Clinical History
A 3-year-old boy attended the emergency room due to increasing abdominal pain. His pain had developed 24 hours previously, and was associated with fever (39° C). Physical examination revealed a non-guarding abdomen but he was tender on palpation in the right lower quadrant.
Imaging Findings
Abdominal ultrasound showed an intestinal ileocolic intussusception associated with acute appendicitis (Fig.1 a, b).
The patient underwent emergency surgery with manual reduction of the intussusception and appendicectomy. The pathological examination revealed a phlegmonous appendicitis.
Discussion
Intussusception is the introduction of a segment of bowel into the lumen of the immediately distal bowel [1, 2]. It occurs mainly in male children and is one of the most common paediatric abdominal emergencies [1, 3, 4]. Peak incidence is between 6 months and 2 years-of-age [1, 2].
The classic clinical triad consists of abdominal pain, vomiting and rectal bleeding, but a sudden colicky-type abdominal pain is the most common symptom [1, 2, 5].
Paediatric intussusceptions are usually ileocolic and idiopathic. In only 5% of cases is it possible to demonstrate an underlying cause: Meckel's diverticulum, polyps, duplication cysts, thick meconium, non-Hodgkin lymphoma, Peutz-Jeghers syndrome, polypoid haemangioma, ectopic pancreas, acute appendicitis, Schönlein-Henoch purpura [1, 2, 5].
Abdominal radiograph is not currently performed when intussusception is suspected, and air or barium enemas are almost exclusively limited to therapeutic purposes. Computed tomography is a sensitive technique for the diagnosis of intussusception and its leading-point [2]. Ultrasound has become the diagnostic technique of choice due to its ability to diagnose or discard intussusception without using ionising radiation [1]. The ultrasonographic appearance of ileocolic intussusception is complex and variable, depending upon the length of the invaginated bowel and the amount of mesenteric fat introduced in it [2]. Small bowel intussusceptions are smaller and occur in atypical locations (periumbilical, lower left quadrant). Usually they contain less mesenteric fat without associated lymphoadenopathy [2].
Ultrasound-guided hydrostatic reduction is considered the procedure of choice for nonsurgical treatment of paediatric intussusception with minimal complication rates [5].
Ultrasonographic signs associated to a lower rate of reducibility and ischaemia are: presence of at least two invaginated lymph nodes (one at least 11 mm of diameter), outer hypoechoic ring of the invagination greater than 10 mm, presence of fluid trapped within the bowel wall layers, lack of Doppler flow in the involved bowel wall, and gas in the intussuceptum.
The existence of a lead-point in the intussusception should be evaluated before making any therapeutic manoeuvres; if there are no indications for urgent surgical intervention, complete reduction allows time to obtain a definitive diagnosis, and to stage and plan the most suitable treatment; partial reduction decreases bowel wall oedema and improves the success of subsequent actions. Should the lead-point requires urgent surgery, therapeutic enema is not recommended.
In our case, we proposed two ways of management: reduce the intussusception considering the appendicitis could be reactive to it, or consider the appendicitis as a leading-point requiring urgent surgery.
Differential Diagnosis List
Ileocecal intussusception associated with acute appendicitis
Ileoileal intussusception
Ileocolic intussusception
Final Diagnosis
Ileocecal intussusception associated with acute appendicitis
