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CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 1  |  Page : 48-50

Diagnostic dilemma in childhood intussusception presenting with encephalopathy


1 Department of Pediatric Medicine, R G Kar Medical College, Kolkata, West Bengal, India
2 Department of Pediatric Surgery, R G Kar Medical College, Kolkata, West Bengal, India

Date of Submission06-Feb-2022
Date of Acceptance16-Feb-2022
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Pankaj Halder
Saroda Palli, Panchanon Tala, Baruipur, Kolkata - 700 144, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjmsr.mjmsr_6_22

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  Abstract 


Intussusception is the telescoping of one bowel segment into another. Usually, children below 1 year of age experience this condition and have classical symptoms such as abdominal pain, vomiting, and bleeding per rectum. However, unusual clinical presentations, especially in older children, may deceptively mislead the diagnosis, particularly in the absence of the classical symptoms. We report a case of an 11-year-old male child who presented with seizures, altered sensorium, and nonbilious vomiting. During the emergency surgery, he was diagnosed with an ileoileal intussusception with proximal gut perforation and peritonitis. He had a speedy recovery from neurological symptoms after the surgical intervention.

Keywords: Exploratory laparotomy, ileoileal, ileostomy, intussusception, perforation peritonitis


How to cite this article:
Ganguly M, Biswas P, Chakraborty P, Halder P. Diagnostic dilemma in childhood intussusception presenting with encephalopathy. Muller J Med Sci Res 2022;13:48-50

How to cite this URL:
Ganguly M, Biswas P, Chakraborty P, Halder P. Diagnostic dilemma in childhood intussusception presenting with encephalopathy. Muller J Med Sci Res [serial online] 2022 [cited 2022 Sep 29];13:48-50. Available from: https://www.mjmsr.net/text.asp?2022/13/1/48/355299




  Introduction Top


Intussusception is one of the most common causes of intestinal obstruction in infancy and early childhood. More than 80% of the intussusceptions are of the ileocolic type.[1] The small bowel intussusception accounts for <10% of all the cases. The classical symptoms are acute abdominal pain, vomiting, and bleeding per rectum.[2] Rarely, the neurological symptoms may precede and mask the gastrointestinal symptoms. The unusual age group and variable presentations contribute to the frequent delay in diagnosis, leading to increased mortality and morbidity. Here, we report a unique case of ileoileal intussusception with perforation peritonitis who had predominantly neurological symptoms, posing a management dilemma.


  Case Report Top


An 11-year-old male child was referred from a district hospital to our emergency with a history of one episode of generalized convulsion, altered sensorium, low-grade fever, and three episodes of nonbilious vomiting for the last 2 days. His immunization status was up to date. He had no history of trauma or ingestion of drugs. After admission, he had another episode of generalized tonic-clonic seizures for 5 min, which was aborted with intravenous sodium valproate. He had a heart rate of 130/min, blood pressure of 94/70 mmHg, respiratory rate of 28/min with a regular respiratory pattern, capillary blood glucose of 121 mg/dl, a body temperature of 101°F, and SpO2 of 94% in room air. He had a decreased tone in all four limbs but had no neck rigidity or signs of meningism. Glasgow Coma Scale was E2 V2 M5 with bilateral symmetrical and reactive pupils and no papilledema (fundoscopic examination). Complete blood count revealed a neutrophilic leukocytosis (TLC 18,480; N68, L19) with C-reactive protein of 6.5 mg/L, Na – 124 mmol/L, K – 3.8 mmol/l, Ca – 1.11 mmol/l, urea – 46 mg/dl, and creatinine – 0.9 mg/dl. Urine output was 0.8 ml/kg/hr at the time of admission. Cerebrospinal fluid analysis was within the normal range (0–1 cells/microliter, lymphocytic, sugar 90 mg/dl [CBG – 116 mg/dl], microprotein was 21 mg/dl with no coagulum). On abdominal examination, there was diffuse tenderness with muscle guarding all over the abdomen. Straight X-ray of the abdomen in erect posture at the time of admission was essentially normal (no evidence of free air under the diaphragm or bowel obstruction). We decided to manage him conservatively with fluid and intravenous antibiotics and monitor his vitals in the pediatric intensive care unit (PICU). After a period of 12 h, he started profuse vomiting with bilious aspirate in nasogastric tube suction, developed bleeding per rectum, and went into shock. Repeat abdominal examination by our pediatric surgeon revealed a circumscribed palpable mass (2.5 cm × 1.5 cm) in the right iliac fossa. Despite extensive medical therapy, he did not respond well, and a repeat urgent portable straight X-ray abdomen showed multiple air–fluid levels [Figure 1]. The child was then taken up for emergency surgery and found to have an ileoileal intussusception with proximal ileal perforation and peritonitis [Figure 2]. Resection of the gangrenous ileal segment and temporary diversion ileostomy were performed. He was eventually managed with fluids, antibiotics, and inotrope support in PICU. He had a dramatic improvement in respect to his previous neurological status within 36 h of surgery. The biopsy report of the resected ileum suggested gangrenous bowel (intussusceptum) but did not find any lead point such as polyp, tumor, or granulomatous lesion in the involved segment of the ileum. We discharged him with a stoma (ileostomy) on the 7th postoperative day. Finally, he underwent ileostomy reversal after 6 weeks. He had a smooth postoperative recovery after the ileostomy closure. Now the child is doing well.
Figure 1: Straight X-ray abdomen showed multiple air–fluid level in an 11-year old male child with neurological symptoms

