Intussusception

Introduction to intussusception Intussusception refers to the insertion of a segment of the intestine into the lumen of the intestine and causes the contents of the intestine to pass through the barrier. Intussusception accounts for 15% to 20% of intestinal obstruction, and there are two types of primary and secondary. Primary intussusception occurs mostly in infants and young children. Secondary intussusception is more common in adults. The largest intussusception is the insertion of the proximal intestine into the distal intestine. The reverse intussusception is rare and inferior to the total. 10% of the number of cases. basic knowledge The proportion of children: the incidence rate of children is about 0.005% Susceptible people: good for infants and young children Mode of infection: non-infectious Complications: peritonitis dehydration

Intussusception

According to the site of intussusception, there are no obvious organic lesions, which are divided into primary intussusception and secondary intussusception. Secondary intussusception is more common in tumor, trauma and postoperative and intestine Inflammatory lesions of the tract.

Primary (30%):

There is no obvious organic factor in the intestine segment and its vicinity, accounting for 75% to 90% of the number of intussusceptions in children, and only 10% to 15% of adults are primary, the incidence of intussusception in infants The age is more than 1 year old, and the incidence of infants is the highest in 5-9 months, and gradually decreases in 2 years and older. It occurs mostly in the seasons with large climate change, especially in the spring and autumn. This season, the upper respiratory tract and lymph nodes have more viral infections. May cause bowel movements to lose normal rhythm, or form sputum, in addition, sudden changes in the food properties of infants, food allergies, diarrhea, etc. may become the triggering factor of intussusception, the neonatal ileocecal mesentery is often not fixed Generally, it should be gradually fixed to the posterior abdominal wall within a few years after birth; because the mesangium is too long and slack, causing the ileocecal part to swim too much, it is the main anatomical factor of the intussusception of this part.

Tumor (25%):

It is the most common cause of intussusception in adults. Intestinal polyps, leiomyoma, lipoma, fibroids and cancer can cause secondary intussusception. This is because the ileocecal or other intestines are present. The presence of tumors often leads to intestinal peristalsis, which becomes the trap of intussusception. Felix analyzed 1214 intussusceptions and 668 cases of small intussusception, of which 383 (57%) were tumors and 116 (30%) were malignant. Of the 546 cases of colonic intussusing, 379 (69.4%) were tumors, of which 261 (69%) were malignant, Nagomey had 2/3 colon intussusception and 1/3 intussusception as cancer, and the latter 70% Metastatic cancer, small intussusception with villous adenoma, lipoma, leiomyoma and various polyps including Bentzjeghers syndrome and other benign lesions are more common, duodenal benign tumors caused by intussusception is rare, Orenstein has reported 1 case Duodenal jejunum intubation complicated with pancreatitis caused by villous adenoma, Jennings also reported a case of lipoma caused by duodenal intussusception.

Trauma and surgery (20%):

Abdominal trauma and reports of intussusception after surgery are increasing. Duncan has 586 cases of laparotomy due to abdominal trauma, and 21 cases have postoperative intestinal obstruction. 6 cases (28.6%) are intussusception. It is worth noting that 6 cases had no small intestine injury, but most of them were accompanied by shock and liver damage. The Second Hospital of Xianyang City had treated a small intestine injury caused by a sharp instrument. After laparotomy, it was rare to form a multi-site intussusception adjacent to the intestine. Intestinal intussusception after abdominal surgery is common in partial gastrectomy, after type II or Roux-Y gastrojejunostomy, in the treatment of obesity empty short circuit shunt and various intestinal fistula. Cooperman reported that the stump of the appendectomy after appendectomy occurred more than 2 weeks after surgery, and there were symptoms until 6 years after surgery. The cause of intussusception after trauma or abdominal surgery is still unclear. It is speculated that it may be related to intestinal wall hematoma. , edema, adhesions, intestinal dysfunction, electrolyte imbalance, intestinal lumen and chronic intestinal dilatation, intestinal anastomosis is associated with poor positioning, abdominal trauma and postoperative small intussusception.

Other reasons (10%):

Intestinal inflammation causes bowel movement disorder, mainly localized ileitis, non-specific ileocecal ulcer, acute ileocecal valve inflammation, acute and chronic appendicitis, etc. In addition, intestinal tuberculosis, bacillary typhoid or typhoid ulcer can cause intussusception Congenital malformations such as Meckel diverticulum, cecum deficiency, ileum colonic line connection and intestinal ascariasis, intestinal balloon swelling, idiopathic purpura intestinal wall hematoma are rare causes of secondary intussusception.

