R a d i o l o g y C a s e R e p o r t s 1 9 ( 2 0 2 4 ) 4 4 5 1 – 4 4 5 6 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/radcr Case Report A rare case of intusscusception in a 6-month-old baby✩ Emmanuel Fiagbedzi a , b , ∗, Joseph Arkorful b , Emmanuel Appiah b , Nicholas Otumi b , Ishmael Ofori b , Philip Nii Gorleku b a University of Ghana, Department of Medical Physics, Accra, Ghana b University of Cape Coast, College of Health and Allied Sciences, Department of Medical Imaging Technology and Sonography, Cape Coast, Ghana a r t i c l e i n f o Article history: Received 10 March 2024 Revised 17 June 2024 Accepted 30 June 2024 Available online 1 August 2024 Keywords: Intussusception Treatment Case Diagnosis a b s t r a c t This case report discusses the clinical presentation, imaging findings, and successful man- agement of a rare case of intussusception in a 6-month-old female infant referred to a re- gional hospital in Ghana. The patient presented with vomiting, lethargy, fever, and currant jelly stool. Differential diagnoses considered included Merkel diverticulum, volvulus, lym- phadenopathy, and hypertrophic pyloric stenosis. Ultrasound imaging revealed a concentric lesion with characteristic signs of intussusception. Ileo-caeco coli intussusception was con- firmed as the diagnosis. Surgical management was used for this patient. The postsurgery phase was without any complications. The patient recovered well and was discharged with a switch to oral medications. Infant intussusception is still a disease with a low morbidity rate. © 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) Introduction 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 symp- toms, 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 ✩ Competing Interests: The authors declare that they have no known have appeared to influence the work reported in this paper. ∗ Corresponding author. E-mail address: emmanuel2g4@gmail.com (E. