A rare case of intusscusception in a 6-month-old baby

The surgical procedure was successful. To support the baby's recovery, a nasogastric (NG) tube was placed to facilitate enteral feeding and medication administration while allowing the digestive system time to heal. Subsequently, the patient was transferred to the recovery ward for close monitoring and observation. The patient's condition remained stable, and was transferred to the pediatric surgical ward on May 24, 2023, at 8:15 PM. The patient was later reviewed at the pediatric surgical ward on May 25, 2023. During the assessment, the patient was observed lying comfortably in her cot with the nasogastric (NG) tube in place, showing no signs of respiratory distress or pain. The wound dressing was found to be clean and dry. The patient's vital signs were stable, with a satisfactory oxygen saturation level (SPO2) of 100%. After the review, medications were switched to the oral route. Following the successful recovery and continued improvement, the patient was discharged from the hospital on May 26, 2023.

We wish to state that patient consent was seek prior to publication of this case.

A 6 months old lethargic febrile female infant who was referred to a regional hospital with a history of a palpable soft, firm and tender mass at the umbilical and left iliac fossa region with vomiting and passage of currant jelly stool for 2 days on the 23 May, 2023. Routine laboratory investigations depicted an increase in lymphocytes, total cell count and hemoglobin was 14.0 g/dL. Upon further review by the Physician she was sent for an ultrasound scan.

Due to the delayed detection of intussusception and the presence of symptoms indicating possible bowel ischemia, the medical recommendation was to proceed with an urgent surgical intervention as seen in Fig. 5 (laparotomy with manual reduction) instead of attempting a nonoperative pneumatic reduction. Patient mother was informed and counselled. Patient was then prepared and was taken to the theatre for a laparotomy with manual reduction of bowel on May 23, 2023 after a consent form was issued by the medical officer and signed by the patient's mother. Intra operative findings was Ileo-caeco-colic intussuception with viable bowel. Fig. 5 Intraoperative image of the rare case of intussusception. Fig 5 Intraoperative image of the rare case of intussusception.

Intussusception in babies is a surgical emergency that needs early diagnosis and treatment in order to prevent morbidity. This is common within the age range of 3 months to 3 years old. It is possible to diagnose the illness based on clinical indicators. A favourable diagnosis may be made by ultrasonography, and imaging plays a significant part in this process. Noninvasive radiological treatment remains the primary therapeutic choice; nevertheless, surgical intervention becomes necessary if these treatments prove ineffective. Although the morbidity and death rates associated with intussusceptions are still very low, this might be high in under-resourced settings.

Approximately 1-4 out of every 2000 children may have intussusception within their first 3 years of life, with a median age ranging from 4 to 9 months. This condition is prevalent globally. About twice as much affects the male sex. This is a pediatric emergency and ranks as the second most frequent cause of gastrointestinal obstruction in young children and infants [ 14 , 15 ]. In Intussusception, the upstream intestinal segment is always imprisoned within the downstream segment by a turning mechanism that resembles a finger. Only 10% of children's intussusception have a pathological lead point, meaning that the majority of cases are idiopathic. Anatomical or viral factors frequently playing a role. In the case of our patient, no pathological lead point was seen (idiopathic). Idiopathic intussusception takes place at the location of lymphoid hyperplasia, the ileo-colic junction. Rotavirus, herpes virus, and adenovirus all point to a viral origin. Tumors, appendicitis, digestive abnormalities, and a few general disorders are other local causes [ 16 ]. Ultrasound is the preferred diagnostic modality for intussusception [ 10 ]. Although CT scans are not typically utilized to confirm a positive diagnosis of intussusception, they are nevertheless the preferred imaging modality when certain abnormalities in the abdomen are present [ 2 ]. Treatment should be made available to the patient after diagnosis; children who exhibit symptoms of shock, peritonitis, or perforation should have surgery right away. For most intussusceptions, noninvasive radiological technique is required; the most common are pneumatic enema, US guided hydrostatic enema, fluoroscopy guided hydrostatic enema, and pneumatic enema [ 17 ]. Nonsurgical radiological technique under sonographic or fluoroscopic guidance is presently the treatment of choice for intussusception in infants and children [ 18 ]. Surgical treatment is often used as the main approach in developing countries, mostly because of the delayed manifestation and accurate diagnosis [ 15 , 19 ]. In developed countries, the mortality rate associated with managing intussusception in infants and children is less than 1% whiles in developing countries, this rate is significantly higher [ 20 ]. The therapeutic approach for pediatric patients is determined on the specific form of intussusception. The most prevalent kind in children, ileocolic intussusception, can be reduced in 85%–90% of cases using an ultrasound-guided, fluoroscopic, pneumatic, or hydrostatic enema. Because there is a higher chance of recurrence in the first 24 hours, close supervision is needed [ 21 ]. Though rare in children, small bowel intussusception may typically be carefully monitored and will resolve on its own without the need for surgery. However, it has been observed that persistent small bowel intussusception is mostly accompanied with intestinal necrosis, necessitating surgical intervention. Surgical intervention is recommended in cases when enema reduction or careful surveillance proves to be ineffective, irrespective of the kind of intussusception. Delays in diagnosis and complications from intussusception have contributed to a decline in mortality over time [ 18 ].