Pathogenesis

There are two basic conditions for inducing intussusception: local organic inducement and abnormal bowel movements. Most of the pathogenesis is due to the loss of normal rhythm of intestinal peristalsis, and persistent local spasm of the intestinal loop muscle. With severe peristalsis, the sacral segment is gradually pushed into the distal lumen. In children, the factors that can cause intestinal peristalsis are enteritis, eating changes, high fever, etc. In view of the highest incidence of infants under 1 year old, it is often the age of children who are weaning and changing food. Some people think that with the change of food, Intestinal bacteria also change, which can cause inflammation of the submucosal Peyer plaque and induce intussusception. In most cases, infantile intussusception occurs at the end of the ileum 50cm, where Peyer spots are also the most, and the toxin produced by the aphid can stimulate the intestine. When the tract causes intestinal peristalsis and adenovirus infection, the lymphatic tissue of the ileocecal tract develops inflammatory proliferation, forming a ring or protuberance in the intestinal lumen, and the mesenteric lymph nodes also enlarge and can compress the intestine; At the same time, the intestinal motility of adenovirus infected patients is often prone to disorder. The same mechanism, when there are tumors or other organic lesions in the intestinal wall, when the peristaltic wave pushes the tumor and the diseased intestine to the distal end, the section of the intestine is pulled together. Into the distal intestinal lumen and cause intussusception.

Most of the intussusception is inserted into the distal intestine in the proximal intestine. The distal intestine is retrogradely inserted into the proximal intestine, which is rare, accounting for 0.2% to 0.5%. Multiple intussusceptions are called multiple intussusception.

The anatomical structure of the intussusception consists of a sheath and a nesting part. The nesting part is further divided into a head and a neck. The intussusception consisting of three layers of intestinal wall is called a single intussusception, and the single set is fully connected. The distal intestine forms a nest of five layers of the intestinal wall as a double nest.

Intussusception can occur in any part of the small intestine or large intestine, according to the top and outer sheath of the intestine, and the different types of the intestine of the neck are divided into 5 types:

1, small intestine type, mostly small intestine antegrade into the small intestine (empty-empty, empty-back, back-ileal intussusception).

2, ileocecal type, from the end of the ileocecal valve into the colon.

3, return type, the end of the ileum into the colon.

4, colon type, the colon is inserted into the colon.

5, jejunal gastric intussusception, is a retrograde intussusception, refers to the retrograde jejunum that occurs after gastric surgery into the stomach cavity. Among the above types, the incidence of ileocecal intussusception is the highest, according to statistics, adults can reach 60%, and children up to 90%.

Pathological changes in intussusception:

1. Intestinal obstruction: The basic pathological change of intussusception is intestinal obstruction. In the early stage of intussusception, the central channel of the intestine still exists. Adults rarely cause complete intestinal obstruction due to large intestinal lumen, and the intussusception of infants occurs 24 hours later. Complete intestinal obstruction, easy to cause dehydration, electrolyte imbalance, infection, poisoning, shock and intestinal perforation, peritonitis.

2. Intestinal wall necrosis: After the intubation of the intussusception enters the sheath, the mesentery is simultaneously pulled in, and the mesenteric blood vessels are compressed. If the early reduction is not performed, the intestinal tube may be necrotic, and the severity is positive with the blood supply time of the intestinal wall. Related, according to the nature of its blood circulation disorders, can be divided into venous necrosis and arterial necrosis.

(1) venous necrosis: more common, mainly occurs in the nesting, mesangial blood vessels are compressed, first caused by venous return obstruction, intestinal tube congestion, edema and exudation, intestinal wall thickening, color purple, with venous pressure Increased, which in turn affects arterial blood supply or vascular embolism, blood flow stops, resulting in complete necrosis of the nesting, also known as congestive necrosis (black necrosis).

(2) Arterial necrosis: less common, due to long-lasting paralysis of the sheath and neck, the contents of the sheath are edema, exudation, and thickening, resulting in a high degree of dilatation of the intestinal wall and the blood flow of the peripheral arteries. Barriers, striped or speckled gray-white ischemic area of the intestine wall, easily pierced, also known as avascular necrosis (white necrosis), clinical attention must be paid to the focal arterial necrosis of the sheath, easy to enema Perforation, surgical reduction is also often due to intestinal color and peristalsis seems to have returned to normal and neglected small focal white necrosis caused by postoperative perforation.

