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Post-Operative Small Bowel Intussusception in a Pediatric Trauma Patient: a Literature Review and Unique Case Report

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Post-Operative Small Bowel Intussusception in a Pediatric Trauma Patient: a Literature Review and Unique Case Report ACS Case Reviews in Surgery Vol. 1, No. 3 Post-Operative Small Bowel Intussusception in a Pediatric Trauma Patient: A Literature Review and Unique Case Report AUTHORS: CORRESPONDENCE AUTHOR:* AUTHOR AFFILIATIONS: Walsh NJa, Dadzie KAb, Jones AJb, Hatley RMa.c Andrew J. Jones, MD a Department of Surgery, Augusta University 1120 15th St, BI-4070 Health, Augusta, GA, USA Augusta, GA, 30912 b Medical College of Georgia at Augusta University, [email protected] Augusta, GA, USA (770) 827-8816 c Section of Pediatric Surgery, Augusta University Health, Augusta, GA, USA Background Intussusception is a well-documented cause of acute abdomen in the pediatric population; however, post-traumatic and post-operative intussusceptions are exceptionally uncommon. Summary An otherwise healthy eight-year-old girl presented as a level II trauma via EMS following a motor vehicle accident (MVA). The patient complained of diffuse abdominal pain and back pain on arrival. Physical exam was remarkable for tachycardia, right coastal margin tenderness to palpation, non-labored breathing, diffuse abdominal tenderness and a seatbelt sign. Abdominal computed tomography (CT) scan was suspicious for duodenal and/or mesenteric injury, warranting an exploratory laparotomy. After this initial operation, she later presented with symptoms of small bowel obstruction. Repeat CT of the abdomen obtained on post-operative day 14 showed dilated loops of distant small bowel, air fluid levels and a swirled appearance of the mesentery, concerning for a closed loop obstruction. She was taken back to the operating room and intra-operative findings revealed a feathery adhesion of the small bowel to the transverse colon with no dilation of the proximal small bowel and a distal jejunojejunal intussusception. Conclusion Due to the rarity of both types of intussusceptions, surgeons and pediatricians alike tend to miss or delay making the diagnosis. Early detection and treatment are essential, and the gold standard of treatment for both posttraumatic and post-operative intussusception is manual surgical reduction. Keywords pediatric, intussusception, post-traumatic intussusception, post-operative intussusception AUTHORS’ CASE STUDY AFFILIATION ADDRESS: CONSENT STATEMENT: Augusta University This article does not contain any studies with human participants or animals Department of Surgery performed by any authors. For this type of study, formal consent is not required. Augusta, GA 30912 FINANCIAL SUPPORT: STATEMENT OF DUPLICATE PUBLICATION: None The authors declare that this case report is not under consideration by any other journal and has not been presented previously. ACKNOWLEDGEMENTS: None DISCLOSURE STATEMENT: The authors declare that they have no conflicts of interest. *PERMANENT ADDRESS: Andrew J. Jones, MD ETHICAL STATEMENT: Department of Surgery The authors declare that they are compliant with COPE standards. Mount Sinai St. Luke’s-Roosevelt 1000 10th Avenue, Suite 2B New York, NY 10019 To Cite: Walsh NJ, Dadzie KA, Jones AJ, Hatley RM. Post-Operative Small Bowel Intussusception in a Pediatric Trauma Patient: A Literature Review and Unique Case Report. ACS Case Reviews in Surgery. 2017;1(3):41-44. American College of Surgeons – 41 – ACS Case Reviews. 2017;1(3):41-44 ACS Case Reviews in Surgery Walsh NJa, Dadzie KAb, Jones AJb, Hatley RMa.c Case Description Focused Assessment with Sonography in Trauma (FAST) was performed in the ED and was negative for any intra-ab- Intussusception, which refers to self-invagination of intes- dominal or cardiac pathology. Computed Tomography tine, is a common cause of acute abdomen. Furthermore, (CT) of abdomen and pelvis showed abnormal wall thick- intussusception is the most common cause of abdominal ening as well as hyper-enhancement and mild dilatation 1 emergencies in children two years of age and younger. of the proximal duodenum suspicious for duodenal and/ The etiology is considered idiopathic in 75 percent of or mesenteric injury, ill-defined right upper quadrant low young children. Other causes include enteric infections or attenuation fluid, and fluid accumulation in the deep pel- underlying disorders such as Meckel’s diverticulum, small vis. These findings were concerning for possible small bow- bowel lymphoma, Henoch-Schonlein purpura, cystic el or mesenteric injury. An emergent laparotomy revealed fibrosis, post-operative and posttraumatic intussusception. mild duodenal hematoma, small bowel mesenteric contu- Post-operative and post-traumatic intussusceptions are sion and transverse colon and duodenal mesenteric defects, 2 very uncommon, with the latter being even less