Intususseption

Intususseption

Q. 1 Claw Sign” is seen in:
 A Intussusception
 B Volvulus
 C Pyloric stenosis
 D Peptic ulcer
Q. 1 Claw Sign” is seen in:
 A Intussusception
 B Volvulus
 C Pyloric stenosis
 D Peptic ulcer
Ans. A

Explanation:

Intussusception


Q. 2

A 10 month old infants present with acute intestinal obstruction. Contrast enema X-ray shows the intussusceptions. Which of the following is the most likely cause?

 A

Payers patch hypertrophy

 B

Mekel’s diverticulum

 C

Mucosal polyp

 D

Duplication cyst

Q. 2

A 10 month old infants present with acute intestinal obstruction. Contrast enema X-ray shows the intussusceptions. Which of the following is the most likely cause?

 A

Payers patch hypertrophy

 B

Mekel’s diverticulum

 C

Mucosal polyp

 D

Duplication cyst

Ans. A

Explanation:

Most common cause of intussusception in an infant is hypertrophy of Peyer’s patches in the terminal ileum from an antecedent viral infection that acts as a lead point.

Peristaltic action of the intestine then causes the bowel distal to the lead point to invaginate into itself.

Idiopathic intussusception occurs in children between approximately 6 and 24 months of age. Beyond this age group, cause of intussusception includes polyps, malignant tumors such as lymphoma, enteric duplication cysts, and Meckel’s diverticulum.

Ref: Schwartz’s Principles of Surgery, 9th Edition, Chapters 28, 39


Q. 3

A 15 year old child presents in the OPD with acute abdominal pain. He also gives history of blood and mucous in the stool. On P/A examination a mass is palpable. The MOST probable diagnosis in this patient is?

 A

Meckel’s diverticulum

 B

Volvulus

 C

Intussusception

 D

Hypertrophic pyloric stenosis

Q. 3

A 15 year old child presents in the OPD with acute abdominal pain. He also gives history of blood and mucous in the stool. On P/A examination a mass is palpable. The MOST probable diagnosis in this patient is?

 A

Meckel’s diverticulum

 B

Volvulus

 C

Intussusception

 D

Hypertrophic pyloric stenosis

Ans. C

Explanation:

A syndrome of colicky pain, passage of blood per rectum and a palpable mass (intussuscepted segment) is characteristic of intussusception.

 
Ref: CSDT 13/e, Page 629; Bailey & Love 25/e, Page 1191.

Q. 4

Recurrent obstruction, mass per abdomen and diarrhoea in a child is suggestive of which of the following condition?

 A

Intussusception

 B

Rectal prolapse

 C

Internal fistula

 D

Haemorrhoids

Q. 4

Recurrent obstruction, mass per abdomen and diarrhoea in a child is suggestive of which of the following condition?

 A

Intussusception

 B

Rectal prolapse

 C

Internal fistula

 D

Haemorrhoids

Ans. A

Explanation:

Recurrent obstruction and mass per abdomen is suggestive of intussusception.

As intussusception has been seen to complicate cases of gastroenteritis this can also explain diarrhoea.

Ref: Bailey & love 25/e, Page 1191; Nelson 17/e, Page 1242.

Q. 5

Recurrent intussusception occurs in about:

 A

<1%

 B

1-5%

 C

5-10%

 D

10-20%

Q. 5

Recurrent intussusception occurs in about:

 A

<1%

 B

1-5%

 C

5-10%

 D

10-20%

Ans. C

Explanation:

Recurrent intussusception occurs in 5 to 10% of patients, independent of whether the bowel is reduced radiographically or surgically.
 
Ref: Schwartz’s principle of surgery 9th edition, chapter 39.

Q. 6

Vaccination causing intussusception

 A

Rotavirus

 B

Parvovirus

 C

Poliovirus

 D

BCG

Q. 6

Vaccination causing intussusception

 A

Rotavirus

 B

Parvovirus

 C

Poliovirus

 D

BCG

Ans. A

Explanation:

Ans. is ‘a’ i.e., Rotavirus

In 1999, a highly efficiaous rotavirus vaccine, Rotashield licenced in United States, was withdrawn from the market after less than one year because of its association with intussuseption.


