEP-shun) is a serious disorder in which part of the intestine (small intestine or colon) slides into another part

of the intestine >often blocks the intestine, preventing food or fluid from passing through >most common cause of intestinal obstruction in children and rare in adults >Most cases of adult intussusception are the result of an underlying medical condition >In contrast, most cases of intussusception in children have no demonstrable cause >Intussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction >2 variants: idiopathic intussusception, which usually starts at the ileocolic junction and affects infants and toddlers, and enteroenteral intussusception (jejunojejunal, jejunoileal, ileoileal), which occurs in older children y occurs most often in babies between 5 and 10 months of age (80% of cases occur before a child is 24 months old) affects between 1 and 4 infants out of 1,000 is more common in boys than in girls

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A lump in the abdomen Swollen (distended) abdomen Vomiting, possibly vomiting bile (yellowbrown or greenish fluid) Diarrhea Fever Dehydration Lethargy

Adults Although rare, intussusception can happen in adults. Signs and symptoms of intussusception in adults may come and go (intermittent symptoms), or they may be unrelenting. They may include: y y y y y y y Changes in the frequency of bowel movements An urgent need to move your bowels (urgency) Rectal bleeding Crampy abdominal pain Abdominal pain or swelling Nausea Vomiting

>Other symptoms may include: y y y y abdominal swelling or distention vomiting vomiting up bile, a bitter-tasting yellowishgreen fluid passing stools (or poop) mixed with blood and mucus, known as currant jelly stool grunting due to pain

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Signs and Symptoms >Infants and children with intussusception have intense abdominal pain, which often begins very suddenly and causes loud, anguished crying causing the child to draw the knees up >A triad of signs and symptoms: vomiting, abdominal pain, and passage of blood per rectum >The pain is usually intermittent, but recurs and may become stronger Signs and symptoms of intussusception in children include: y y Severe abdominal pain that comes and goes (intermittent pain) Stool mixed with blood and mucus (sometimes referred to as "currant jelly" stool because of its appearance)

y Causes

>In infants, the causes of intussusception are unknown because it is seen most often in spring and fall > Bacterial or viral gastrointestinal infections may cause swelling of the infection-fighting lymph tissue that lines the intestine, which may result in pulling one part of the intestine into the other. >For most cases of intussusception in children, the cause is unknown. Possible triggers may be: y Viral infection

A noncancerous growth or a cancerous tumor in the intestine Diagnosis and Treatment

>In kids younger than 3 months or older than 5 years, intussusception is more likely to be caused by an underlying condition such as enlarged lymph nodes, a tumor, or blood vessel abnormality in the intestines In adults, the cause of intussusception may be: y y y y Noncancerous (benign) or cancerous (malignant) growths Scar-like tissue in the intestine (adhesions) Surgical scars in the small intestine or colon Problems with the movement of food through the digestive tract (motility disorders, such as irritable bowel syndrome, gastroparesis and Hirschsprung's disease) Long-term (chronic) diarrhea

>abdominal X-ray, which may or may not show a blockage in the intestines >An ultrasound also might be done to help make the diagnosis To confirm a diagnosis of intussusception, your child may need: y A physical exam. The doctor may suspect intussusception or another type of intestinal obstruction if your child has a lump in the abdomen, along with intermittent pain or inconsolable crying. Blood or urine tests. Your child's doctor may order blood and urine tests, as well as a fecal occult blood test, which checks for blood in the stool. Ultrasound or other abdominal imaging. Taking images of your abdomen or your child's abdomen with an ultrasound, X-ray or computerized tomography (CT) scan may reveal intestinal obstruction caused by intussusception. Abdominal imaging also can show if the intestine has been torn (perforated). Air or barium enema. An air or barium enema is basically a colon X-ray. The doctor will likely use air first and use barium only if necessary as a second choice. During the procedure, the doctor will insert air or liquid barium into your colon or your child's colon through the rectum. This makes the images on the X-ray clearer. Sometimes an air or barium enema will correct intussusception, and no further treatment is needed. A barium enema can't be used if the intestine is torn.

