Jejunojejunal Intussusception at Birth: A Rare Clinical Scenario.

We report a case of intussusception presenting as bilious vomiting in a term neonate. Intussusception should be considered as a differential diagnosis even in the neonatal period. Ultrasound scan may help in early diagnosis. This condition needs to be operated early as delayed treatment may lead to bowel necrosis. Copyright:

INTRODUCTION

Intussusception is a common cause of intestinal obstruction seen in the age group of 6 months to 2 years. It is characterized by a classic triad of bloody stools, colicky pain, and palpable mass per abdomen. This disease is rarely seen in the neonatal period, with only 0.3% of all intussusception cases being reported in neonates.[1] The classic features of intussusception are often absent in neonatal presentation. Most of the cases reported are in premature babies, and clinical features are often confused with necrotizing enterocolitis (NEC). In term neonates, it mimics intestinal obstruction. Common sites of intussusception are usually ileoileal or ileocolic, with jejunum being a very rare site. Here, we present a rare case of neonatal jejunojejunal intussusception in a term neonate with probable onset before birth.

CASE REPORT

A 4-day-old term neonate, delivered by emergency cesarean section in view of meconium-stained amniotic fluid with a birth weight of 2.9 kg, was referred from a peripheral hospital with complaints of multiple episodes of bilious vomiting starting from day 1 of life. The baby had passed small quantity of meconium after birth. In view of bilious vomiting, the baby was started on antibiotics and intravenous fluids and was not fed for 3 days. As condition remained same, he was referred on day 4 of life for further evaluation. Anomaly ultrasound scan done at the second trimester was normal. On examination, he was alert, active maintaining stable vital parameters. Abdomen was soft to palpate with no mass felt and no distension noted. Bowel sounds were heard and staining of meconium was noted at anal orifice. Nasogastric aspirate was bilious. The baby passed small amount of meconium once after admission. X-ray of the abdomen showed distended stomach and duodenum with absent distal bowel shadow [Figure 1]. Contrast enema showed normal colon. Laparotomy done on day 5 of life showed a segment of jejunum 15 cm from duodenojejunal junction entering distal bowel for a distance of up to 15 cm. On reduction of intussusception, ischemic and perforated segments were noted in intussusceptum which was resected and end-to-end anastomosis was done. Rest of the bowel was normal. No obvious reason for the initiation of intussusception such as polyp or mesenteric abnormalities was noted [Figure 2]. Histopathology of the jejunum showed features consistent with ischemic jejunitis secondary to intussusceptions. Postoperative course was uneventful, and the baby was started on feeds on the 4th postoperative day and was discharged on the 8th postoperative day.

Figure 1

Abdominal X-ray anteroposterior view supine

Figure 2

Peroperative image of intussusception

DISCUSSION

Intussusception is usually considered in differential diagnosis for intestinal obstruction in the late infancy. However, it contributes to 3% of all cases of intestinal obstruction in neonatal age.[1] Intussusception has been reported even during intrauterine life.[2] It is one of the rare causes for intestinal atresia, contributing to 0.6%–13% of all cases of intestinal atresia.[3] Most of the reported cases of neonatal intussusception are diagnosed after 5 days of age, and the mean duration from time of onset of symptom to surgery has been reported to range between 10 and 19 days.[456] This delay in surgery is due to suspicion of diseases such as NEC, sepsis, or meconium plug syndrome. Babies are fairly stable with no abdominal distension, mass per abdomen, or pain till the stage of perforation in intussusception, and hence, conservative management is often instituted for long time before deciding on surgery.[17] However, early diagnosis is essential as early surgical intervention can salvage ischemic bowel and reduce morbidity associated with perforation. Our case was unique as our baby developed symptoms soon after birth and probably developed intussusception just before birth. To the best of our knowledge, such perinatal intussusception has not been reported till date. The earliest age of presentation reported in the literature is at 40 h of age.[8] Our case developed symptoms on day 1 of life and got operated on day 5 of life. By this time, intestine had already showed signs of necrosis which was well contained within outer intestinal layer. This stresses the need for early use of ultrasonography, which is useful in diagnosing intussusception in neonates.[146] This investigation tool is often used to rule out anomalies in cases of intestinal obstruction, and awareness of intussusception in the neonatal age should help in making early diagnosis.

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Conflicts of interest

There are no conflicts of interest.