CASE REPORT Intermittent intestinal obstruction due to chronic colo-colic • •Intussusception Abstract A two year old boy presented with a two month history of intermittent bloody diarrhoea, and associated intermittent colicky abdominal pain and weight loss. A small mass was pal pable over the left abdomen. Abdominal rad iograph showed colon ic obstruction and barium enema revealed colo-col ic intussusception. At laparotomy, the intussusception had reduced spontaneously and was found to be caused by a ben ign juvenile polyp. The clinical and imaging WCGPeh MBBS, DMRD, FRCR, FAMS Associate Professor WCheng* MBBS, FRCSE, FRCSG, FRACS Assistant Professor Departments of Diagnostic Radiology and 'Surgery (Paediatric Surgery Division), The University of Hong Kong, Queen Mary Hospital, Hong Kong 19 SA JOURNAL OF RADIOLOGY. June 1997 features, and management of the chronic form of intussusception are discussed. Case report A two year old Chinese boy pre- sented with a two month history of intermittent diarrhoea. Mucus and blood was occasionally noted in the stools. There was associated intermit- tent colicky abdominal pain and weight loss of 2 kg.The child enjoyed previous good health. Prior to admis- sion, he was seen by a private practi- tioner and had been treated with an- tibiotics without improvement. On examination, a small firm mass was palpable over the left upper abdomen. Ultrasound scan did not however show any abnormality. Stool cultures for various micro-organisms, and blood serology and cultures, were all negative. Abdominal radiograph (Figure I), done during the next severe episode Figure 1: Supine abdominal radiograph shows dl/atatlon of the small bowel and the proxima/ hemi-c%n. topage22 Ready for everything. Announcing ImagePoint, from Hewlett-Packard" The innovative, ergonomic keyboard is designed for comfort and ease of use. 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HiPerformance Systems For more Information please contact LynneHe Lewis at HIPerformance Systems, sole authorised distributor of HewleH·Packard medical equipment, at (011) 806-1229 or Glen Strike In Durban (031) 207-2073 or Diane Romburgh in Cape Town (021) 658-6202 Inlermittent intestinal obstruction due lo chronic colo-colic intussusception (rom page 19 of abdominal pain, showed dilated loops of gas-filled small bowel, as well as distention of the ascending and transverse colon. An urgent barium enema was performed on suspicion of colonic obstruction in the region of the splenic flexure. Complete ob- struction at the proximal descending colon was confirmed, with a concave defect at the head of the barium col- umn and a classic "coiled-spring" ap- pearance, typical of intussusception, beyond that (Figure 2). Combination of plain radiographic and barium en- ema findings were highly suggestive of the colo-colic type of intussuscep- tion. In addition, there was a polypoi- dal filling defect located just distal to the intussusception site on the barium study (Figure 2). Attempted hydro- static reduction of intussusception using barium was unsuccessful. Figure 2: enema coned to show the descending colon and proximal sigmoid colon shows the "coiled-spring" appearance of intussusception (arrowheads), 85 well as a polypoidal filling defect (arrows). Laparotomy was performed later the same day.At surgery however, the colo-colic intussusception was found to have reduced spontaneously. A mass was palpable within the proxi- mal descending colon and colotomy revealed a 3.5 x 2.5 x 1.7 cm polyp (Figures 3a and b), corresponding in is usually considered early in the dif- ferential diagnosis of a young child presenting with a short history of ab- dominal pain and vomiting. Chronic intestinal intussusception of greater than two weeks duration is uncom- mon, occurring in 6.5% of patients in one large series.' Chronic intussus- ception behaves differently from the acute form in that abdominal pain and vomit- ing are less severe, with di- arrhoea and weight loss be- ing recognized features. Chronic intussusception may even rarely present as failure to thrive. Except for the typical intermittent col- icky abdominal pain, symp- toms of chronic intussus- ception are generally rather non-specific. 2-4 Chronic in- tussusception tends to be found in older children and it has been suggested that at an older age, the anatomy is such that intussusception occurs without significant impairment of the blood supply.' Ultrasound is now re- garded as an accurate method to diagnose intus- susception, offering the ad- vantages of being quick, simple, non-invasive and ra- diation-free. It has been recom- mended that contrast enema should be reserved for ultrasonically-equivo- cal cases or for therapeutic reduction. 5 Spontaneous reduction of intussus- ception has been reported to cccur/" On retrospect, the clinical picture of this patient fitted that of a chronic, intermittent-occurring and spontane- ously-reducing intussusception. At the Figure 3: Intraoperative photographs show (a) a palpable mass within the proximal descending colon, and (b) colotomy revealing the lead point, a juvenile polyp. site to the polypoidal filling defect seen on barium enema. Histopathol- ogy of the excised specimen showed features of a benign juvenile polyp. The patient recovered uneventfully and has remained well to date. Discussion Intestinal intussusception is á common surgical emergency in children, requiring urgent diagnosis and treatment. Acute intussusception 22 SAJOURNAL OF RADIOLOGY. June 1997 topage23 Intermittent intestinal obstruction due to chronic colo-col ic intussusception from page 22 time of ultrasound and at surgery, the intussusceptum was not identified, while in-between, it produced the characteristic barium enema appear- ances of intussusception. Colo-colic intussusception is the least frequently encountered type of intussusception, while the ileo-colic type is by far the commonest form." Although detection oflead points us- ing ultrasound has been reported," the site of the polyp within a gas- and fae- cal-filled colon and absence of the spontaneously-reduced intussuscep- tum probably made ultrasonic assess- ment difficult in this patient. Causa- tive lead points are not detected in the majority of intussusceptions, be- ing reported in only 2.5-10% of cases.l''!' The presence of barium interposed between the intussusceptum and in- tussuscipiens, the so-called "dissection sign", could have contributed to fail- ure of hydrostatic reduction in this patient. The "dissection sign" causes concentric compression of the intus- susceptum and hence a decrease in the reductive force, due to fluid dy- namics of the dissected barium. There is evidence that this sign may be a reliable predictor of failure of hydro- static reduction." In any case, even successful reduction of an intussus- ception does not exclude a lead point. Careful review of all imaging studies and meticulous examination during laparotomy should be carried out to diagnose lead points in order that they may be adequately treated. As chronic intussusception is frequently associ- ated with a predisposing lesion and a low success rate of hydrostatic reduc- tion, early surgical intervention is rec- ommended for this form of intussus- ception." References 1. Reijnen JAM, Festen C, Joosten HJM. 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