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Figure 2: Peroperative pictures showed ileo-ileal intussusception with proximal ileal perforation and necrosis of the adjacent ileum

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  Discussion Top


Intussusception is one of the common surgical emergencies that mostly trouble infants between the 5th and 9th months of their life. It is broadly classified as ileocolic, ileo-ceco-colic, colocolic, jejunojejunal, ileoileal, sigmoidorectal, and appendicocecal.[3] Of these, the ileocolic intussusception is a classical and common clinical entity. The condition is rare in the adolescent period and is usually associated with an obvious lead point. Our patient had an ileoileal intussusception and had no obvious lead point. About 90% of the intussusception in infants are idiopathic (no obvious triggering factor).

Patients with intussusception usually have gastrointestinal symptoms and may have a classic triad of symptoms such as abdominal pain, palpable or shifting mass in the abdomen, and bloody stool (red currant jelly), although it varies from series to series.[4] Our patient was an adolescent child and had predominantly neurological symptoms, which led us to a diagnostic dilemma.

The pathophysiology of altered mental status was unclear in our case.[5] Louachama stated that various neuromediators (endotoxins, intestinal neurohormones, and endorphins) released by the ischemic bowel probably have action on the nervous system.[6] Pumberger et al. reported 13 cases where neurological symptoms were preceded by gastrointestinal symptoms.[7] The prominent neurological signs in an older child with intussusception compel a pediatrician to perform an exhaustive investigation panel to exclude the possible causes of acute encephalitis such as infectious, vascular, toxic, electrolytic, autoimmune, metabolic, and epileptic.[8],[9]

Early surgical reduction of the intussusception is recommended because of the probability of ischemic necrosis of small bowels. One of the limitations of our study was that we did not have a portable ultrasonography facility in our PICU that could diagnose the case earlier. A straight X-ray of the abdomen in erect posture may show specific findings of bowel obstruction or an air crescent sign between the walls of the intussusceptum and intussuscipiens. Computed tomography is costly but delineates properly even in transient intussusception.[10]


  Conclusion Top


Intussusception in the late childhood period may present with vague signs and symptoms. The clinical presentation of such cases, where neurological symptoms predominate, may at times mislead to a definitive diagnosis. Due to the rarity of this condition in older children, it easily escapes the eye of a physician and often results in delayed management. Hence, acute intussusception should also be considered in children presenting with neurological symptoms and with less obvious gastrointestinal symptoms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stringer MD, Pablot SM, Brereton RJ. Pediatric intussusception. Br J Surg 1992;79:867-76.  Back to cited text no. 1
    
2.
Kim YS, Rhu JH. Intussusception in infancy and childhood. Analysis of 385 cases. Int Surg 1989;74:114-8.  Back to cited text no. 2
    
3.
Diaz-Rosales J, Enriquez-Dominguez L, Castillo-Moreno JR, Gutierrez-Ramirez PG. Adult intussusception by tumor inileum: A diagnostic dilemma. Int J Stud Res 2012;2:18-20.  Back to cited text no. 3
  [Full text]  
4.
Ghritlaharey RK. Surgical management of intussusception in children: A retrospective review of 212 cases. Ann Natl Acad Med Sci 2021;57: 226-31.  Back to cited text no. 4
    
5.
Dankoff S, Puligandla P, Beres A, Bhanji F. An unusual presentation of small bowel intussusception. CJEM 2015;17:318-21.  Back to cited text no. 5
    
6.
Louachama O, Rada N, Draiss G, Fouraiji K, Ouled Saiad M, Bouskraoui M. An unusual neurological form of acute intussusception in an infant: Late diagnosis and management. Case Rep Pediatr 2019;2019:1-3.  Back to cited text no. 6
    
7.
Pumberger W, Dinhobl I, Dremsek P. Altered consciousness and lethargy from compromised intestinal blood flow in children. Am J Emerg Med 2004;22:307-9.  Back to cited text no. 7
    
8.
Kleizen KJ, Hunck A, Wijnen MH, Draaisma JM. Neurological symptoms in children with intussusception. Acta Paediatr 2009;98:1822-4.  Back to cited text no. 8
    
9.
Domínguez-Carral J, Puertas-Martín V, Carreras-Sáez I, Maraña-Pérez AI, Escobar-Delgado T, García-Peñas JJ. Neurological symptoms in children with intussusception. An Pediatr (Barc) 2014;80:293-8.  Back to cited text no. 9
    
10.
Bousseaden A, Afifi R, Essamri W, Benelbarhdadi I, Ajana FZ, Benazzouz M, et al. Adult colocolic intussusception diagnosed by ultrasonography: A case report. J Med Case Rep 2011;5:294.  Back to cited text no. 10
    


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