Q. 7

Commonest cause of intestinal obstruction in children is –

 A

Intussusception

 B

Volvulus

 C

Hernia

 D

Adhesions

Q. 7

Commonest cause of intestinal obstruction in children is –

 A

Intussusception

 B

Volvulus

 C

Hernia

 D

Adhesions

Ans. A

Explanation:

Ans. is ‘a’ i.e., Intussusception

Intussusception

o Intussusception occurs when a portion of the alimentary tract is telescoped into an adjacent segment.

o It is the most common cause of intestinal obstruction between 3 months and 6 year of age.

o It is more common in males.

o Intusssception may be –>  i) Ileocolic (most common)            ii) Cecocolic          iii) Ileoileal

o The upper portion of bowel that invaginates into lower portion is called intussusceptum.

o Lower portion which recieves telescoped upper portion is called intussuscipiens.


Q. 8

A 10 month old infants presents with acute intestinal obstruction. Contrast enema X-ray shows the intussusceptions, likely cause is –

 A

Peyer’s patch hypertrophy

 B

Meckle’s diverticulum

 C

Mucosal polyp

 D

Duplication cyst

Q. 8

A 10 month old infants presents with acute intestinal obstruction. Contrast enema X-ray shows the intussusceptions, likely cause is –

 A

Peyer’s patch hypertrophy

 B

Meckle’s diverticulum

 C

Mucosal polyp

 D

Duplication cyst

Ans. A

Explanation:

Ans. is ‘a’ i.e., Peyer’s patch hypertrophy

Pathogenesis of intussusception

o Between the age of 3 to 9 months, cause of acute intussusception is idiopathic.

o It is postulated that gastrointestinal infection or the introduction of new food proteins result in swollen peyer’s patches in the terminal ileum. The prominent mounds of tissue leads to mucosal prolapse of the ileum into the colon thus causing an intussusception.

In 2-8% of patient, recognizable lead points for the intussusception are found, such as a meckel’s diverticulum, intestinal polyp, neurofibroma, intestinal duplication, hemangioma or malignant condition such as lymphoma.


Q. 9

True about Meckel’s diverticulum is/are ‑

 A

Bleeding PR

 B

Can be a leading point of intussusception

 C

Multiple diverticuli common

 D

a and b

Q. 9

True about Meckel’s diverticulum is/are ‑

 A

Bleeding PR

 B

Can be a leading point of intussusception

 C

Multiple diverticuli common

 D

a and b

Ans. D

Explanation:

Answer ‘a’ i.e. Bleeding PR ; ‘b’ i.e. Can be a leading point of intussusception


Q. 10

Most common type of Intussusception is

 A

Deo-colic

 B

Dio-ileal

 C

Colo-colic

 D

Caeco-colic

Q. 10

Most common type of Intussusception is

 A

Deo-colic

 B

Dio-ileal

 C

Colo-colic

 D

Caeco-colic

Ans. A

Explanation:

Ans. is ‘a’ i.e., Deo – Colic 


Q. 11

What is intussuscepiens –

 A

The entire complex of intussusception

 B

The entering layer

 C

The outer layer

 D

The process of reducing the intussusception

Q. 11

What is intussuscepiens –

 A

The entire complex of intussusception

 B

The entering layer

 C

The outer layer

 D

The process of reducing the intussusception

Ans. C

Explanation:

Answer is ‘c’ i.e. The outer layer

  • An intussusception is composed of three parts:

–  The entering or inner tube – intussusceptum

–  The returning or middle tube

Intussusception

  • Intussusception is the telescoping of one portion of the intestine into the other.
  • It is the most common cause of intestinal obstruction in early childhood (3 months to 6 years)
  • Pathogenesis:

Intussusception occurs most often near the ileocecal junction (ileocolic intussusception). Ileoileo-colic, jejuno­jejunal, jejuno-ileal, or colo-colic intussusception also have been described.

