Case Report

Intussusception- A Case Report

Gurubacharya SM1, Gurubacharya RL2
1
Dr. Simmi M Gurubacharya, MD Paediatrics, Lecturer, 2Dr. Rajesh L Gurubacharya, MD Paediatrics, Assistant Professor,
Department of Pediatrics, College of Medical Sciences, Kathmandu University.
Address for Correspondence: Dr. Rajesh Lal Gurubacharya
E-mail: rajesh_pul@hotmail.com

Abstract
Intussusception, the invagination of a portion of the intestine into itself, is one of the emergencies in infancy
and childhood. The etiology may be idiopathic or secondary to some pathology within the wall of the bowel.
Most cases (90%) are idiopathic1,2 with no identifiable lesion acting as the lead point or pathological apex3 of the
intussusceptum Children may present at any age but this occurs most commonly in the first year. The mode of
presentation may vary depending upon the time of presentation. A case of intussusception confirmed with the help
of an abdominal ultrasound in 10 month old infant who presented with only persistent vomiting but in the absence
of classic features is reported with brief review of literature.

Key words: vomiting, USG, classic triad

Introduction or rashes over the body. However, the mother told that the
Intussusception (IS), the most common cause of acute child was crying excessively, intermittently and was noticed
bowel obstruction in infants and young children which to be in distress due to vomiting. The patient was born at
commonly occurs at the terminal ileum (i.e.ileocolic). The hospital; birth weight was normal. Her immunisation was
telescoping proximal portion of bowel (i.e. intussusceptum) complete according to EPI (national) schedule. Her feeding
invaginates into the adjacent distal bowel (i.e. intussuscipiens). history was also normal. The developmental milestones were
Most patients recover if treated within 24 hours. If left appropriate for age.
untreated, this condition is uniformly fatal in 2-5 days.
Mortality with treatment is 1-3% Recurrence is observed in On physical examination, child was of average built.
3-11% of cases. Most recurrences involve intussusceptions Her height, weight and head circumference were within
that were reduced with contrast enema. Overall, the male- normal limits. Pulse rate, respiratory rate, temperature and
to-female ratio is approximately 3:1. Intussusception is most BP were normal. She was anicteric. There were no features
common in infants aged 3-12 months, with an average age of dehydration. Her hernial orifices were normal. Rest of the
of 9 months4. Intussusception occurrence is rare in persons general examination was also normal. Systemic examination
younger than 3 months, and it becomes less common in revealed no abnormalities. All routine investigations
persons older than 36 months. The classic triad of colicky including SGOT, SGPT were normal. Finally USG of the
abdominal pain, vomiting, red currant jelly stools or whole abdomen was advised because of the major symptom
abdominal mass occurs in 12.5%-46% of cases4. i.e. the persistent vomiting was present without pointer to
rule out or confirm any surgical condition. However, USG
Ultrasonography in Pediatrics; an accurate, safe and confirmed (Fig.1) the diagnosis, which was a suspected
valuable clinical tool is being increasingly used as the intussusception, the most common cause of acute intestinal
primary investigation for the diagnosis of IS and to guide air obstruction in infants.
or hydrostatic enema reduction4,5. The use of ultrasonography
for a patient with suspected IS prevents unnecessary Fig.1: USG Showing Loops with the Loops of Bowel
radiological or surgical procedures being performed, and
reduces radiation exposure while maintaining a high level
of diagnostic accuracy5. When small-bowel intussusception
is detected in infants and children undergoing abdominal
sonography, intussusception length greater than 3.5 cm
is a strong independent predictor of the need for surgical
intervention6.

Case Report
A 10-month-old female infant was brought to the OPD
with complaints of persistent vomiting, non-bilious, non-
projectile in nature for two days for which the child was given
anti-emetics from outside. According to the mother, there
was no history of fever, loose stools mixed with blood and
mucus, coryza, cough, any urinary problems, nor convulsions

J. Nepal Paediatr. Soc. Vol 27, No. 2 -84-

Discussion by progressive compression of the bowel just distal to it as
Intussusceptions commonly occur below one year , 7 done in our case. If reduction is not possible, or gangrene
a finding confirmed in our case. Intussusception is said to has set in, resection of the affected bowel has to be done,
occur in well-nourished infants8, though also seen in many followed by either Mickulicz procedure or a primary end-to-
malnourished children. The patients usually present with end anastomosis which did not happen in our child. A newer
symptoms of pain, vomiting, blood in the rectal discharge mode of therapy introduced by the Chinese is the concept of
and a palpable mass but not occurred in our case except air pressure enema reduction of intussusception12,13.
vomiting. Early on, the abdomen is flat or scaphoid, as time
passes distension and intestinal loops may obscure the mass. Conclusion
The ‘classic’ picture of intussusception (vomiting,
Intussusceptions, can be of various types like the ileo- abdominal pain, bloody/red currant jelly stool, or abdominal
ileal, ileo-caecal, ileo-colic, ileocaeco-colic, jejuno-ileal, mass) might not be frequently present in children with
colo- colic of which the ileo-colic was the most common and intussusception. Reliance on ‘classic’ features alone might
only 2 -8%7,8,9 of intussusceptions have a recognizable lesion delay diagnosis. Median time to confirmation of diagnosis is
acting as the lead point. Various lesions have been cited like usually 19 hours from onset of symptoms4. Delayed diagnosis
Polyps, Meckel’s diverticulum, Hypertrophied Lymphoid is associated with poorer patient outcomes. Thus in the light
Patch, Human Reovirus like agent a cause of gastroenteritis in of above mentioned case, child with persistent vomiting
children8, Enteric Cysts, Ectopic Pancreatic Tissue, and even without pointer may need to be differentiated from common
Henoch-Schonlein purpura8. It can occur after abdominal surgical condition particularly in an infant to prevent fatality.
operative manipulations like Eke resection of coarctation of Also the importance of USG is stressed, which is a simple and
aorta, resection of Wilms tumour, biopsy for neuroblastoma. useful method of making the diagnosis of intussusception.