Intussusception prevention

1, usually to avoid cold in the abdomen of children, timely add clothing, to prevent intestinal dysfunction caused by climate change.

2, to prevent infection in the intestines, pay attention to breastfeeding health, prevent disease from the mouth.

Intussusception complications Complications dehydration of peritonitis

If it is more than 24 hours, the intestine will develop ischemia and necrosis, and surgery is needed. If the time is longer, the perforation of the intestinal wall tissue may cause complications such as peritonitis, or even life-threatening, and may be dehydrated, electrolyte imbalance and toxic shock. Wait.

Intussusception symptoms Common symptoms Peritoneal irritation, blood stasis, abdominal pain, acute abdomen, severe pain, upper abdominal pain, constipation, severe abdominal pain, bloating, blood circulation disorder

Intussusception is divided into acute, subacute and chronic type 3 according to clinical urgency and degree of obstruction. Acute intussusception occurs mostly in infants, characterized by persistent and complete acute intestinal obstruction; subacute intussusception, sputum The occurrence time is short and short, and it is incomplete intestinal obstruction, which is more common in children; chronic intussusception is a chronic recurrent episode, which occurs in adults, and its clinical symptoms vary with pathological changes.

1, acute intussusception: more abdominal pain, vomiting, blood in the stool, lumps and changes in general condition.

(1) Abdominal pain: the first symptom of intussusception, accounting for 90% to 100% of the main complaints. After intestinal intussusception, the intestinal lumen is obstructed, and the proximal intestinal segment undergoes severe peristalsis and spasmodic contraction. Every peristaltic wave occurs, so that the nesting section advances continuously, and the mesentery is pulled into the sheath to cause severe pain. The nutrition is good, and the normal and healthy baby often has paroxysmal crying, pale, and violent movements. It is painful. After 10 to 20 minutes, it will fall asleep or play as usual. After a few minutes, it will suddenly attack. Repeatedly, the child with weak constitution or intussusception on the basis of enteritis and dysentery can not cry badly. It is only manifested as uneasiness and paleness. When older children suffer from intussusception, the interval of abdominal pain is generally longer.

(2) Vomiting: Reflex vomiting caused by traction of the mesentery is one of the early symptoms of infantile intussusception. It often occurs shortly after the onset of paroxysmal crying. Most of the spit is milk or other food. Often with bile, after 12 to 24 hours, vomiting can be gradually stopped, but often refused to breastfeed or diet, vomiting later, or even vomiting liquid, indicating that the intestinal obstruction caused by the nesting is very serious.

(3) Blood in the stool: the blood circulation disorder of the intestinal wall is inserted into the intestine. The blood in the intestine is mixed with the secretion of intestinal mucosa to produce blood in the stool. The blood in the stool often occurs 4 to 12 hours after the abdominal pain. At first, it is mixed with yellow, and the dark red is discharged soon. Jam-like stool, sometimes deep red blood, or just a little bloodshot, there is blood in the stool in the early stage of ileo-type nesting, small intestine-type intussusception occurs later, and older children often lack the symptoms of intussuscal blood in the stool, or It occurs only a few days after the onset of the disease. If the child does not have self-defecation, the anus can be seen with gloves and blood.

(4) Abdominal mass: In the initial period of abdominal pain, the abdominal period can be smoothly checked, and the mass formed by the intussusception will be examined from the right lower abdomen, and the right rib, the middle upper abdomen and the left abdomen will be touched. Infant intussusception is mostly ileocecal, and the mass of the mass is mostly distributed along the colon. In severe cases, it can reach the rectum. The surface of the mass is smooth and movable. The shape is like a sausage or banana. It is medium hardness and slightly elastic. This is established. The most significant signs of diagnosis, the incidence of more than 1 to 2 days, due to significant flatulence in the small intestine above the nest, it is often difficult to lick the mass.

(5) general condition: with the intussusception of the disease can progress, the expression is indifferent, showing a serious illness, 48 hours after the occurrence of intestinal necrosis can produce signs of peritonitis, the general condition worsens, often high fever, severe water and electrolyte imbalance , obvious symptoms of poisoning and shock and other performance.

2, chronic intussusception: mostly occurs in adults, the symptoms are quite atypical, 83% ~ 92% have organic lesions leading to intussusception, the course of its development is slow, manifested as chronic, intermittent, incomplete obstruction, symptoms Appeared for several days, several months to more than one year, and finally can gradually develop into acute complete obstruction, the initial recurrence of intestinal inflammation and intestinal dysfunction symptoms, abdominal pain accompanied by nausea and vomiting, there may be a small amount in the stool Mucus and blood can also be completely normal. The abdominal mass can appear or harden during the onset of pain, and the intestinal type can be seen. The pain can be restored to its original state during the intermittent period. If the nest is self-reset, the abdominal mass can completely disappear.

Felix reported that 75% of spastic abdominal pain, nausea and vomiting 68%, abdominal distension 45%, tenderness 60%, intestinal peristalsis change 34%; 25% to 50% can reach the mass, 30% to 60% have bloody stools Or stool occult blood test is positive.

3, subacute intussusception: typical abdominal pain, abdominal mass and mucus blood is not significant, early manifestations of intestinal dysfunction, easily misdiagnosed as enteritis, amoebic colitis, bacillary dysentery, hernia and abdominal mass It was misdiagnosed as intestinal ascariasis, and it was not diagnosed and correctly treated in a variety of cases until the blood vessel in the intestine became a strangulated intestinal obstruction. The sign was wrapped in the sheath and there was blood supply. Obstruction, has not been able to contaminate the abdominal cavity, so the peritoneal irritation is not obvious, but the patient's general condition can be rapidly deteriorated. It is common in intussusception in older children or adults. In addition, the jejunal intussusception after gastrectomy has Abdominal pain, early vomiting bile or gastric drainage increased, generally after surgery, small intussusception, may have abdominal distension, abdominal pain, abdominal mass, a small number of mucous bloody stools, mostly occurred within 2 weeks after surgery, mostly subacute, late Chronic recurrence is less common.

Intussusception examination

In the case of acute intussusception, dark red mucus bloody stools can be seen in the stool examination, and red blood cells are dominant under the microscope; chronic intussusception, fecal occult blood test can be positive.

1, anal diagnosis

For the routine examination of the disease, it can be seen that the blood is smear or the blood is discharged. When the individual intussusception is severe, the apex can reach the rectum. At this time, the rectal examination can cause a cervical lumps.

2, X-ray inspection

(1) Abdominal plain film: There is no reliable sign in intussusception. In the case of complete obstruction, part of intestinal flat film can be seen in some intestinal effusion and continuous dilated small intestine fistula, complicated with intestinal necrosis, peritonitis, intestinal paralysis, and peritoneal effusion. Symptoms, even in the abdominal plain film to see the direct signs of intussusception, such as in the lower right or right abdomen to see a section of the inflatable colon with a dachshund-like soft tissue mass, the tumor is missing in the proximal colon, sometimes a thin layer around the mass Surrounded by shell-like gas.

Rigler used the "bicycle cushion" to describe the flat intussusception of the small intestine, which means that the conical translucent intestine is seen on the basis of the intestinal effusion and the thickening of the intestinal wall, which is shaped like a bicycle cushion. Formed for the top of the nesting, the surgery is a back-return type nesting.

(2) barium meal examination: for the diagnosis of small intussusception, adult chronic and jejunal-gastric anastomosis, and rare duodenal intussusception.

1 The characteristics of X-ray image of small intussusception are: A. After taking 300ml of dilute tincture, the elixir descends to the intestine near the intussusception and the speed is slow. The dagger is slightly stagnant at the top of the nest, and the intestine is above the nest. Mild dilatation, and there is reverse motility, B. When the dagger is placed in the intestine, the intestine is a bird's beak or conical narrow and prolonged in a linear shape. Significantly, the mucosal folds are arranged in a longitudinal direction, and the distal end of the narrow intestine segment can be seen as a retrograde sheath, showing a dilated sheath with a crescent-shaped, semi-annular or spring-like appearance, D. The intestine wall forms a parallel translucent shadow or a soft tissue-like filling defect. E. Occasionally, the primary tumor in the small intestine is filled with a defect in the occlusion, or the invasive proximal scarring stenosis caused by inflammation, or mesenteric Embedding the lateral filling defect area formed, the position and shape of the F. lesion can be changed or even disappeared at different times.

