Intussusception in a preterm newborn

Abstract

Intussusception, the second most common abdominal emergency in childhood, is three times more common in men, and the peak age is before 2 years.1DiFiore J.W. Intussusception.Semin Pediatr Surg. 1999; 8: 214-220Abstract Full Text PDF PubMed Scopus (86) Google Scholar, 2Raza H.A. Basamad M.S. El Komy M.S. Maghrabi A.A. Habbach H. Abokrecha A.Y. Diagnosing intussusception in preterm neonates: case report and overview.J Clin Neonatol. 2014; 3: 103-105Crossref PubMed Google Scholar, 3Mooney D.P. Steinthorsson G. Shorter N.A. Perinatal intussusception in premature infants.J Pediatr Surg. 1996; 31: 695-697Abstract Full Text PDF PubMed Scopus (31) Google Scholar The incidence in neonates is 0.3–1.3 per 6000 cases.2Raza H.A. Basamad M.S. El Komy M.S. Maghrabi A.A. Habbach H. Abokrecha A.Y. Diagnosing intussusception in preterm neonates: case report and overview.J Clin Neonatol. 2014; 3: 103-105Crossref PubMed Google Scholar, 3Mooney D.P. Steinthorsson G. Shorter N.A. Perinatal intussusception in premature infants.J Pediatr Surg. 1996; 31: 695-697Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 4Avansino J.R. Bjerke S. Hendrickson M. Stelzner M. Sawin R. Clinical features and treatment outcome of intussusception in premature neonates.J Pediatr Surg. 2003; 38: 1818-1821Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Till date, only 17 reports are available in PubMed and less than 50 cases in the English literature. Most of the cases were misdiagnosed as necrotizing enterocolitis (NEC), causing a delay in treatment. Herein, we present a case, demonstrating how it is important that an early diagnosis in premature neonates with nonspecific symptoms affects the outcome. A boy weighing 2030 g born at the 30th week of gestation by vaginal delivery was admitted on postnatal 17th day due to bilious vomiting and rectal bleeding for the last 2 h. Pregnancy was uneventful. He was followed up in the neonatal intensive care unit (NICU) for 10 days and intubated for a day. He tolerated oral feeding and had daily defecation. His general condition was mildly poor and skin turgor was decreased, suggesting 10% dehydration at the time of admission. There was tenderness and a suspicious mass at the right lower quadrant, with normal bowel sounds. Laboratory examinations were normal, except for elevated leukocyte count and C reactive protein (CRP) levels. Abdominal X-ray showed only mildly dilated intestinal loops (Fig. 1A). An intussuscept, 2 cm in length and located at the right abdominal quadrant without a classical target sign, was reported in ultrasonography (Fig. 1B). Because of a higher possibility of NEC, he was followed up for 6 h with antibiotics, supportive treatment, and intestinal decompression. Bilious drainage from the nasogastric tube increased. Due to deterioration in clinical status, it was decided to perform an operation. There was an ileoileal intussusception without a precipitating cause, and it was reduced manually (Fig. 1C). There was no ischemia or necrosis. He was followed up in the NICU and intubated for a day. He had defecation 30 h after the operation, tolerated oral feeding 3 days' postoperatively, and was discharged on the 5th day. He has been free of any problems for the last 2 years. Diagnosis of intussusception requires high suspicion in premature infants. Clinical symptomatology alone is not reliable. These symptoms in premature neonates when constellate with abdominal distension are very suggestive of NEC, the most common acquired gastrointestinal emergency in the NICU. This leads to delay in treatment of patients. Most of the reported cases were diagnosed peroperatively or at autopsy.2Raza H.A. Basamad M.S. El Komy M.S. Maghrabi A.A. Habbach H. Abokrecha A.Y. Diagnosing intussusception in preterm neonates: case report and overview.J Clin Neonatol. 2014; 3: 103-105Crossref PubMed Google Scholar, 3Mooney D.P. Steinthorsson G. Shorter N.A. Perinatal intussusception in premature infants.J Pediatr Surg. 1996; 31: 695-697Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 4Avansino J.R. Bjerke S. Hendrickson M. Stelzner M. Sawin R. Clinical features and treatment outcome of intussusception in premature neonates.J Pediatr Surg. 2003; 38: 1818-1821Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 5Puvabanditsin S. Garrow E. Samransamraujkit R. Lopez L.A. Postnatal intussusception in a premature infant, causing jejunal atresia.J Pediatr Surg. 1996; 31: 711-712Abstract Full Text PDF PubMed Scopus (13) Google Scholar The most crucial step during the neonatal period is the timing of surgery. As time passes, the probability of developing ischemia and necrosis increases. Premature neonates are at an increased risk of developing intestinal hypoperfusion causing intestinal stasis and dysmotility, which would be a reasonable explanation for intussusceptions and rapid deterioration. The case presented here differs from those reported in the literature in not only being diagnosed