common. which were repaired. Kocher maneuver was performed to fully evaluate the duodenum and nearby structures. There Post-operative intussusception (POI) is well known to was no additional retroperitoneal exploration performed occur mostly after operations involving the gastrointesti- during this laparotomy. nal (GI) system but has also been reported post retroper- itoneal dissections and tumor resections, diaphragmatic The patient’s initial postoperative course was unremark- 3 procedures, and extensive bowel manipulation. Posttrau- able. She had and uneventful stay in the Pediatric Inten- matic intussusception (PTI) is exceedingly rare, with only sive Care Unit (PICU) and was transferred to the pediat- 2,4,5 22 reported cases in the English literature. This usually ric floor on postoperative day three. After the initiation presents after blunt abdominal trauma, and the cause is of clear fluid diet, she complained of abdominal pain and often unknown. We report a case of jejunojejunal intus- nausea and experienced multiple episodes of bilious vom- susception of an eight-year-old girl after blunt abdominal iting. Patient was made NPO and her symptoms initially trauma and exploratory laparotomy. improved, but she again experienced increasing abdominal pain and vomiting after several days. Repeat CT of the An otherwise healthy eight-year-old girl presented as a abdomen obtained on postoperative day 14 showed dilated level II trauma via EMS following a motor vehicle acci- loops of distant small bowel, air fluid levels and a swirled dent (MVA). She was a restrained passenger in the rear appearance of the mesentery, concerning for a closed loop seat behind the driver in an MVA involving her car and obstruction. At immediate exploration, she had a signifi- a school bus. Significant damage was noted to her vehi- cant adhesion from the small bowel to the transverse colon cle. EMS reported possible transient loss of consciousness causing both obstruction and distal long-segment jejuno- during the incident. jejunal intussusception which was manually reduced with- out incident. She tolerated the procedure well and was On arrival, the patient complained of diffuse abdom- admitted back to the floor postoperatively. Her hospital inal pain and back pain on arrival. History was limited course subsequent to her second operation was uneventful. due to patient’s age, clinical condition and absence of a guardian. Physical exam was remarkable for tachycardia, right coastal margin tenderness to palpation, non-labored Discussion breathing, diffuse abdominal tenderness and a seatbelt Even though intussusception is a well-known cause of sign. Laboratory studies revealed a white blood cell count acute abdomen in the pediatric population, the etiology is 3 of 13,400mm, hemoglobin of 13.4g/dL, amylase level usually unknown. Some well-documented causes include of 119U/L, lactic acid of 3.5mmol/L and lipase level of enteric infections, underlying disorders such as Meckel 126U/L. Chest radiograph showed ill-defined opacities in diverticulum, small bowel lymphoma, Henoch-Schonlein the right lung suggestive of pulmonary contusion. A possi- Purpura, and cystic fibrosis. Postoperative and posttrau- ble right proximal humeral fracture (which was later ruled matic intussusception cases are very rare, with the latter out from repeat X rays) and lower lateral right and left rib being even less common. fractures were noted on additional plain films. American College of Surgeons – 42 – ACS Case Reviews. 2017;1(3):41-44 ACS Case Reviews in Surgery Walsh NJa, Dadzie KAb, Jones AJb, Hatley RMa.c POIs have been described following various forms of sur- after initiation of clear fluid diet. This presentation was gical procedures. Approximately 51 percent of POIs occur similar to most POIs reported in literature. Specifically, the following surgeries involving the GI system, 20 percent intussusception occurred after surgery involving the GI sys- postretroperitoneal tumor resections, nine percent fol- tem, presented with bilious vomiting and occurred within lowing diaphragmatic surgeries, six percent after urinary the first week after initial operation. Intramural hemato- system surgeries and four percent postpartial pancreatec- ma, however, was also noted during the first laparotomy, tomy.3 The etiology is thought to be multifocal, but per- as reported in 18 percent of cases of PTIs. Repeat CT was istaltic impairment is believed to be the most prominent concerning for a closed loop obstruction even though an cause.3 Causes of this disorder in peristalsis include exces- intussusception was not reported per se. We are uncertain sive bowel manipulation, abnormal serum electrolytes, if the intussusception was related directly to the intramu- anesthetic agents, post-operatively administered medica- ral hematoma, the initial operation which involved bowel tions or impaired bowel innervation.6 Approximately
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