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A Case Series on Intussusceptions in Infants Presenting with Listlessness

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A Case Series on Intussusceptions in Infants Presenting with Listlessness ABDOMINAL CONDITIONS © 2010 SNL All rights reserved A case series on intussusceptions in infants presenting with listlessness Intussusception is characterised by abdominal pain, vomiting and blood in stools. However, in younger infants it may present with non-classical symptoms such as listlessness, pallor, decreased feeding, and being non-specifically unwell. Three cases of intussusception in young infants who presented with being listless and had some or no features to suggest a clinical diagnosis of intussusception are described which are designed to highlight the non-classical features of intussusception likely to be encountered in very young infants. Siba P. Paul1 ntussusception is one of the most tachycardia and prolonged capillary refill MBBS, DCH Icommon surgical emergencies time he was given a fluid bolus of 20mL/kg Paediatric Trust Registrar encountered in infancy and early with 0.9% sodium chloride. He was [email protected] childhood. This is a condition where the intermittently responding to his parents proximal segment of the bowel telescopes but was not irritable. His cardiovascular 1 David C. A. Candy into the distal segment causing and respiratory examination was MBBS, MSc, MD, FRCP, FRCPCH, FCU obstruction1. The classic triad of symptoms otherwise normal. Consultant Paediatric Gastroenterologist consists of abdominal pain, vomiting and He was distressed by an abdominal blood in stools1. It is often seen in children Nikila Pandya2 examination and was found to be drawing aged four months to two years, with a peak up his legs and crying while being MD, DCH, FRCPCH incidence during four to nine months of Consultant Paediatrician examined. The provisional diagnosis at age2. However, infants may present with that point was either sepsis, gastroenteritis Department of Paediatrics non-classical symptoms such as listlessness, or a suspected intussusception. A chest and 1 St Richard’s Hospital, Chichester decreased feeding, non-specifically abdominal film (FIGURE 1) was organised 2 Maidstone General Hospital, Maidstone appearing unwell, looking pale, etc. We which showed clear lung fields. The Keywords present three cases of infants with abdominal X-ray looked very abnormal intussusception, who presented with being with paucity of gas. Subsequently he intussusception; classic triad; hypotonia; listless and pale, with a view to heightening passed fresh mucousy blood per rectum listless infant; ultrasonography; early the awareness of this condition. which resembled a ‘redcurrant jelly’ stool, weaning hence a clinical diagnosis of Key points Case 1 intussusception was made. He needed a A healthy six-month-old male infant, Paul S.P., Candy D.C.A., Pandya N. A case series on intussusceptions in infants presented with intermittently looking very presenting with listlessness. Infant 2010; pale and being poorly responsive over an 6(5): 174-77. eight-hour period. He had non-bilious 1. Intussusception is the most common vomiting on six different occasions and his surgical emergency in infants and mother reported blood spots in the nappy young children. earlier in the day. He was reported to be 2. The classic triad of symptoms consists fully immunised and had been weaned of abdominal pain, vomiting and early on to solid food at around four redcurrant jelly stool. months of age. 3. Symptoms such as lethargy, irritability, The initial assessment revealed a very listlessness may present early in the pale looking infant with a heart rate of illness with no abdominal signs. 158/min, temperature of 36.1°C, 4. Ultrasonography or contrast enemas are the preferred investigations to respiratory rate of 36/min, oxygen diagnose intussusception. saturation of 99% in air, blood glucose of 5. If reduction of intussusception is 6.7 mmol/L and a central capillary refill unsuccessful surgical intervention may time of three seconds. He had a patent be necessary. airway and was breathing comfortably. He 6. Chronic intussusception can present was given two litres per minutes of face FIGURE 1 Chest and abdominal X-ray shows with non-specific symptoms and failure mask oxygen due to his initial presentation evidence of abnormal gas pattern with to thrive. and diagnostic uncertainty. In view of the paucity of gas. Lung field appears clear. 