Ileoileal intussusception and ileal stricture associated with necrotizing enterocolitis in a premature infant: report of a case

Intussusception in preterm neonates: A systematic review of a rare condition

Background

While necrotizing enterocolitis (NEC) is a prevalent condition in preterm neonates admitted to neonatal intensive care unit (NICU), intussusception is exceedingly uncommon and often overlooked. This is due to the fact that they share many clinical characteristics. The initial misdiagnosis of intussusception in preterm neonates (IPN) especially has led to a delay in their management, which increases the risk of developing compromised bowel. Additionally, it is difficult to reach a diagnosis as neonatal intussusception does not have any classical radiological signs even when contrast enema is used. This systematic review is based on the published literature including case reports and case series to review the clinical features of IPN and how to differentiate it from NEC in order to shed the light on this rare disease and how having a high index of suspicion would help practitioners to make an early and accurate diagnosis

Methods

A systematic literature search to report all cases of relevant articles that reported IPN till date. All cases that were born before 37 weeks gestational age, presented within the neonatal period and having well established documentation were included in the study. Any case that did not have these criteria was excluded from our study.

Results

Only 52 cases met these criteria during the period from 1963 till date. An average of 10 days had elapsed before the cases were confirmed to have IPN either clinically or intraoperatively. The most frequent manifestations were abdominal distension and bilious gastric residuals, occurring in 85% and 77% of the cases respectively, followed by bloody stools in 43% of cases. However, this triad was present only in approximately one-third of the cases. Only 13 cases were diagnosed as having intussusception preoperatively. About two thirds of the intussusception were located in the ileum. Pathological lead point was present in 7 cases only; 4 of them were due to Meckel’s diverticulum. Nine cases only out of the 52 cases with IPN died.

Conclusion

It is crucial to detect the clues for diagnosis of intussusception because in contrast to NEC, it is unresponsive to conservative management, affects the viability of the bowel and surgery is essential.

Intussusception in a premature neonate: A rare and often misdiagnosed clinical entity

Intussusception is a very rare cause of intestinal obstruction in neonates. It is of extremely rare occurrence among premature neonates. We present a case of 11-day-old premature neonate who presented with abdominal distension, intolerance to feeds, vomiting, significant bilious aspirate and bleeding per rectum. The initial diagnosis of necrotizing enterocolitis (NEC) led to a delay in the diagnosis. On exploratory laparotomy, it turned out to be a case of ileo-colic intussusception with Meckel's diverticulum as a lead point. This site of intussusception (ileo-colic) and presence of a lead point among premature neonate is of exceedingly rare occurrence and very few such cases have been reported. In this article, the published work about clinical features and management on intussusceptions in premature neonates has been reviewed. The authors intend to highlight the difficulty in distinguishing the NEC and intussusception. Subtle clinical and radiological features which can help in differentiating the two conditions have been emphasized. This can avoid the delay in diagnosis and management which can prove critical. High index of suspicion with timely intervention is the key for optimizing outcome. A diagnosis of intussusception should always be considered in any preterm infant with suspected NEC.

Intussusception in an extremely premature infant following bacterial sepsis

Intussusception occurring in premature infants is exceedingly rare and shows substantially different characteristics from that in the typical age group or non-premature neonates. We present a case of intussusception in an extremely premature infant following bacterial sepsis, in which necrotizing enterocolitis was initially suspected. The correct diagnosis was made at 35 days old using abdominal ultrasonography, but the general condition of the infant had deteriorated to the point where surgery could not be performed. The patient died of multiple organ failure, and autopsy revealed ileo-ileal intussusception without a recognizable anatomical leading point. Possible mechanisms for this rare clinical entity are discussed.

[Acute intussusception, a rare cause of small bowel obstruction in premature neonates: the advantages of early diagnosis]

We report a case of intussusception in a premature neonate who presented with early signs of upper gastrointestinal tract obstruction. Diagnosing acute intussusception in premature infants is difficult because of its infrequency relative to other neonatal abdominal problems and because the clinical symptomatology shows similarities with that of necrotizing enterocolitis. In the reported case, the diagnosis was made by sonography. Unlike full-term neonates, the presence of a pathological lead point is very infrequent. The intussusception is predominantly located in the small bowel and is most often associated with bowel compromise. This disease should be considered in all neonates with signs of intestinal obstruction to permit a better prognosis via prompt surgical intervention.

Intussusception in neonates: analysis of 14 Japanese patients

OBJECTIVE

To clarify the clinical features and pathogenesis of intussusception in neonates.

METHODS

Fourteen neonates were diagnosed with intussusception between June 1974 and January 2001. Patients were divided into two groups according to whether or not signs were present on the first day of life. The clinical features were interrelated with the pathological findings.

RESULTS

All six patients in the group whose signs were present on the first day of life also had intestinal atresia or malrotation. Among patients whose signs began less than 24 h after birth, five of eight patients suffered hypoxia. Moreover, it was very difficult to establish the diagnosis of intussusception, particularly in the group of late-onset type intussusception.

CONCLUSIONS

Hypoxic events may play a crucial aetiologic role in the pathogenesis of late-onset neonatal intussusception.

Clinical features and treatment outcome of intussusception in premature neonates

BACKGROUND/PURPOSE

Less than 1.3% of all cases of intussusception occur in term neonates. Intussusception in premature neonates (IPN) is exceedingly rare. Its rarity and difficulty to differentiate IPN from common neonatal diseases like necrotizing enterocolitis (NEC) often delays its diagnosis. The authors set out to characterize diagnosis, treatment, and outcome of this rare condition.

METHODS

The authors analyzed 2 new cases of IPN and 33 previously reported cases from the literature.

RESULTS

The 35 patients with IPN had an average gestational age, postconceptual age at diagnosis, and birth weight of 28.4 +/- 0.6 weeks (all data, mean +/- SEM), 31.1 +/- 0.5 weeks, and 1,165 +/- 21 g, respectively. Gastrointestinal symptoms first presented at age 8 +/- 1 days. A preoperative diagnosis of NEC was assumed in 24 patients, delaying diagnosis by 10 +/- 2 days. Intussusception was diagnosed radiographically in 2 patients (1 contrast enema and 1 ultrasound scan) and during surgery or autopsy in the remainder. Resection was reported in 28 patients for bowel that was irreducible, necrotic, or perforated. The overall mortality rate was 20%, mainly owing to sepsis.

CONCLUSIONS

Intussusception in the premature neonate often is misdiagnosed as NEC, delaying operative intervention. Contrast enema has limited diagnostic capability. Early diagnosis may be achieved with use of ultrasound scan. Intussusception can be treated successfully with resection and primary anastomosis, achieving good results.