Complications >the risk of complications, which include irreversible tissue damage, perforation of the bowel, >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 peritonitis, an infection of the lining of the abdominal cavity. Risk factors for intussusceptions include: y Age. 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 3 months and 6 years, with the majority of cases occurring in children younger than 1 year. Sex. Intussusception affects boys more often than girls. Abnormal intestinal formation at birth. Malrotation, a condition present at birth (congenital) in which the intestine doesn't develop correctly, also is a risk factor for intussusception. A prior history of intussusception. Once you've had intussusception, you're at increased risk to develop it again. y

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

Volvulus >twisting of the intestine at least 180 degrees on itself. It's marked by sudden onset of severe abdominal pain. >Volvulus results in blood vessel compression and causes obstruction both proximal and distal to the twisted loop. >occurs in a bowel segment long enough to twist and most common area, particularly in adults, is the sigmoid colon; the small bowel is a common site in children. Other common sites include the stomach and cecum. >A volvulus is a condition in which the bowel becomes twisted causes obstruction of the intestine, and also often cuts off the blood supply to the intestine. The resulting death of some or all of the intestine may in turn cause the person to die. >due to a redundant sigmoid colon or a mobile ascending colon, and may be precipitated by an unusual amount of residue in the involved portion of the bowel CAUSES >It may be caused by the stomach being in the wrong position, a foreign substance, or an abnormal joining of one part of the stomach or intestine to another >It most commonly occurs in the sigmoid colon, the ileocecal area, or the small intestines >Obstruction, pain, and distention occur quickly and, if not relieved, often result in gangrene Symptoms >Colonic distention and pain appear rapidly as a result of the obstruction >abdominal pain and vomiting >A volvulus of the large intestine will also cause constipation and swelling of the abdomen. Diagnosis >In the case of a sigmoid volvulus there is a classical picture on barium enema X-ray that includes a "bird's-beak" appearance or sign, whereby the proximal rectum narrows down toward the point of the obstruction, thus creating a beaklike projection

>Confirmatory Abdominal X-rays may show multiple distended bowel loops and a large bowel without gas. In midgut volvulus, abdominal X-rays may be normal. >In cecal volvulus, barium from a barium enema fills the colon distal to the section of cecum; in sigmoid volvulus, barium may twist to a point and, in adults, take on an "ace of spades" configuration. >Abdominal x-ray of dilated colon, Barium fills the rectum to the rectosigmoid > "beak-like" appearance of the rectosigmoid, which is typical of a sigmoid volvulus. Treatment >The severity and location of the volvulus are considered when determining therapy >For children with midgut volvulus, surgery is required >For adults with sigmoid volvulus, nonsurgical treatment includes proctoscopy to check for infarction and reduction by careful insertion of a flexible sigmoidoscope to deflate the bowel >Expulsion of flatus and immediate relief of abdominal pain indicate success of nonsurgical reduction >If the bowel is distended but viable, surgery consists of detorsion (untwisting); if the bowel is necrotic, surgery includes resection and anastomosis. Prolonged total parenteral nutrition and l.V. administration of antibiotics are usually necessary. Sedatives may be needed.

Definition of Hernia >A hernia is an abnormal protrusion, or bulging out, of part of an organ through the tissues that normally contain it. In this condition, a weak spot or opening in a body wall, often due to laxity of the muscles, allows part of the organ to protrude. >A hernia occurs when part of an internal organ or body part protrudes through an opening into another area where it shouldn't

> most common occur when a piece of the intestine pokes through a weak area in the wall of the abdomen causes an abnormal bulge under the skin of the abdomen, usually near the groin or the navel. y Types Of Hernia y Inguinal hernia A piece of intestine pokes through a weakness in the inguinal canal, a natural passageway through the abdominal wall near the groin. In males, the inguinal canal is the normal route for the testes to descend into the scrotum before birth. Inguinal hernias account for 75% of all hernias, and are 5 times more common in males than females. They usually are present at birth, but can develop in adults. Indirect inguinal hernia: This affects men only. A loop of intestine passes down the canal from where a testis descends early in childhood into the scrotum. If neglected, this type of hernia tends to increase progressively in size (a "sliding hernia") causing the scrotum to expand grossly. Direct inguinal hernia: This affects both sexes. The intestinal loop forms a swelling in the inner part of the fold of the groin. Femoral hernia A piece of intestine pokes through the passage that normally is used by large blood vessels (the femoral artery and vein) when they pass between the abdomen and the leg. This type of hernia causes a bulge in the upper thigh, and is more common in women than men. This affects both sexes, although most often women. An intestinal loop passes down the canal containing the major blood vessels to and from the leg, between the abdomen and the thigh, causing a bulge in the groin and another at the top of the inner thigh. Epigastric, or ventral, hernia A piece of intestine bulges through a weakness in abdominal muscles between the navel and breastbone. Most people with ventral hernias are men, usually between ages 20 and 50. Umbilical hernia A piece of intestine bulges through the abdominal wall next to the navel. The area of weakness in the abdominal wall can be very small (less than half an inch) or it can be as large as 2 inches to 3 inches. Umbilical hernias are common in newborns, but may disappear gradually over time.