preoperatively, but it is also the earliest diagnosed and the only one in which the intussusception was manually reduced. Several patients were misdiagnosed with NEC, causing a 28-day delay in the operation. The abdominal plain film is not usually helpful in the diagnosis of neonatal intussusception. Although abdominal ultrasonography is the key modality in diagnosis, it has been mostly performed to exclude congenital anomalies, thus underutilizing its usefulness. The decision for performing an operation could be taken after severe clinical deterioration of the patient or in the presence of free air in abdominal graphs. Only three cases have been reported to be diagnosed preoperatively within the earliest 28 h after the first symptom.3Mooney D.P. Steinthorsson G. Shorter N.A. Perinatal intussusception in premature infants.J Pediatr Surg. 1996; 31: 695-697Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 5Puvabanditsin S. Garrow E. Samransamraujkit R. Lopez L.A. Postnatal intussusception in a premature infant, causing jejunal atresia.J Pediatr Surg. 1996; 31: 711-712Abstract Full Text PDF PubMed Scopus (13) Google Scholar Rectal contrast enema should not be used, despite its usefulness for the diagnosis and treatment of intussusception, due to the vulnerability of the intestines to perforation.2Raza H.A. Basamad M.S. El Komy M.S. Maghrabi A.A. Habbach H. Abokrecha A.Y. Diagnosing intussusception in preterm neonates: case report and overview.J Clin Neonatol. 2014; 3: 103-105Crossref PubMed Google Scholar, 4Avansino J.R. Bjerke S. Hendrickson M. Stelzner M. Sawin R. Clinical features and treatment outcome of intussusception in premature neonates.J Pediatr Surg. 2003; 38: 1818-1821Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Even though pneumatic reduction is the preferred treatment for intussusception in our center, it was not chosen in this case due to the elevated risk for perforation. Prompt diagnosis and shorter operation time enabled faster improvement and shorter postoperative period in contrast to its counterparts in the literature in which resection of intestines was required and the length of stay was 3 weeks.2Raza H.A. Basamad M.S. El Komy M.S. Maghrabi A.A. Habbach H. Abokrecha A.Y. Diagnosing intussusception in preterm neonates: case report and overview.J Clin Neonatol. 2014; 3: 103-105Crossref PubMed Google Scholar, 3Mooney D.P. Steinthorsson G. Shorter N.A. Perinatal intussusception in premature infants.J Pediatr Surg. 1996; 31: 695-697Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 4Avansino J.R. Bjerke S. Hendrickson M. Stelzner M. Sawin R. Clinical features and treatment outcome of intussusception in premature neonates.J Pediatr Surg. 2003; 38: 1818-1821Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Open surgery should be the treatment of choice due to the possibility of congenital anomalies. Late diagnosis might result in extended surgery, longer hospital stays, and death, mostly due to sepsis or perforation. NEC itself may lead to intussusception. The etiology of three patients in the literature has been reported as strictures due to NEC.6Smith V.S. Giacoia G.P. Intussusception associated with necrotizing enterocolitis.Clin Pediatr (Phila). 1984; 23: 43-45Crossref PubMed Scopus (26) Google Scholar, 7Hirokawa S. Uotani H. Yoshida T. Tsukada K. Ileoileal intussusception and ileal stricture associated with necrotizing enterocolitis in a premature infant: report of a case.Surg Today. 2001; 31: 1097-1099Crossref PubMed Scopus (9) Google Scholar However, most of the remaining were due to intestinal atresia, while some others were due to Meckel diverticula, duplication cysts, or hamartomas.1DiFiore J.W. Intussusception.Semin Pediatr Surg. 1999; 8: 214-220Abstract Full Text PDF PubMed Scopus (86) Google Scholar, 2Raza H.A. Basamad M.S. El Komy M.S. Maghrabi A.A. Habbach H. Abokrecha A.Y. Diagnosing intussusception in preterm neonates: case report and overview.J Clin Neonatol. 2014; 3: 103-105Crossref PubMed Google Scholar, 3Mooney D.P. Steinthorsson G. Shorter N.A. Perinatal intussusception in premature infants.J Pediatr Surg. 1996; 31: 695-697Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 4Avansino J.R. Bjerke S. Hendrickson M. Stelzner M. Sawin R. Clinical features and treatment outcome of intussusception in premature neonates.J Pediatr Surg. 2003; 38: 1818-1821Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 5Puvabanditsin S. Garrow E. Samransamraujkit R. Lopez L.A. Postnatal intussusception in a premature infant, causing jejunal atresia.J Pediatr Surg. 1996; 31: 711-712Abstract Full Text PDF PubMed Scopus (13) Google Scholar The patient presented here did not have any lead point. The subtle clinical and radiologic features of intussusception in premature neonates are difficult to distinguish from those of early NEC. The application of ultrasound is a feasible method in the early detection of intussusception, facilitating prompt surgical intervention and improving the outcome after surgery.