The intussusceptum, a proximal segment of bowel, telescopes into the intussuscipiens, a distal segment, dragging the associated mesentery with it. This leads to the development of venous and lymphatic congestion with resulting intestinal edema, which can ultimately lead to ischemia, perforation, and peritonitis. Approximately 75 to 95 percent of cases of intussusception in children are considered to be idiopathic because there is no clear disease trigger or pathological lead point. Idiopathic intussusception is most common in children between three months and five years of age. (ages vary from book to book)

In idiopathic or primary intussusception, the lead point is generally attributed to hypertrophied Peyer’s patches within the ileal wall. Intussusception occurs frequently in the wake of an upper respiratory tract infection or an episode of gastroenteritis, providing an etiology for the enlargement of the lymphoid tissue. Adenoviruses, and to a much lesser extent rotaviruses, have been implicated in up to 50% of cases.

Secondary Intussusception: An intussusception may have an identifiable lesion that serves as a lead point, drawing the proximal bowel into the distal bowel by peristaltic activity. These anatomic lead points tend to increase in proportion to age, especially after 2 years of age.

The most common pathologic lead point is a Meckel’s diverticulum followed by polyps and duplications.

  • Clinical features

Intussusception classically produces severe cramping abdominal pain in an otherwise healthy child. The child often draws his or her legs up during the pain episodes and is usually quite during the intervening periods. Vomiting is almost universal.

Initially the passage of stools may be normal while later on blood mixed with mucus is evacuated – red currant jelly stool

An abdominal mass may be palpated – a sausage shaped mass, which may increase in size and firmness during the paroxysms of pain.

There may be an associated feeling of emptiness in the right iliac fossa (sign of Dance)

On rectal examination, blood-stained mucus may be found on the finger. Occasionally in extensive ileocolic or colocolic intussusception, the apex may be palpable or even protrude from the anus.

  • Diagnosis can be made on Barium enema which shows characteristic

claw sign

–  coiled spring sign On ultrasound which shows

–  target sign

pseudokidney sign.

When the clinical index of suspicion is high, hydrostatic reduction by contrast agent or air diagnostic and the therapeutic procedure of choice. Hydrostatic reduction is contraindicated in hemodynamic instability.


Q. 12

A 10 month old infant presents with acute intestinal obstruction. Contrast enema X-ray shows the intussusceptions, Likely cause is

 A

Payers patch hypertrophy

 B

Mekel’s diverticulum

 C

Mucosal polyp

 D

Duplication cyst

Q. 12

A 10 month old infant presents with acute intestinal obstruction. Contrast enema X-ray shows the intussusceptions, Likely cause is

 A

Payers patch hypertrophy

 B

Mekel’s diverticulum

 C

Mucosal polyp

 D

Duplication cyst

Ans. A

Explanation:

Ans. is ‘a’ i.e., Peyer’s Patch Hypertrophy 

  • Bailey writes – “The condition is encountered most commonly in children, in whom it occurs in an idiopathic form, with a peak incidence at 3-9 months. Between 70% and 90% cases are classed as idiopathic, and an associated illness such as gastroenteritis or urinary tract infection is found in 30%. It is believed that hyperplasia of Peyer’s patches in the terminal ileum may be the initiating event. This may occur secondary to weaning. In light of the seasonal variation, with peak incidence in spring and summer, it may be related to upper respiratory tract infection pathogens such as adenovirus or rotavirus.”
  • Intussusception associated with a known pathologic lead point is seen in older children. The most common lead point is Meckel’s diverticulum.
  • This patient is 10 months old, so most likely the cause should be hypertrophy of Peyer’s patches.

Q. 13

Features of intussusception are-

 A

Pincer sign

 B

Target sign

 C

Dove sign

 D

Coiled spring sign

Q. 13

Features of intussusception are-

 A

Pincer sign

 B

Target sign

 C

Dove sign

 D

Coiled spring sign

Ans. B

Explanation:

Answer ‘b’ i.e. Target sign

  • Radiological investigations and signs seen in Intussusception

Plain film

– features of small intestinal obstruction

– abdominal soft tissue density in some cases which may show

  • target sign –> soft-tissue mass with concentric area of lucency due to mesenteric fat
  • meniscus sign —> crescent of gas within colonic lumen that outlines the apex of intussusception Barium Enema
  • Claw sign —> rounded apex of intussusception protrudes into the contrast column
  • Coiled spring sign —> edematous mucosal folds of returning limb of intussusceptum outlined by contrast material.

