Rare presentation of small bowel intussusception in childhood

Small bowel intussusception complicated simultaneously by volvulus in an older child is rare but clinically significant, necessitating urgent operative management. We report a local case of jejuno‐jejunal intussusception complicated by volvulus and bowel infarction in a 9‐year‐old Chinese girl, with diagnosis made on preoperative computed tomography and confirmed at laparotomy. An intestinal polyp as the lead point for intussusception was identified operatively.     

Postoperative intussusception in childhood

Over a period of 10 years, five children developed postoperative intussusception after intra-abdominal procedures at the Department of Pediatric Surgery of the Johannes Gutenberg University Mainz. Two appendectomies, one ileal resection for a Meckel's diverticulum, one operative procedure for Hirschsprung's disease plus intestinal neuronal dysplasia type B, and one hiatoplasty with jejunostomy preceded the intussusception. Three of the five children were older than 2 years. The clinical symptoms consisted primarily of abdominal distension, diffuse abdominal pain, bilious vomiting, and rectal bleeding in one case. Preoperative diagnosis was achieved in four cases by abdominal ultrasound. Plain abdominal radiographs demonstrated dilated loops of small intestine with air-fluid levels in four of the five cases. In the case without radiographic findings, the jejunojejunal intussusception was missed even by a bowel follow-through. The intussusceptions were ileocolic (3), ileoileal (1), and jejunojejunal (1). A hydrostatic procedure to reduce an ileocolic intussusception was not successful. Operative treatment of the intussusception was performed in three cases within 5 days, once at 32 days, and once 3 months after the primary operation, in all cases by laparatomy and simple manual reduction without intestinal resection. In contrast to idiopathic intussusception, noninvasive hydrostatic procedures are not indicated in postoperative intussusception, since protection of intestinal anastomoses from hydrostatic pressure and exclusion of other causes of postoperative ileus are mandatory.     

Acute intussusception in infancy and childhood

Summary 20 cases of acute intussusception in the paediatric age group have been presented. Three-fourths of the patients were below one year of age. Males predominated in the ratio of 9∶1. All the patients were operated upon. The postoperative complications were more common in the cases where resection of the gut was carried out. Four children in the group died in the hospital. From the Department of Paediatric Surgery, Post-graduate Institute of Medical Education and Research, Chandigarh-11.     

Complex presentation of intussusception in childhood

The simultaneous occurrence of intussusception and volvulus in the paediatric age group is rare. We report the case of a volvulus of an ileoileal intussusception in an 8-year-old boy. This is the first time that computerised tomography (CT) images of a volvulus of an ileoileal intussusception have been published, and they clearly demonstrate both pathologies. This case highlights the use of CT in determining the nature of an abdominal mass and demonstrates how helpful it can be in diagnosing the cause of small bowel obstruction in children.     

Reactive lymphocytes and intussusception in childhood

The peripheral blood smears of 15 infants with idiopathic intussusception and 23 controls with acute gastroenteritis were examined. We found an increased absolute number of reactive lymphocytes in the infants with intussusception compared to the controls (0.14×10⁹/1 +/– 0.08 and 0.07×10⁹/l +/– 0.07, respectively). This finding could reflect the irritation and enlargement of the intestinal lymphatic system that is believed to act as the lead point in idiopathic intussusception. Another explanation could be adenovirus infection, often associated with idiopathic intussusception, which is known to provoke morphologic changes in lymphocytes. These changes in the peripheral blood smear are mainly of pathogenetic interest and do not have a significant diagnostic impact in infants presenting with the typical clinical picture. However, in a child with suspected intussusception lacking typical clinical signs, the finding of reactive lymphocytes will recommend careful supervision.     

Twenty-one cases of small bowel intussusception: the pathophysiology of idiopathic intussusception and the concept of benign small bowel intussusception

Ultrasonography (US) was used to study intussusceptions prospectively at Kiyama Hospital in 1999 and 2000 under the classification of small bowel intussusception (SBI) and large bowel or ileo-ileo-colic intussusception (LBI). The clinical features, management, outcome and etiology were analyzed. All LBIs and SBIs with ischemic symptoms and SBIs complicated by LBI were treated by enema reduction, whereas SBIs considered to be nonischemic were observed. SBI was seen in 21 patients with a mean age of 62.6±31.2 months. Four cases (19.0%) were diagnosed during the course of LBI. US showed mesenteric lymphoid hyperplasia in 15 (71.4%). Hydrostatic enema reduction was successful in 9/9, and SBI reduced naturally in the other 12 (benign SBI). LBI occurred in 38 patients with a mean age of 27.8±21.2 months. Mesenteric lymphoid hyperplasia was observed in 29 (76.3%). Hydrostatic enema reduction was successful in 37/38. SBI occurs more frequently and in a wider age group than previously considered. Many SBIs reduced naturally, suggesting that they were only transient invagination phenomena and should be called benign SBI. The frequent association of SBI with LBI and also the frequent association of mesenteric lymphoid hyperplasia with both SBI and LBI seem the key to the pathophysiology of intussusception.     