2 adult chronic intussusception: adult intussusception occurs mostly in the ileocecal area, and secondary to tumors, polyps, etc., X-ray images are: A. tincture in the nest, first into the nest, or nested The central tube, its performance is more characteristic, that is, the intestine cavity of the nesting part is obviously narrowed, because the filling part has different filling agents, different performances, and when filling for a long time, the wrinkles are vertical and flat, and when the filling is insufficient, It is only in a narrow and thin line shape, and the distal intestine is enlarged, and is wrapped around the central tube in a cup-shaped or spiral shape. B. Because the adult intussusception is more common in the ileocecal junction, the end of the ileum and its mesentery are involved. In the ascending colon, the tension of the mesangium causes the whole nesting part to be displaced inward and downward. When there is a local sputum, irritating, etc., the above-mentioned nested structure is unclear, if the ascending colon is seen, the hepatic curvature is inward. The phenomenon of lower displacement should be considered due to the occlusion of the ileocecal part, and the tuberculosis and tumor of the ileocecal area should be excluded. C. The expectorant was semi-obstructed by the extension of the nesting time, and the D. In the form, the expectorant only passes from one of them to the distal colon.

(3) Air enema examination: air enema inspection intussusception is developed on the basis of successful rehydration of water pressure perfusion. Since air enema is a bright gas, the nesting part is set as a soft tissue mass with high density. Shadow, not only can be diagnosed early, and has a complex effect, so it has dual clinical significance, with air enema to do colonic insufflation, the pressure is 6 ~ 8kPa, in the fluoroscopy, slowly inject air from the anus, initially air into the intestine The cavity is relatively easy, and suddenly stops when it reaches the head of the nest. Because the head of the sleeve protrudes into the inflatable colon, the front end of the air column forms a clear cup-shaped shadow. In the case of an airless enema, a low-pressure barium enema can also be used. method.

3, endoscopy: after partial gastric resection, gastrojejunostomy anastomosis can be confirmed by fiberoptic gastroscopy, endoscopic findings of congestion and edema of the small intestine mucosa through the anastomosis to the stomach, chronic intestinal intussusception can be used fiberoptic enteroscopy To diagnose, and at the same time, biopsy can be used to help determine the pathological nature. The nesting involving the colon can be diagnosed by colonoscopy, sigmoidoscopy or fiberoptic colonoscopy.

4, ultrasound examination: Intussusception sound image mainly for intestinal obstruction, intussusception and intestinal wall ischemia and other characteristics.

(1) manifestations of intestinal obstruction: the intestines above the intussusception are dilated and filled with liquid or semi-liquid content.

(2) The performance of the nesting part: the ultrasound of the nested part presents a substantial mass, the cross-section shows the "concentric circle" sign formed by the multi-layered intestinal wall, and the longitudinal section shows the "sleeve" sign, when the nesting When the intussusception is close to the abdominal wall or pediatric patients, a high-resolution probe of 5 to 7.5 MHz can be used to make the sign clearer.

(3) Intestinal wall ischemic necrosis:

1 peritoneal effusion, free anechoic area in the abdominal cavity, can be found in the liver and kidney gap, between the intestines.

Two sets of effusions in the stack showed a crescent-shaped dark area between the two layers of the intestine serosal layer.

The movement of the intestines near the 3 sets of folds was weakened, and no dynamic peristalsis or minimal peristalsis was observed dynamically, and the contents of the intestines were still.

4 color Doppler examination: such as the lack or disappearance of blood flow signals in the intestine, especially the arterial signal, when the disappearance prompts intestinal wall ischemia.

5, CT: Intussusception is characterized by a layered soft tissue mass in the abdominal cavity, the shape of which is parallel to the mass and vertical or oblique relationship.

When the intestine segment is parallel to the plane, the typical nesting has three layers of target ring structure, the outermost layer is the expanded and thick sheath sheath, the intestinal wall is thickened, and the middle layer is the fat-like low density of the mesentery with the insertion. , often on one side, which can be seen as dilated veins, in the form of spots or strips. When the intussusception is perpendicular to the plane, it can often clearly show the profile of the nesting. The inner layer is the soft tissue density, oral contrast agent. After that, the contrast agent is filled in the sheath and the central tube, and the mucosal fold development is changed by "spring".