Ultrasound

  • Target sign
  • Bull’s eye sign
  • Pseudokidney sign
  • Also know
  • Dance sign – feeling of emptiness in rt. iliac fossa on palpation

Q. 14

A child was operated for intussusceptions. He underwent resection of the affected ileal segment which revealed a tumor. The most likely tumor would be:

 A

Lymphoma

 B

Villous adenoma

 C

Carcinoid

 D

Smooth muscle tumor

Q. 14

A child was operated for intussusceptions. He underwent resection of the affected ileal segment which revealed a tumor. The most likely tumor would be:

 A

Lymphoma

 B

Villous adenoma

 C

Carcinoid

 D

Smooth muscle tumor

Ans. B

Explanation:

Ans is ‘b’ i.e. Villous adenoma 

The vast majority of cases of intussusception does not have a pathologic lead point and are classified as primary or idiopathic intussusceptions. Approximately 5 to 25 % of children have pathological lead points (percentages vary from book to book).

“The most common pathologic lead point is a Meckel’s diverticulum followed by polyps and duplications. Other benign lead points are the appendix, hemangiomas, carcinoid tumors, foreign bodies, ectopic pancreas or gastric mucosa, hamartomas from Peutz-Jeghers syndrome, and lipomas. Malignant causes, which are very rare, include lymphomas, lymphosarcomas, small bowel tumors, and melanomas.” – Ashcraft’s Pediatric Surgery , Fifth edition George Whitfield Holcomb, J. Patrick Murphy, and Daniel J. Ostlie Chapter 39

Frankly we have not got any documented evidence that ‘vinous adenoma’ is the most common pathological lead point among the given options. What we get is that ‘polyps’ are the 2 most common pathological lead point after Meckel’s diverticulum. But the problem is that ‘vinous adenomas’ constitute a very small percentage of all the polyps. Still this is our best option. We have confirmed this from a Prof. of Surgery.


Q. 15

Recurrent pain abdomen with intestinal obstruction and mass passes per rectum goes in favour of ‑

 A

Internal herniation

 B

Stricture

 C

Strangulated hernia

 D

Intussusception

Q. 15

Recurrent pain abdomen with intestinal obstruction and mass passes per rectum goes in favour of ‑

 A

Internal herniation

 B

Stricture

 C

Strangulated hernia

 D

Intussusception

Ans. D

Explanation:

Answer is ‘d’ i.e. Intussception 


Q. 16

Recurrent obstruction, mass per rectum and diarrhoea in child –

 A

Intussusception

 B

Rectal prolapse

 C

Internal hernia

 D

Haemorrhoids

Q. 16

Recurrent obstruction, mass per rectum and diarrhoea in child –

 A

Intussusception

 B

Rectal prolapse

 C

Internal hernia

 D

Haemorrhoids

Ans. A

Explanation:

Answer is ‘a’ i.e. Intussusception 

  • Although I could not find any documented evidence of diarrhoea in Intussusception, the given picture goes with intussusception only.
  • Intussusception has been seen to complicate cases of gastroenteritis (Nelson 17/e p1242). Probably this can explain the diarrhoea.

Q. 17

Commonest cause of intussusception is –

 A

Submucous lipoma

 B

Meckel’s diverticulum

 C

Hypertrophy of submucous peyer’s patches

 D

Polyp

Q. 17

Commonest cause of intussusception is –

 A

Submucous lipoma

 B

Meckel’s diverticulum

 C

Hypertrophy of submucous peyer’s patches

 D

Polyp

Ans. C

Explanation:

Ans. is ‘c’ i.e., Hypertrophy of submucosa peyer’s patches 


Q. 18

A 12 month old male child suddenly draws up his legs and screams with pain. This is repeated periodically throughout the night interspersed with periods of quiet sleep. When seen after 12 hours the child looks pale, has just vomited andpassed thin blood-stained stool; there is a mass around umbilicus. What is the most likely diagnosis

 A

Appendicitis

 B

Intussusception

 C

Gastro-enteritis

 D

Roundworm obstruction

Q. 18

A 12 month old male child suddenly draws up his legs and screams with pain. This is repeated periodically throughout the night interspersed with periods of quiet sleep. When seen after 12 hours the child looks pale, has just vomited andpassed thin blood-stained stool; there is a mass around umbilicus. What is the most likely diagnosis