This affects both sexes. An intestinal loop protrudes through a weakness in the abdominal wall at the navel (but remains beneath the skin). Parumbilical hernia This looks like an umbilical hernia, but it is not present at birth. Parumbilical hernias often are caused by long-standing strain on the abdominal muscles, which commonly occurs in people who are overweight, or in women who have been pregnant many times. Incisional hernia A piece of the intestine bulges through a weakness in the abdominal wall in an area where surgery has been done previously. This is a hernia that occurs at the site of a surgical incision. This is due to strain on the healing tissues due to excessive muscular effort, lifting, coughing, or extreme pressure. Hiatal hernia This hernia involves the stomach rather than the intestines. A piece of the stomach slips through a normal opening in the diaphragm and passes upward into the chest. This affects both sexes. A loop of the stomach when particularly full protrudes upward through the small opening in the diaphragm through which the esophagus passes, thus leaving the abdominal cavity and entering the chest.

Description of Hernia >Hernias cause pain and reduce general mobility >They never cure themselves, even though some can be cured (at least temporarily) by external manual manipulation >Depending on the nature of the protruding organ and the solidity of the structure through which it is protruding, a hernia may cause complications that are medically dangerous. >One major danger of a hernia is that if bowel is contained within the protruding loop it may hinder or stop the flow through the intestine (occlusion) >More serious still, if the loop itself becomes twisted outside its containing structure, or compressed at the point where it breaks through that structure (a strangulated hernia), the blood supply to the loop will also cease and the entire hernia will undergo tissue death (necrosis). This requires immediate emergency surgery.

Causes and Risk Factors of Hernia >Umbilical hernias can be present from birth, but most happen later due to pressure on openings or weaknesses in the abdominal cavity or wall >Hernias tend to run in families, and can be caused by such things as coughing, straining during elimination, lifting heavy objects, accumulation of fluid in the abdominal cavity, and obesity >Chronic lung disease can also cause a hernia. Symptoms of Hernia >depending on the cause and the structures involved >Most begin as small, hardly noticeable breakthroughs. At first, they may be soft lumps under the skin, a little larger than a marble; there usually is no pain >Gradually, the pressure of the internal contents against the weak wall increases, and the size of the lump increases. >Early on, the hernia may be reducible - the protruding structures can be pushed back gently into their normal places. If those structures, however, cannot be returned to their normal locations through manipulation, the hernia is said to be irreducible, or incarcerated. > The location of this bulge depends on the specific type of hernia. For example, an inguinal hernia appears as a bulge in the groin, while an umbilical hernia appears as a bulge near the navel >Some hernias can cause twinges of pain or a pulling sensation, while others do not cause any symptoms >A hernia is considered "incarcerated" if a portion of intestine becomes trapped and is unable to slide back into the abdomen. > Rarely, the trapped intestine can strangulate twist and die because its blood supply is cut off. This causes severe pain and requires immediate treatment. Treatment of Hernia >For small, non-strangulated and non-incarcerated hernias, various supports and trusses may offer temporary, symptomatic relief. However, the best treatment is herniorrhaphy (surgical closure or repair of the muscle wall through which the hernia protrudes).
Treatment >standard surgery, surgery using mesh plugs or patches, and surgery done using a telescope through a small incision (laparoscopic surgery). If you are considering having a hernia repaired, you and your surgeon will discuss which technique is most appropriate for you. Hernias that become incarcerated or strangulated require immediate medical attention. Your doctor will try to push the hernia back through the hole in which it is stuck. If this can't be done, emergency surgery may be needed. Otherwise, most hernia repairs can be done on an outpatient basis at a convenient place and time. Umbilical hernias usually are not treated surgically unless the hernia continues past the child's third or fourth birthday, becomes larger, causes symptoms or strangulates. Umbilical hernias are more likely to need surgery if the opening through which the hernia passes is greater than 2 centimeters. Hiatal hernias that are not causing symptoms of acid reflux do not need to be treated. When symptoms occur, treatment is designed to decrease reflux. Surgery may be recommended for large hiatal hernias that cause continuing symptoms, or for hernias that become stuck inside the chest.

Diagnosis Rarely, you may have symptoms of a hernia, but the doctor will be unable to find it at the time of examination. In these circumstances, your doctor may recommend a computer tomography (CT) scan or an ultrasound of the abdomen. Expected Duration Most hernias stay the same or get larger over time. Umbilical hernias, however, are a special case. Most small umbilical hernias that appear before a baby is 6 months old will disappear before the child's first birthday. Even larger umbilical hernias may disappear before age 3 or 4. Prevention To prevent hernias associated with increased abdominal pressure, avoid activities that cause abdominal strain, such as lifting heavy weights. Losing weight is helpful if you are overweight. If you frequently need to strain when you move your bowels, speak to your doctor. Your doctor may prescribe stool softening medication or suggest that you modify your diet to include more high fiber foods.