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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 57-59

Bowel intussusception in premature baby: Needs high degree suspicion for early detection


Department of Paediatric Surgery, Sion Hospital, Mumbai, Maharashtra, India

Date of Web Publication29-Jan-2019

Correspondence Address:
Dr. Aboli Raghuvir Hukeri
Department of Paediatric Surgery, 4th Floor, Room No. 440, College Building, Sion Hospital, Sion, Mumbai - 400 022, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_89_18

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  Abstract 


Intussusception is a rare entity in neonates, and its' symptomatology is almost exactly similar to necrotizing enterocolitis (NEC). A 30-week preterm newborn was initially suspected to have to NEC based on clinical conditions and radiological findings, which turned out to be jejunojejunal intussusception with bowel gangrene on exploratory laparotomy. An initial diagnosis of NEC was made, and the neonate was treated with nonsurgical management. This led to difficulty in the diagnosis of intussusception. The patient died of sepsis in postoperative period. In preterm newborns, conditions other than NEC can have similar pathological abdominal findings, and hence suspicion is needed for timely diagnosis and urgent surgical management.

Keywords: Intussusception, necrotizing enterocolitis, neonate, preterm


How to cite this article:
Hukeri AR, Gupta A, Kothari P, Dikshit V, Kekre G, Deshmukh S, Deshpande A, Kulkarni A. Bowel intussusception in premature baby: Needs high degree suspicion for early detection. J Clin Neonatol 2019;8:57-9

How to cite this URL:
Hukeri AR, Gupta A, Kothari P, Dikshit V, Kekre G, Deshmukh S, Deshpande A, Kulkarni A. Bowel intussusception in premature baby: Needs high degree suspicion for early detection. J Clin Neonatol [serial online] 2019 [cited 2019 Jul 22];8:57-9. Available from: http://www.jcnonweb.com/text.asp?2019/8/1/57/250987




  Introduction Top


Intussusception is an extremely rare clinical entity in neonates, especially among premature ones.[1],[2] This clinical entity is confused with other causes of intestinal obstruction making delays in correct diagnosis.

We report a case of intussusception in a preterm neonate of 30 weeks of gestation whose initial diagnosis was made as necrotizing enterocolitis (NEC) and turned out to be jejunojejunal intussusception with bowel gangrene on exploratory laparotomy.

We report the case to create awareness regarding the rare entity for which a high degree of suspicion is needed to avoid delay and unnecessary management.


  Case Report Top


A preterm male neonate, weighing 1160 g, was delivered by cesarean section for severe maternal preeclampsia at 30 weeks of gestation. The Apgar score was one at 1st min. Hence, he was managed on assisted ventilation immediately after birth in view of severe birth asphyxia with no spontaneous respiration. Natural surfactant-beractant was administered through endotracheal tube at 100 mg/kg dose within 30 min of life for respiratory distress syndrome. Total parenteral nutrition (TPN) was initiated from day of life one, and breast milk feeding with orogastric tube was started on the day of life two. His general condition remained stable until day of life four. Neonate developed bilious vomiting with coffee-ground colored orogastric aspirate and progressive abdominal distension. He passed a small amount of meconium daily. Initial X-ray abdomen and pelvis [Figure 1] showed generalized bowel dilatation without pneumatosis intestinalis or free air. Complete blood counts and serum electrolytes were found within normal limits. Arterial blood gas showed compensated metabolic acidosis. C-reactive protein (CRP) was 7 mg/L. NEC was suspected. Orogastric feedings were discontinued on the same day, and umbilical catheters were removed. Broad-spectrum antibiotics were started. The patient had same findings till 18 h of onset of the event after which there was increase in abdominal girth. Repeated X-ray showed few dilated bowel loops in center surrounded by ground glass opacity [Figure 2]. Abdominal ultrasound showed mild interbowel-free fluid, dilated bowel loops and none other details could be seen due to gaseous distention of bowel loops which created a difficulty in ultrasound-guided needle aspiration. The neonate was intervened for intraperitoneal drain placement which revealed scanty amount of serous peritoneal fluid. After 12 h of drain placement, the clinical condition of the patient did not improve, but abdominal distension continued with dilated fixed bowel loops on repeat X-ray [exactly same as [Figure 2]. The patient was taken for urgent exploratory laparotomy which revealed a jejunojejunal intussusception at 38 cm from ligament of Treitz, with proximal dilated and gangrenous bowel [Figure 3]. The proximal bowel gangrene was probably because of excessive distention leading to luminal venous followed by arterial compression. Resection of gangrenous necrotic segment of length 32 cm and diverting double-barrel jejunostomy and ileostomy were performed. The total remaining small bowel length was 5 cm from duodenojejunal flexure and 20 cm with the intact ileocaecal valve. Postoperatively, neonate was managed on TPN and broad-spectrum antibiotics such as meropenem and metronidazole. Repeat CRP was 78 mg/L, and blood culture grew Gram-negative bacilli sensitive to meropenem. The baby continued to progress with disseminated intravascular coagulopathy, and on postoperative day 3, the patient died. Histopathology report of resected bowel showed transmural infarction and jejunal intussusception without leading point.
Figure 1: X-ray abdomen+pelvis on onset of the incidence (day of life 4)

