ANNALS OF IBADAN POSTGRADUATE MEDICINE
K.I. Egbuchulem1, T.A. Lawal1,2, M.C. Nweke3, A.O. Adeoye3
This study was carried out in the Departments of Surgery and Histopathology, University College Hospital, Ibadan.
Intussusception is the most common, non-congenital, cause of intestinal obstruction in infants. There are various patterns of intussusception seen in children with the most common being ileo-colic variety. Compound intussusception in which intussusception involves more than one non-adjacent segment is a rare finding in the literature and it can be associated with worse morbidity than typically occurs, especially in a region where delayed presentation is a major contributor to morbidity and mortality in the treatment of intestinal obstruction.
We report the first documented case of double compound intussusception in an African child and reviewed relevant literature.
Keywords: Antegrade and retrograde; children; compound; intussusception
Dr. T.A. Lawal,
Department of Surgery,
University College Hospital,
PMB 5116, Ibadan 200212,
Intussusception is the invagination of a segment of intestine into the lumen of an immediately adjoining segment, which is mostly a distal segment with resultant intestinal obstruction. It is the most common acquired cause of intestinal obstruction in childhood1 and can occur in variants including: ileo-ileal, colo-colic and ileo-colic, which are the most commonly seen type in 75 to 80%.2,3 Almost always, the invagination is from proximal to more distal segments of bowel and rarely, however, it may occur in a retrograde fashion. The rarest form of the pathology is compound intussusception in which intussusception involves both antegrade and retrograde patterns on different segments of bowel. Compound antegrade and retrograde intussusceptions are very rare and there had been no documentation in the English literature of such variety in an African child. This report is aimed at establishing the fact that while it is true that ileo-colic intussusception is the commonest form in children, a high index of suspicion should be developed by clinicians in looking out for rare forms as in our index case. We report the case of an 11-month-old Nigerian managed on account of double compound intussusception and reviewed relevant literature.
An 11 month old boy was referred with a five day history of passage of watery stools, postprandial vomiting and a four day history of progressive abdominal distension associated with intermittent discomfort and inconsolable crying. There was associated high grade fever and he passed red currant, jelly stools a few times before presentation. The patient had an episode of upper respiratory tract infection, which lasted a few days, two weeks prior to presentation.
Examination revealed an acutely ill child who was lethargic, febrile, pale and dehydrated. He also had tachycardia (140/minute) and tachypnoea (44/minute). The abdomen was distended with visible peristalsis but no generalized abdominal tenderness. A sausage shaped mass was palpated on the left hypochondrium with positive sign of Dance (absence of loops of bowels in the right half of the abdomen) and bowel sounds were hyperactive. There was no mass palpable in the rectum but the gloved finger was stained with mucoid blood-stained faeces. A diagnosis of acute intestinal obstruction secondary to intussusception was made and the child was resuscitated.
Plain abdominal radiographs showed dilated loops of bowel with multiple air fluid levels. He was resuscitated with intravenous fluids, electrolyte, intravenous antibiotics and worked up for emergency exploratory laparotomy. The findings at surgery were: a retrograde colo-colic intussusception (proximal sigmoid colon into descending colon); antegrade ileo-colic intussusception as far distally as the proximal descending colon; perforations at the neck of both intussusceptions with devitalized bowel in between them and an area of necrotic bowel 10 cm from the neck of the ileo-colic intussusception. There was minimal peritoneal soilage and about 50 millilitres of sero-fibrinous peritoneal fluid was drained. He had resection of both intussusceptions (Figure 1) and intervening devitalized bowel with an end to end primary ileo-sigmoid anastomosis.
Postoperatively, he had oliguria, hypoproteinaemia and sepsis, but made good clinical progress and was discharged home. He was followed up in the outpatient clinic over a three-month period and had sustained clinical improvement.
Histopathology examinations of the resected proximal ileum and caecum showed multiple intussusceptions involving the sigmoid and descending colon (colo-colic) and ileum up to the proximal descending colon (ileo-colic). There was marked distortion of the architecture of the appendix and intussuscipiens with extensive suppurative necrosis, vascular congestion and stromal oedema. Sections of the intussusceptions showed glandular epithelium overlying markedly hyperplastic lymphoid follicles with prominent germinal centres. Overall features were in keeping with intussusceptions with reactive follicular hyperplasia (Figure 2).