Repeated nesting, that is, the formed nest is then inserted into the distal intestine, and the target ring is increased to 6 layers. The nesting part can be located at the center or side of the sheath. It is very important to observe the mesenteric changes carefully. The edema mesenteric nesting is divided into 2 The layer, the head is biased to one side of the sheath.

Multiple intussusception is common in several adjacent intestinal lumens that occur around or around the nesting target ring. If thickened mesangial vessels are seen, the blood vessels are twisted, and they are gathered and extended to other intestines, even if no other is seen. The target ring can also be used as one of the multiple occlusion signs.

Mesenteric edema, mesenteric vein showed coarse, suggesting mesenteric strangulation, poor venous return, such as gas shadow between the intestinal wall or the surrounding fat space, indicating perforation.

The shape of the necropsy intussusception is constant and the morphology is specific.

CT can determine the nature of the nesting according to the density in the nest, or the CT value. For example, the fat density of the fat is mostly the density of the lipoma. The appendix is mostly a mucous cyst. If the irregular solid mass is mostly a malignant tumor, etc. Can cause nesting.

6. MRI: There are few reports on application. The manifestation is that the proximal intubation of the intussusception is obviously dilated, and the gas and liquid-liquid planes are formed. The congenital round long/short T1 length/other T2 soft tissue mass signals can be seen in the intestine tube area. A small amount of free liquid is a long T1 long T2 signal.

7, other: Lande introduced the use of abdominal angiography to diagnose intussusception, Duszynski reported the use of nuclear 99Tc diagnosis of this disease, has not been widely used.

Intussusception diagnosis

diagnosis

Can be diagnosed based on clinical performance and laboratory tests.

Differential diagnosis

1, bacterial dysentery: acute onset, accompanied by vomiting and abdominal pain, at the same time can be bloody and confused with intussusception, but bacterial dysentery frequent stools, containing a lot of mucus and pus, early body temperature can be as high as 39 ° C Above, abdominal pain is not as strong as intussusception, no abdomen in the abdomen, and a large number of white blood cells and phagocytic cells can be seen in the stool, while intussusception stools are mainly red blood cells, and occasionally intussusception is secondary to bacillary dysentery. Pay attention.

2, appendicitis: infants under 2 years old with acute appendicitis are rare, and appendicitis generally no bloody stool, the abdominal mass is more late than intussusception, and more often in the appendicitis to form a package appendicitis or abscess around the appendix.

3, aphid intestinal obstruction: sick children have a history of worms, manifested as abdominal pain, bloating, vomiting, and sometimes spit out aphids, most can be in the umbilical or lower right abdomen and a cord-like or sausage-like mass, finger pressure High and low unevenness or sensation, X-ray examination, plain film can see multiple mites in the lumps; barium enema often shows that the mites in the expanded intestinal tract in the typical noodle-like or cluster small round filling defects.

4, abdominal purpura: manifested as abdominal pain, vomiting, blood in the stool and other symptoms, more common in children over 5 years old, fecal dark red or blood red, abdominal tenderness, but no lumps, can be complicated by rash, joint pain or hematuria, it is worthy of vigilance Yes, abdominal cyanosis due to intestinal dysfunction, can be complicated by intussusception, if necessary, can be X-ray examination to identify.

5, hemorrhagic necrotic enteritis: clinical manifestations of blood in the stool, abdominal pain, vomiting, stool is washed water, with special corruption and odor, early high fever and systemic symptoms.

6, acute necrotic enteritis: can be expressed as abdominal pain, vomiting and bloody stools, but the disease has a history of diarrhea, early can be manifested as abdominal distension, high fever and frequent spit, frequent stools, washed water samples, more, with Special odor, the general condition deteriorates quickly, often shows severe dehydration, skin patterns and other shock symptoms.

7, allergic purpura: more common in older children, most have fresh hemorrhagic rash, accompanied by joint pain, sometimes accompanied by hematuria, bloody stools are mostly dark red, the abdomen can not touch the mass, these symptoms help with the intestines Stack identification, sometimes this disease can be complicated with intussusception, should pay attention, X-ray examination should be done if necessary.

8, other: there are still strangulated internal hemorrhoids, intestinal torsion, colon polyps and other intestinal bleeding diseases, and sometimes misdiagnosed as intussusception, can be carefully identified by physical examination and necessary auxiliary examination.

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