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Figure 2: X-ray abdomen+pevis on18 hours of onset of incidence

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Figure 3: Proximal dilated and gangrenous bowel with distal viable and collapsed bowel and the transition between the two bowels is site of jejunojejunal intussusception

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In our case, NEC was the first diagnosis made on clinical and radiological findings basis which lead a baby to have further consequences of gangrene and sepsis. Hence, we report the case to create awareness about the rare entity.


  Discussion Top


In the neonatal period, the reported incidence of intussusception is 0.3%–2.7%.[1],[2] It is exceedingly rare in premature neonates.[1]

The most common site of intussusception in full-term neonates is ileocolic junction[2] while in preterm it is ileum.[1],[2]

Clinical signs of intussusception are abdominal distension, bilious aspirate in Ryle's tube, intolerance to feeds, per-rectal passage of currant jelly stools or bleeding. These are very similar to signs of NEC, especially considering preterm population.

Plain abdominal radiographic imaging in neonatal intussusception is generally unremarkable with features of obstruction such as multiple air-fluid levels or dilatation of bowel loops. Although ultrasonography of abdomen has high sensitivity in identifying lead point and intussusceptions,[1],[2],[3],[4] distended bowel loops overlapping the intussusception may obscure it masking and delaying correct diagnosis.

Unlike in older children, etiology of intussusception remains unclear in most neonatal cases, but sometimes, meconium plugs,[1] duplication cyst, hamartoma, and Meckel's diverticulum[1] are seen as pathological leading points (PLP).[1] In premature neonates, intestinal dysmotility and stricture, as a result of perinatal insult leading to intestinal hypoperfusion/hypoxia, may act as a leading point for intussusception.[2]

In cases of intussusceptions of large bowel or ileocolic region (which have not progressed to gangrene); hydrostatic reduction with fluoroscopic guidance can be attempted. While if any intussusception is found on exploratory laparotomy, manual reduction, or resection of PLP or gangrenous portion, whichever applicable for the specific site and status of bowel involved, remains the treatment of choice.

The prognosis is good if case is timely managed and not associated with gangrene, sepsis, comorbidities due to prematurity.

Differential diagnoses of intussusceptions in newborn are NEC (more common in preterm), bowel atresia, meconium plug syndrome, meconium ileus, and intestinal neuronal dysplasia. For each of these, definitive treatment is different while the treatment of NEC, the first and most suspected condition due to similar clinical and radiological findings in preterm neonates, can be medical management, peritoneal drainage, or exploratory laparotomy. Difficulty in correct diagnosis of intussusception in neonates may end up in not providing the definitive management for the particular intussusceptions which may jeopardize the viability of involved bowel.[1],[5]

To avoid the delay in correct diagnosis, treating clinicians should be aware of entity “intussusception in neonates” although they will face such conditions rarely. Only high degree of suspicion and timely exploratory laparotomy will help to lead diagnosis of intussusceptions, which have not been detected even radiologically.


  Conclusion Top


Preterm neonatal intussusception is an uncommon entity about which treating doctor should be aware of. Similar clinical and radiological findings can also be due to other conditions, and high index of suspicion is needed for timely diagnosis and useful intervention for intussusception.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was supported by LTMMC, Sion.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bothara VP, Pandey A, Rawat J. Neonatal intussusception: A review. J Neonatal Surg 2018;7:5.  Back to cited text no. 1
    
2.
Price KJ, Roberton NR, Pearse RG. Intussusception in preterm infants. Arch Dis Child 1993;68:41-2.  Back to cited text no. 2
    
3.
Ein SH, Marshall DG, Girvan D. Peritoneal drainage under local anesthesia for perforations from necrotizing enterocolitis. J Pediatr Surg 1977;12:963-7.  Back to cited text no. 3
    
4.
Ohuoba E, Fruhman G, Olutoye O, Zacharias N. Perinatal survival of a fetus with intestinal volvulus and intussusception: A case report and review of the literature. AJP Rep 2013;3:107-12.  Back to cited text no. 4
    
5.
Avansino JR, Bjerke S, Hendrickson M, Stelzner M, Sawin R. Clinical features and treatment outcome of intussusception in premature neonates. J Pediatr Surg 2003;38:1818-21.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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