Radiological evidence of bowel obstruction in intussusception

Several criteria have been proposed to identify patients likely to be at risk from barium reduction of intussusception, those with a high probability of having a pathological lead point, and those in whom an enema is unlikely to be successful. Signs of peritonitis and septicaemia are regarded as absolute contraindications to attempted barium reduction of intussusception, but as yet the radiological appearance of small bowel obstruction per se has not been substantiated as a contraindication. The presence of small bowel obstruction indicates that therapeutic reduction is less likely to be successful than in patients with normal or nonspecific plain radiographs (31% vs 57%) but is not in itself an indication that the examination would be unsafe. Patients with small bowel obstruction are acceptable risks for safe and successful therapeutic enemas, provided there is no clinical evidence of gangrenous bowel. Offprint requests to: J. de Campo     

Recurrent bowel intussusception and celiac disease

We report a 1-year-old girl with acute abdominal pain. Clinical examination revealed distended abdomen with increased intestinal peristalsis without other pathologic signs. Ultrasound of the abdomen showed a small bowel intussusception. Seven days later, after a new episode of sudden acute abdominal pain, ultrasound revealed a new bowel intussusception. Ig A and Ig G antigliadin-antibodies were elevated and intestinal biopsy revealed total villous atrophy. After being placed on a gluten-free diet the girl was free of colicky complaints and on repeated ultrasound there was no sign of intussusception. With recurrent intussusception, celiac disease should be considered as a cause.     

Adenovirus infection and childhood intussusception.

OBJECTIVE--To investigate the possible relationship between enteric adenovirus types 40 and 41 and intestinal intussusception in children. DESIGN--Prospective, case-control patient study. PATIENTS--Sixty-three consecutive children suspected clinically of having intestinal intussusception were enrolled in this study. Of these, 25 children (mean age, 1.4 years; range, 3 months to 5 years) had barium enema examination-proved intussusception. Age-matched normal controls (24) and controls with diarrhea (21) were obtained within 1 month of the index case. MEASUREMENTS AND RESULTS--Stools were tested for the presence of nonenteric adenovirus and enteric adenovirus using a monoclonal antibody-based enzyme immunoassay. Five (20%) of 25 children with intussusception had nonenteric adenovirus in their stools compared with one (4%) of 24 normal controls, none (0%) of 21 of the controls with diarrhea, and none (0%) of 37 patients suspected of having intussusception who had negative results on barium enema examination. However, no stool samples were positive for enteric adenovirus. CONCLUSIONS--Nonenteric adenovirus infection and intestinal intussusception may be associated. However, because enteric adenovirus was not found in any of the groups studied, no conclusions can be made regarding their possible influence on the risk for developing intussusception.     

Small bowel transplantation in children

Small bowel transplantation has become a life-saving procedure for selected adults and children with intestinal failure who are intolerant to parental nutrition. There are few pediatric data available on the results of this procedure. In this article we review the background of intestinal transplantation, present the results from the University of Western Ontario in London, Ontario and the University of Miami in Miami, Florida, and discuss some future directions. The majority of successful transplants are fully functional, and these children are able to assume a normal diet.     

Small bowel injuries in children

OBJECTIVE: To determine the common features of small bowel injury (SBI) in childhood and the consequences of delayed diagnosis. METHODOLOGY: A retrospective case review was performed of children with traumatic SBI between January 1988 and November 1999. RESULTS: Twenty-eight patients were identified with SBI. Road trauma accounted for 71% of them. Tachycardia was present on admission in 82% of patients with SBI including all but one of the intestinal perforations. SBI was associated with a Chance fracture of the lumbar spine in three patients (11%). An abdominal computed tomography scan with intravenous contrast was abnormal in all patients with a perforation or mesenteric tear. Diagnosis was delayed in six patients, one of whom died as a result of sepsis from a small bowel perforation. CONCLUSIONS: Persistent tachycardia with an appropriate mechanism of injury following blunt abdominal trauma requires active exclusion of SBI. Delayed diagnosis is associated with significant morbidity and mortality.     

Asymptomatic small bowel intussusception associated with post-transplant lymphoproliferative disease

Abstract:  A 2-yr-old boy who had undergone orthotopic liver transplantation for biliary atresia 6 months prior presented with generalized lymphadenopathy. Physical exam revealed lymphadenopathy only; the patient had no gastrointestinal signs or symptoms. CT was used to evaluate the patient's lymphadenopathy. The findings were consistent with PTLD, and an incidental intussusception causing small bowel obstruction was found. The intussusception was successfully managed expectantly, and the patient's PTLD responded to administration of rituximab. The etiology, diagnosis and management of intussusception is discussed.