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Intussusception - Garnasmokkun -
í börnum
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Almennt• Görnin fellur inn í sjálfa sig• Algengasta kviðarbráðatilfellið
meðal ungra barna– Sérstaklega <2 ára
• 80% barna sem fá invagination
• Sjaldgæft fyrir 3ja mánaða og eftir 6 ára
• Algeng ástæða fyrir intestinal obstruction (garnateppu) milli 6 og 25 M– #2 á eftir pylorus stenosu
• Oftast idiopathic– Öfugt við fullorðna
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Faraldsfræði
• Algeng ástæða fyrir intestinal obstruction (garnateppu) milli 6 og 25 M– #2 á eftir pylorus stenosu
38 af 100 þúsund 1 árs börnum31 af 100 þúsund 2ja ára börnum26 af 100 þúsund 3ja ára börnum
• 3 strákar vs. 2 stelpur• Heilbrigð börn• Árstíða-variation
– viral gastroenteritis– Rotaveiru bóluefni = x22 áhætta ?
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• Algengast við ileo-cecal mótin
• Ileo-ileo-colic
• Jejuno-jejunal
• Jejuno-ileal
• Colo-colic
intussuscipiens
intussusceptum
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Botnlangabólgu-áhrifin
• Aukinn þrýstingurVenur lokastBjúgur myndastÞrýstingur eykst enn frekar Ischemia, perforation, peritonitis
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Pathogenesa
• Veirur
• Veiruviðbrögð– Hypertrophia í Peyer´s patches– Lead point
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Lead points
• Small bowel lymphoma • Meckel diverticulum • Duplication cysts • Polypar • Æða malformationir• Innsnúinn botnlangi• Sníkjudýr (t.d. Ascaris lumbricoides)• Henoch-Schönlein purpura - hematoma• Cystic fibrosis – þykkar hægðir• Post op - adhesionir
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Saga
• Verulegir kviðverkir
• Krampakenndir15-20 min á milli
• Versna og styttra á milli
• Grætur mikið
• Geta verið verkjalaus milli kviða
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Skoðun
• Fósturstellingin
• Meðvitundarbreytingar– Aðallega hjá nýburum– Virðast einnig oft verkalaus
• Pylsulaga massi í kvið
• Blóð og slím í hægðum (currant-jelly stool)– 70% blóð
• Verkir + B+ P = 15% við komu
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Greining
• #1 láta sér detta hana í hug
• Ef mjög mikill grunur => gera strax barium– Stabilisera fyrst og smella niður NG tubu
• Hjá hinum: Ómun eða Rtg abd
• Barium getur oft reponerað– Eða perforeraðKirurgar þurfa að vita af
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Myndgreining – Rtg abd
• Geta sýnt:– Vantar loft í colon– Frítt loft – „Target sign” við hæ. Nýra
• Tveir sammiðja hringir
– „Crescent sign" • Þétting innan í lykkju
• CT einnig gott
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Myndgreining – ómun• Ómun sýnir „coiled
spring" mynstur • aka „bull´s eye”
mynstur • Næmi og sertæki
um 100% ef ómarinn er flinkur
• Doppler getur greint ischemiu
• Getur greint lead point hjá 2/3
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Myndgreining
• Barium contrast
• Loft – kontrast– Betra ef perforation
• Minni rifa• Minni erting
– Minni geislun– Minni kostnaður
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Myndgreining+meðferð
• Reponering gengur í 60-90% ef ileo-cecal
• Gengur frekar ef engin pathologia
• 10% koma aftur eftir reponeringu– Ekki endilega skurðleyfi fyrir kirurga
• Ef gengur upp fær sjúklingur oft hita yfir 38°C
• Hafður í obsi
• <1% perforera
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Myndgreining+meðferð
• Contrast enema
• Intussusception
• Í miðjum colon transversum
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Myndgreining+meðferð
• Sami sjúklingur
• Búið að reponera „ofar” í colon ascendens
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Röntgenlækningar
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Kirurgisk Meðferð
• Reponera manualt ef rtg klikkar
• Ef patologia þá resection
• Ef manual virkar ekki þá resection
• Kemur aftur hjá 1% ef manual rep
• Kemur aftur hjá 0% ef resection
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