1. Think bowel obstruction (severe abdo pain, constipation and
vomiting) then think Intersucception or Hirschrung's
Intersucception
The invagination of proximal bowel into a distal segment e.g ileum -> caecum. Bowel becomes
compressed, so distends and compresses bowel, leads to intestinal obstruction and disturbed
peristalsis.
Aetiology: M:F 3:2.
90% Idiopathic. ?Assoc. with viral infection and inflammation of Peyer's patches.
10% have lead point. Typically if child >2yrs may be due to Mechel's Diverticulum, Polyps, HSP,
Tumour etc.
Presentation:
- Typically 2mths -2 years
- Sudden onset severe paroxysmal colicky abdo pain (10-20 mins)
- During pain child becomes pale and draws up legs.
- Vomiting (bile stained)
-Palpable sausage shaped mass in abdomen
- Abdominal distention
- Redcurrant Jelly Stool (blood stained mucus)
- Lethargy, irritability
- Shock - dehydration/pallor
Management:
 ABCDE - Fluid resucitation and NG Tube
 X-ray - Distended small bowel, abscence of gas in distal bowel/rectum
 USS - Donut/Target sign, Psudeokidney/sandwich appearance
 Enema e.g. Rectal air insufflation (75% success)
 Surgery if peritonitis/perforation/prolonged history
Complications:Peritonitis,Ischaemia,Necrosis,Haemorrhage,Perforation,Chronicintersucception.
5% recurrence. 1% Mortality. Fatal if untreated.
USS: Logitudinal (L) sandwich like layers. Transverse (R) Donut sign.

2. Hirschprung's Disease
Absence of ganglion cells in the myenteric and submucosal plexuses of the large bowel, mainly
rectum. Extends proximally from rectum, resulting in a narrow contracted segment, for a variable
distance, ending in normal dilated colon.
Epidemiology: 1/5000. M:F 4:1. 30% FH.
Associated with Down's Syndrome, MEN, Waardenburg's Syndrome and GI abnormalities.
Presentation:
- Neonates
- Intestinal obstruction: Failure to pass meconium
-Abdominal distension
-Repeated bile stained vomit
- PR: Narrowedsegmentandrelease of liquidstool orflatulus,temporarydilationandrelief.
In infantsmaypresentwith HirschprungsEnterocolitis(assoc.CDiff infection).Px :Abdo pain, fever,
vomiting, foul-smelling bloody diarrhoea. 30% Mortality. Tx: Abx
Older children: Chronic constipation, abdo distension, no soiling, growth failure
Diagnosis:SuctionRectal Biopsy- showsabscence of ganglion cells and large ACh +ve nerve trunks.
Anorectal manometry/barium study may indicate length of problem.
Management:
NG Tube
Enemas to decompress
Surgery: 2-stage with temp colostomy or one stage anastomoses.
Complications: Persistent constipation, soiling and incontinence, leakage of anastomosis,
enterocolitis, strictures and adhesions