In light of the clinical presentation, differential diagnoses such as merkel's diverticulum, volvulus, lymphadenopathy, infantile hypertrophic stenosis were considered [ 12 ]. To confirm the diagnosis and rule out these conditions, further investigations, including ultrasound examination and intra operative findings were perused. The differential diagnosis for a rare congenital defect known as merkel diverticulum is diagnosed when a segment of the small intestine protrudes through a weak area in the abdominal wall [ 6 , 10 ]. It may manifest with symptoms similar to intussusception, such as vomiting, bloody faeces, and abdominal pain. However, it possesses sonographic characteristics like a short bowel connection to a blind-ending peristaltic loop [ 3 , 13 ].

The occurrence of intussusception in a female newborn at the age of 6 months is a significant medical issue characterised by the inward folding of a portion of the intestine, resulting in a blockage inside the gut [ 1 ]. This illness poses a significant risk to a child's life and need immediate medical intervention [ 2 ]. Intussusception in babies manifests via several symptoms, such as abrupt and vociferous weeping triggered by abdominal discomfort, the act of bringing the knees towards the chest, the presence of blood and mucus in the stool resembling currant jelly, episodes of vomiting, the presence of a mass in the abdomen, weakness, and diarrhoea [ [3] , [4] , [5] ]. In children, risk factors include cystic fibrosis, infections and intestinal polyps, while in adults, factors like bowel adhesions, endometriosis and intestinal tumors are relevant [ 2 ]. Diagnosing intussusception in newborns under 3 months old might be difficult due to the presence of vague symptoms [ 1 , 6 ]. Lethargy and pallor, particularly when there are no stomach symptoms, might serve as significant indicators. Emesis is a persistent manifestation of intussusception, irrespective of its nonbilious nature. The presence of per rectum bleeding and a palpable lump in the epigastrium might aid in the process of diagnosing the condition [ 7 ]. Prompt identification is crucial for effective therapy [ 8 ]. Medical imaging plays a crucial role in diagnosing intussusception; ultrasound is preferred in children, while computed tomography (CT)scans are more common in adults [ 9 , 10 ]. Treatment typically involves enemas for children and may require surgical intervention if enemas are unsuccessful. Surgical removal of section of the bowel is often necessary in adults [ 11 ].

The patient underwent an ultrasound examination. An ultrasound with the following specifications was used; Machine type: Mindrary DC 30, Exam preset: abdominal, Transducer: both linear and curviliear transducers of frequency ranges 7.5-15 and 2.5-5.0MHz. The findings of the examination were obtained from greyscale (Bmode). Color Doppler was activated to assess the vascularity of bowels. TGC, overall gain, focus, PRF and depth were all adjusted to suit the examination. Patient remain in supine position throughout the examination. The findings revealed concentric lesion with rings of alternating hypoechoic and hyperechoic layers ( Fig. 1 ), giving a target sign on transverse view and pseudo kidney sign on sagittal view, indicative of bowel seen at the left iliac fossa. This lesion shows minimal flow on color doppler ( Fig. 2 ) interrogation and a minimal peritoneal fluid seen ( Fig. 3 ). The liver is of average size measuring 6.9 cm with homogeneous parenchymal echotexture, smooth surface, and sharp edge. No intra or extrahepatic dilatation. The pancreas is of normal sonographic appearance. The spleen is of average size measuring 4.5 with homogeneous parenchymal and echotexture. No focal mass seen. The gall bladder wall is of uniform thickness with no intraluminal sludge or calculus seen. Both kidneys are of average size measuring RT = 5.2 × 2.5 cm and LT = 6.1 × 2.8 cm with good corticomedullary and sinus differentiation. No focal mass, calculus or hydronephrosis seen bilaterally. No intraabdominal mass or intraperitoneal fluid collection seen. Abdominal organs displayed normal sonographic appearances ( Fig. 4 ). Fig. 1 A concentric lesion with rings of alternating hypoechoic and hyperechoic layers; a classical sonographic appearance of intussusception. Fig 1 Fig. 2 A concentric lesion with rings of alternating hypoechoic and hyperechoic layers with minimal flow on color doppler interrogation. Fig 2 Fig. 3 Minimal peritoneal fluid (ascites). Fig 3 Fig. 4 A ultrasound image of normal liver, right and left kidney and spleen. Fig 4 A concentric lesion with rings of alternating hypoechoic and hyperechoic layers; a classical sonographic appearance of intussusception. A concentric lesion with rings of alternating hypoechoic and hyperechoic layers with minimal flow on color doppler interrogation. Minimal peritoneal fluid (ascites). A ultrasound image of normal liver, right and left kidney and spleen.