Case Study: Intussusception & Peritonitis Surgical Review
1. Features of Peritonitis
| Clinical Feature |
Pathophysiological Basis |
| No movement with respiration |
Diaphragmatic splinting due to pain from inflamed peritoneum. |
| Rigidity |
Reflex contraction of abdominal wall muscles in response to peritoneal irritation. |
| Tenderness (generalized & rebound) |
Localized and generalized peritoneal inflammation; rebound from sudden release increases peritoneal stretch, triggering pain. |
2. When to Send Intussusception Patient to Surgery Without Imaging
| Clinical Scenario |
Justification for Immediate Surgery |
| Sausage-shaped mass + Peritonitis |
Suggests bowel ischemia or perforation → laparotomy is mandatory. No imaging delay. |
Branch-Off: Peritonitis = Surgical Abdomen → Exploratory Laparotomy.
Imaging wastes precious time in unstable patients.
3. Post-Op Review Checklist
| Question |
Reason |
| Additional treatment needed? |
Adjuvant therapy, ongoing infection control, nutritional support |
| Complications post-op? |
Early identification prevents escalation—bleeding, sepsis, DVT |
| Has oral intake started? |
Marker of GI recovery (return of bowel function) |
4. Atelectasis – Pathophysiology Post-Op
- Cause: Anaesthesia → ↓ ciliary clearance, mucus plugging → ↓ surfactant → alveolar collapse.
- Effect: Hypoxia, especially in dependent lung zones.
- Prevention: Incentive spirometry, early ambulation, physiotherapy.
5. Postoperative Timeline of Expected Events
| Post-op Day |
Expected Occurrence |
| Day 1–2 |
Metabolic stress response: ↑ cortisol, catabolism, fluid shifts |
| Day 3 |
Atelectasis risk ↑ due to immobility, retained secretions |
| Day 5–7 |
Wound infection peaks |
| Day 7+ |
Anastomotic leak, DVT risk ↑ |
6. Dance Sign in Intussusception
- What: Empty Right Iliac Fossa
- Why: Terminal ileum invaginates into colon → vacated RIF.
7. Barium Enema in Intussusception
| Utility |
Explanation |
| Diagnostic |
Shows “Coil spring” appearance |
| Therapeutic |
Hydrostatic pressure may reduce intussusception |
Alternate Non-Invasive Options
- Soap + Water enema
- Saline Enema under USS
- Drawbacks: Risk of perforation, delay in definitive care if failed.
8. Ultrasound Findings in Intussusception
| View |
Diagnostic Sign |
| Transverse |
Target sign / Doughnut sign |
| Longitudinal |
Pseudokidney sign |
9. Pathophysiology of Intussusception
- Telescoping of bowel → venous congestion → bowel wall edema → ischemia → gangrene
- Commonly triggered by lymphoid hyperplasia (e.g. post-viral infection in children)
10. Types of Intussusception
| Type |
Description |
| Ileo-colic |
Most common in infants |
| Ileo-ileal |
Less common |
| Colo-colic |
Lead point often present (e.g., polyp, tumor) |
| Retrograde |
Reversed direction of invagination |
11. Gangrenous Bowel = Significant Blood Loss – Why?
- Friable, necrotic tissue has inflamed, edematous, hypervascular borders.
- Resection leads to massive capillary oozing.
- Septic/coagulopathic patients bleed more.
12. Treatment of Intussusception
Non-Operative Options
| Method |
Notes |
| Barium enema |
Radiologic + therapeutic |
| Saline enema + USS |
Max 3 attempts; low risk if skilled |
| Hydrostatic / Pneumatic reduction |
Pneumatic more effective, safer in some settings |
Operative Management
- Indications: Peritonitis, failure of non-op, gangrene
- Procedure:
- Attempt manual reduction (“milking”)
- If unsuccessful or gangrenous: Resection + primary end-to-end anastomosis
Consultant Challenge – Integration Task
Case:
You’re the SHO. A 6-month-old presents with bilious vomiting, palpable mass, rigid abdomen.
You order an ultrasound. While waiting, vitals drop. Do you still wait?
When you take them to theatre, what anatomical layers do you anticipate during entry?
What factors can prevent successful reduction? Explain clearly.
Consultant Challenge – Case Answer
Case Recap:
- Patient: 6-month-old
- Presentation: Bilious vomiting, palpable sausage-shaped mass, rigid abdomen
- Status: Deteriorating vitals while awaiting ultrasound
Stepwise Clinical Reasoning:
1. Do you still wait for imaging?
No.
- Why: Bilious vomiting + peritonitis signs + hemodynamic instability = surgical abdomen.
- Ultrasound delay risks bowel necrosis, perforation, death.
- Action: Expedite resuscitation → Call anesthesia → Proceed for emergency laparotomy.
2. Anticipated Anatomical Layers During Laparotomy:
Midline incision approach
| Layer |
Description |
| 1. Skin |
Subumbilical vertical incision |
| 2. Subcutaneous tissue |
Camper’s + Scarpa’s fascia |
| 3. Linea alba |
Midline fibrous structure |
| 4. Transversalis fascia |
Thin layer above peritoneum |
| 5. Peritoneum |
Entering the abdominal cavity |
| 6. Small bowel loops |
Carefully inspected; seek intussuscepted segment |
3. Factors Preventing Successful Manual Reduction
| Factor |
Explanation |
| Bowel gangrene |
Fragile, non-viable; risks perforation if manipulated |
| Tight lead point |
Tumor or Meckel’s diverticulum can act as an anchor |
| Delayed presentation |
Edema, inflammation makes reduction unsafe |
| Adhesions or anatomical abnormalities |
May prevent retrograde milking of intussusception |
Integration Flashcards – Intussusception & Peritonitis
Q1: What are the three hallmark signs of peritonitis on physical exam?
- A: No movement with respiration, Rigidity, Generalized/Rebound tenderness
Q2: What sign on physical exam indicates intussusception with displaced bowel?
- A: Dance sign (Empty right iliac fossa)
Q3: Why is barium enema both diagnostic and therapeutic?
- A: Shows coil-spring appearance (diagnosis); hydrostatic pressure may reduce intussusception (treatment)
Q4: What ultrasound sign confirms intussusception in transverse view?
- A: Target sign / Doughnut sign
- A: Signs of peritonitis, shock, or failed non-operative reduction
Q6: What are the non-operative options for reducing intussusception?
- A: Barium enema, saline enema under ultrasound, pneumatic reduction
Q7: Why is gangrenous bowel risky to resect?
- A: Friable tissue with increased bleeding risk due to edema and inflammation
Q8: Post-op, what complication should you suspect on Day 3 with low oxygen sats?
Q9: What post-op day is wound infection most likely to develop?
Q10: What determines whether intussusception can be milked or must be resected?
- A: Presence of gangrene, adhesions, or non-reducible lead point