 A

Appendicitis

 B

Intussusception

 C

Gastro-enteritis

 D

Roundworm obstruction

Ans. B

Explanation:

Ans. is ‘b’ i.e., Intussusception 


Q. 19

Signe-de-Dance is –

 A

Empty right iliac fossa in intussusception

 B

Pincer shaped appearance in barium enema in intussusception

 C

Tenderness at the McBurney’s Point

 D

Passing of large quantities of urine in hydronephrosis

Q. 19

Signe-de-Dance is –

 A

Empty right iliac fossa in intussusception

 B

Pincer shaped appearance in barium enema in intussusception

 C

Tenderness at the McBurney’s Point

 D

Passing of large quantities of urine in hydronephrosis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Empty right iliac fossa in intussusception.


Q. 20

Coiled spring appearance on barium enema is seen in:

 A

Carcinoma colon

 B

Sigmoid volvulus

 C

Intussusception

 D

Deal atresia

Q. 20

Coiled spring appearance on barium enema is seen in:

 A

Carcinoma colon

 B

Sigmoid volvulus

 C

Intussusception

 D

Deal atresia

Ans. C

Explanation:

Ans. Intussusception


Q. 21

The “Target sign” ultrasonographically means:

 A

Ovarian carcinoma

 B

Ectopic kidney

 C

Intussusception

 D

Liver metastasis

Q. 21

The “Target sign” ultrasonographically means:

 A

Ovarian carcinoma

 B

Ectopic kidney

 C

Intussusception

 D

Liver metastasis

Ans. C

Explanation:

Ans. Intussusception


Q. 22

A child wa, ,aerated for small intes mass with intussusception and after f ,eration the tumor was diagnosed in histological sc,tion. Which is the most likely tumor associated

 A

Carcinoid

 B

Villous adenoma

 C

Lymphoma

 D

Smooth muscle tumor

Q. 22

A child wa, ,aerated for small intes mass with intussusception and after f ,eration the tumor was diagnosed in histological sc,tion. Which is the most likely tumor associated

 A

Carcinoid

 B

Villous adenoma

 C

Lymphoma

 D

Smooth muscle tumor

Ans. C

Explanation:

Ans. c. Lymphoma

  • Most common tumor of small bowel in children is lymphoma, which can lead to intussusception

Small-Bowel Neoplasm

  • MC tumor of small bowel: Leiomyoma° >AdenomaQ
  • MC tumor of small bowel in children: LymphomaQ
  • MC malignant tumor of small bowel: Carcinoid >AdenocarcinomaQ
  • MC site of small bowel malignancy, carcinoids, lymphoma: IleumQ

Lead Points in Intussusception:

  • Approximately 5-10% of cases have a true pathologic lead point. The older the toddler, the more likely there will be a lead pointQ.
  • MC lead point is Meckel’s diverticulumQ
  • Most common tumor of small bowel in children is lymphoma, which can lead to intussusception
  • Other lead points include polyps (villous adenoma), the appendix, intestinal duplication, foreign bodies, and tumors such as hamartomas associated with Peutz-Jeghers syndrome.

Q. 23

A 6 months old child woke up in night, crying with abdominal pain, which got relieved on passing red stool. What is the most likely diagnosis?

 A

Meckel’s diverticulum

 B

Intussusception

 C

Malrotation

 D

Intestinal obstruction

Q. 23

A 6 months old child woke up in night, crying with abdominal pain, which got relieved on passing red stool. What is the most likely diagnosis?

 A

Meckel’s diverticulum

 B

Intussusception

 C

Malrotation

 D

Intestinal obstruction

Ans. B

Explanation:

Ans. b. Intussusception


Q. 24

Rotavirus vaccine – contraindication is ‑

 A

SCID

 B

Intussusception

 C

Severe allergic reaction

 D

All of the above

Q. 24

Rotavirus vaccine – contraindication is ‑

 A

SCID

 B

Intussusception

 C

Severe allergic reaction

 D

All of the above

Ans. D

Explanation:

Ans. is ‘d ‘i.e., All of the above



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