Rare case of transverse sigmoid intussusception without an anatomic lead point in a 6 years old female: Case report and literature review

Abstract

Colo-colic intussusception is a surgical emergency in which a part of the intestine slides into the distal adjacent part. Transverse sigmoid intussusception is a rare serious clinical condition requiring immediate surgical intervention. We present a 6-year-old female with intermittent abdominal pain, watery bloody stool and obstipation. Digital rectal examination revealed a firm tender mass; finger showed a current jelly stool. The ultrasound showed a donut sign and underwent a laparotomy and the postoperative recovery was uneventful. All children with imprecise signs and symptoms, especially presenting with bloody mucus stool, can be mistaken for gastroenteritis, have high risk of perforation. They must be considered as surgical cases until proven otherwise.

Introduction

Colo-colic intussusception is uncommon in children above 3 years and usually occurs in the setting of a pathologic lead point. There have been few reported cases of Colo-colic intussusception caused by a juvenile polyp in the splenic flexure [1]. Colo-colic intussusception has also been reported without an anatomic lead point [2]. Transverse-sigmoid intussusception is a rare occurrence as the descending colon lies fixed in its retroperitoneal position [3]. Intussusception is a leading etiology of bowel obstruction in young children between the ages of 3 months and 3 years [4]. Due to the possible complications that can result from not recognizing a Colo-colic intussusception in time including ischemia, perforation and peritonitis, a high level of awareness and timely diagnosis is critical [1].

We present a 6 years old female with transverse-sigmoid intussusception without an anatomic lead point.

Case presentation

A 6-year-old female was referred from a Health center IV where the child was treated as gastro-enteritis for 6 days then brought by parents to the emergency department of a teaching hospital with intermittent abdominal pain, watery bloody stool at first then obstipation with 2 episodes of vomiting for the 3 previous days.

The pain was initially colicky then continuous in nature on the left lower quadrant of the abdomen and has been accompanied by gradual distension of the abdomen followed by nausea, associated with low-grade fever. His past medical and surgical history was unremarkable. The patient was referred to the teaching hospital for an abdominal ultrasound to rule out a surgical condition.

On physical examination, vital signs showed Pulse rate of 132 beats per minute, respiratory rate of 32 cycles per minutes, SPO2 of 96%, temperature of 38°C with mild dehydration but no pallor. We noticed a slight abdominal distension and palpated of tender firm mass in the left iliac fossa with generalized tenderness. Rebound was positive. Bowel sounds were absent in the left abdomen. Digital rectal examination revealed a firm tender mass, finger showed a current jelly stool (mucus bloody stools), and anal canal was found to be ballooned. The rest of the systemic examination was found to be unremarkable.

Among the blood investigations, hemogram revealed a leukocytosis of 14.500/mm³, with a hemoglobin of 12 g/dl, platelet of 440.10⁹, renal and liver function tests, serum electrolytes were found to be within normal range. The ultrasound showed an intraluminal 5.5 × 2.2 × 2.7 cm mass in the left lower quadrant with a target sign like appearance (Fig. 1), and a pseudokidney sign (Fig. 2) suggestive of an intussusception. The diagnosis of intussusception was confirmed based on clinical and investigations findings.

Fig. 1.

A bullseye appearance as concentric alternating the echogenic (bright) bands corresponding to the mucosa and muscularis, while the hypoechoic (darker) bands represent the submucosa, called target or doughnut or Donut or Bulls eye sign on an abdominal ultrasound scan, indicator of intussusception.

Fig. 2.

A reniform mass with a central hyperechoic (bright) region surrounded by a hypoechoic (darker) region: Pseudokidney sign on longitudinal ultrasound scan, sign of intussusception.

The laparotomy was undertaken using the upper transversal incision, 3 cm above the umbilicus and the following findings were noted: (a) the small bowel and ascending colon collapsed, ileocecal junction was found to be normal; (b) transverse colon-descending colon intussusception (Fig. 3) with an 6 cm in the descending colon, oedematous but viable intussusceptum (transverse colon) (Fig. 4). The intussusception was reduced manually by milking the sigmoid (intussuscipiens) toward to the transverse colon (intussusceptum) using a gauze soaked in a warm normal saline. Inspection of the colon and palpation to look for other anomalies or a mass, none was found. No intestinal resection was done. In postoperative, we administered intravenous antibiotics, epicephine 1 g per day for 4 days, metronidazole 250 mg 3 times a day for 4 days and intravenous paracetamol 500 mg 3 times a day for 2 days and intravenous fluids (Dextrose 5%, Normal saline 0.9% and Dextrose 25%) 2 liters for 24 hours.

Fig. 3.

The swelling of the transverso-sigmoid intussusception (transverse colon in the Sigmoid colon), in yellow arrow color.

Fig. 4.

Edematous with dark point color on the transverse colon but still viable bowel.

Twelve hours postoperatively the patient was allowed oral clear fluids and semi-solid diet after 24 hours. The patient was discharged on oral drugs on the fifth postoperative: Tablet cefixime 100 mg 2 times a day for 7 days. In the follow-up period, the patient did not develop any complications.

Discussion

Pediatric intussusception is normally ileo- cecal, idiopathic by cause and comprised between 6 months and 3 years of age with a peak of incidence between 5 and 9 months [5,6] with a little prevalence on males. The incidence of Colo-colic intussusception was 1.3% at children center of Beijing. The reason might be related to ethnic and geographic differences [7]. It often occurs near the ileocecal junction and rarely only involves the colon [8].

A case of Colo-colic intussusception without a pathologic lead point in a 7-year-old boy was reported by Mahmudloo et al. as in our case report in 6 years [2], but the majority of the case reports in the literature reported juvenile polyps responsible for this variety of intussusception in the pediatric age group [6]. Many cases caused by juvenile colonic polyp in pediatric age group were reported [7,9].

The clinical symptoms of abdominal pain (acute or intermittent), bloody mucus stool and vomiting are often considered the main features of intussusception. However, less than 25% of patients have this classic triad, leading to a delayed diagnosis or misdiagnosis [5]. Patients with colonic intussusception had a significantly higher incidence of rectal masses or prolapse [7]. Due to the rarity of Colo-colic intussusception, diagnosis can be challenging and the ultra sound scan represent the first level of diagnostic tools. The presence of a “target sign” or a “ pseudo-kidneys sign“ image at the US scan in of a Colo-colic intussusception, as in our case report and should be followed by diagnostic/ therapeutic enema or open surgery, which better for children according to complication related to enema reduction. The most frequent location of the intussusception is the left lower quadrant (sigma and rectum) but sometimes it can reach the transverse colon, as in our case report [10] or rarely in the right colon [4,5]. Until obstruction occurs, diagnosis is difficult due to its unspecific symptoms and requires a high index of suspicion [2,6,8].

Ultrasound is recommended first because of its high diagnostic sensitivity (82%-95%) in the detection of intussusception and lack of radiation exposure for children, which was also confirmed by our study [9,11,12]. Therefore, it should be used at the initial visit for all children with the above symptoms and all clinical suspicion of intussusception, including Colo-colic intussusception [12]. However, almost all Colo-colic intussusception is caused by pathologic lead points and should be treated with surgical interventions, including colonoscopic polypectomy, open surgery or laparoscopic surgery [13], but there was no lead point in our case. The most common lead point in Colo-colic intussusception is juvenile polyps [11]. The effect of laparoscopic surgery on Colo-colic intussusception in children is controversial, and the treatment of Colo-colic intussusception caused by other lead point remains poorly understood [7]. Given the pathologic lead points found in most Colo-colic intussusceptions, therapeutic enemas, especially hydrostatic barium enemas, were previously considered to be avoided, and these patients often required open surgery [3,6,8]. However, treating Colo-colic intussusception caused by a pathologic lead point is currently considered the same as treating those without a pathologic lead point, involving a careful attempt at reduction using a minimally invasive approach [5,6]. Thus, open surgery remains the primary treatment in patients with Colo-colic intussusception and may be preferable to laparoscopic surgery [2,4,6].

Conclusion

A high level of awareness and timely diagnosis is recommended to all patients with bloody mucus stool to avoid misdiagnosis. They must be considered as surgical cases until proven otherwise.

Open surgery remains the primary treatment for Colo-colic intussusception in children. The role and use of hydrostatic enema or air reduction is not preferable for children who have already bloody mucus stool, as they have high risk of perforation.

Ethical approval

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Provenance and peer review

Not commissioned, externally peer-reviewed.

Author contributions

JBM, MM and TF managed the patient and wrote the first draft. JB, SML and GKS helped in editing and reviewing the paper. All authors read and approved the final version to be published.

Patient consent

Written informed consent was obtained from the patient's parents/legal guardian for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.