174 VOLUME 6 ISSUE 5 2010 infant ABDOMINAL CONDITIONS further fluid bolus of 20mL/kg of 0.9% sodium chloride and was started on intravenous cefotaxime. The blood invest- igation results showed a C-reactive protein (CRP) of 9mg/L, white cell count of 14.5 x 109/L, platelets of 395 x 109/L and haemoglobin of 11.7 gm/dL. He was referred to the regional paediatric surgical unit where a diagnosis of intussusception was confirmed. He had a failed trial of reduction of the intussusception by hydrostatic pressure and needed an open surgical reduction. He made an uneventful recovery and was reported to be well at further follow-up. Case 2 FIGURE 2 Abdominal X-ray shows evidence of FIGURE 3 Abdominal X-ray shows evidence of A healthy four-month-old female infant, abnormal gas pattern with a right-sided soft abnormal gas pattern with paucity of gas. presented with intermittently looking very tissue mass suggestive of intussusception. pale and listless for about six hours. She was reported to be not feeding well. She had no history of vomiting or diarrhoea, uneventful recovery. She was reported to no cough or cold, and did not have a fever. be well at further follow-up. She had had the first set of primary immunisations and had been weaned early Case 3 1 1 on to solid food at around 3 /2 months of A healthy 4 /2-month-old male infant age. The initial assessment revealed a very presented with intermittent shrill crying pale looking infant with a heart rate of episodes for about eight hours. He had had 148/min, temperature of 36.9°C, pyloric stenosis at five weeks of age and respiratory rate of 48/min, oxygen had laparoscopic pyloromyotomy, but saturation of 94% in air, blood glucose of represented a week later with vomiting 5.8 mmol/L and a central capillary refill which resolved with open pyloromyotomy. time of <2 seconds. She had a patent He had had non-bilious vomiting on two airway and was breathing comfortably in occasions during his present illness and a air. She was responding appropriately to blood streaked offensive stool earlier in the her parents and was not irritable. The evening. cardiovascular and respiratory The initial assessment by the casualty examination was otherwise normal. She officer revealed a pale looking infant, disliked an abdominal examination and listless with a heart rate of 158/min, was found to be drawing up her legs and temperature of 36.1°C, respiratory rate of crying while being examined. The 36/min, oxygen saturation of 99% in air, provisional diagnosis at this point was one blood glucose of 6.7 mmol/L and a central of sepsis or a suspected intussusception. capillary refill time of two seconds. There An abdominal film (FIGURE 2) was was no increased work of breathing. organised which showed multiple loops The review by the paediatric team of small bowel, with a soft tissue revealed an irritable but listless child with impression in the right side which was normal systemic examination. He disliked suspicious for an intussusception mass. an abdominal examination and had FIGURES 4 and 5 Ultrasound scan of the She remained stable and was given a tenderness on deep palpation. The abdomen shows classical ‘target’ sign of fluid bolus of 20mL/kg of 0.9% sodium provisional diagnosis at that point was intussusception. chloride. The blood investigation results gastroenteritis or a suspected intussuscep- showed a CRP of <1 mg/L, white cell count tion. An abdominal X-ray (FIGURE 3) was confirmed the diagnosis of intussusception of 12.2 x 109/L, platelets of 765 x 109/L and abnormal with paucity of gas. (FIGURES 4 and 5). haemoglobin of 10.9 gm/dL. Overnight he passed blood and faeces on He was referred to the regional She was referred to the regional one more occasion. He was kept nil by paediatric surgical unit where he had a paediatric surgical unit where a diagnosis mouth and given intravenous maintenance failed trial of reduction of the of intussusception was confirmed on fluids. His CRP was 12mg/L, white cell intussusception by air enema and needed abdominal ultrasound scan. She had a count 8.4 x 109/L, platelets 383 x 109/L and an open surgical reduction. He made an successful reduction of the intussusception haemoglobin 11.2 gm/dL. He had an uneventful recovery and was reported to be by hyrdrostatic pressure and made an abdominal ultrasound scan which well at further follow-up. infant VOLUME 6 ISSUE 5 2010 175 ABDOMINAL CONDITIONS Discussion infants and these generally present early1,9. Patients often present with non-specific Historical background symptoms such as looking mottled or pale, Intussusception was first described by irritability, decreased appetite, listlessness 3 4 Barbette of Amsterdam in 1674 . Hunter or lethargy9. Clinicians may face a in 1789 discussed the surgical pathology of diagnostic dilemma in children presenting intussusception. The exact year of surgical solely with neurologic manifestations and reduction of intussusception remains may investigate for causes of sepsis or controversial – 1784 according to neurological conditions thus delaying the Hutchinson but 1672 according to diagnosis of intussusception9. In this group Ashhurst4. In 1876 Hirschsprung first FIGURE 6 Possible foci for intussusception. the physical examination may be entirely described the reduction of intussusception normal except for the infant being 5 by hydrostatic pressure methods . In July lethargic or listless. 1999, reports of intussusception associated Intussusception should be considered in with the rotavirus vaccine led to the differential diagnosis of young children suspension of the programme6.
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