Due to the pathogenesis of this disease, the mesentery Acknowledgement

of the invaginated bowel is compressed between the layers of
The author would like to acknowledge the parents who
the intussusceptum, hence the longer it remains unreduced the
kindly consented for publication. The authors are thankful
higher the chances of gangrene setting in and lesser chances
to the Director and the hospital management for granting
of reduction (of the intussusception). In 1871, Hutchinson
permission to publish the case report.
successful operated upon an infant with intussusception8.
Shortly afterward Hirschsprung10 reported a series of children
whose intussusception was reduced by retrograde hydrostatic
References
pressure. Since that time the mode of therapy has become 1. Kim YS, Rhu JH. Intussusception In Infancy and
controversial. More and more institutions are shifting to Childhood: Analysis of 385 Cases. Int Surg 1989;
barium enema reduction as primary treatment in most of their 74:114-118.
patients. 2. AI-Salem AH, Habash 8M. Ileoileal Intussusception: A
Report of Four Cases. Ann Saudi Med 2000; 20:310-
To achieve success with this method, certain principles 312.
must be vigorously observed8. The pre-requisites before
attempting a barium enema are that duration of symptoms 3. Stringer MD, Pablot SM, Brereton RJ. Pediatric
should be less than 2 days as not happened in our case, there Intussusception. Br J Surg 1992; 79: 867-876
should not be signs of intestinal obstruction on abdominal 4. Blanch AJ, Perel SB, Acworth JP. Paediatric
radiography, and there should be no signs of localised or Intussusception: Epidemiology And Outcome. Emerg
generalised peritonitis. The barium enema reduction is Med Australas 2007; 19(1):45-50.
confirmed if there is free flow of barium into the terminal ileum, 5. Justice FA, de Campo M, Liem NT, Son TN, Ninh
expulsion of faeces and flatus with barium, disappearance TP, Bines JE. Accuracy of Ultrasonography For The
of the mass, and clinically child becomes comfortable. Diagnosis Of Intussusception In Infants In Vietnam.
Reduction attempts are abandoned9 if the intussusception Pediatr Radiol. 2007; 37(2):195-199.
does not move for more than 10 minutes; there is partial
reduction, a poor ileal reflux, a persistent mass in the ileum, 6. Munden MM, Bruzzi JF, Coley BD, Munden RF.
or leak of barium suggesting colonic perforation11. The Sonography Of Pediatric Small-Bowel Intussusception:
benefits of barium enema reduction procedure are complete Differentiating Surgical From Nonsurgical Cases: AJR
reduction without surgery, no anaesthesia is required, no Am J Roentgenol. 2007; 188(1):275-9.
morbidity, early ambulation, less stay in the hospital, no 7. Dennison WH, Shaker M. Intussusception In Infancy
scar. The disadvantages are its uselessness in ileo ileal And Childhood. Brit J Surg 1970; 57:679-684.
intussusception; recurrence rate is higher (11%) than after
8. Ravitch MR. Intussusception. In: “Paediatric Surgery”,
operative reduction (3%)11, specific recognizable lead points
4th Ed.Welch KJ, Randolph JG, Ravitch MM, O’Neill
can be missed (2-8%), in unsuccessful cases a dangerous
JA, Rowe MI, editors. Chicago: Year Book Medical
delay, colonic perforation11, and the possibility of reducing
Publishers, Inc; Chicago, 1986, pp 868-881.
nonviable bowel.
9. Rosenkrantz JG, Cox JA, Silverman FN, Martin LW.
The standard treatment of intussusception used to be Intussusception In 1970s: Indication For Operation. J
operative reduction by milking back of the intussusception Paed Surg 1977; 12:367-373.

-85-
10. Hirschsprung H. Tilfaelde Of Subakut Tannin- 12. Guo JZ, Ma XX, Zhou QH. Results of Air Pressure
Vagination. Hospitalstid 1876; 3:321-327. Enema Reduction Of Intussusception 6396 Cases: 13
11. Ein SH, Mercer S, Humphrey A, Mac-donald P. Colon Years. J Paed Surg 1986; 21:1201-1203.
Perforation During Attempted Barium Enema Reduction. 13. Jinzine Z, Yenxia W, Linchi W. Rectal Inflation
J Paed Surg 1981; 16:313-315. Reduction Of Intussusception In Infants. J Paed Surg
1986; 21:12-13.

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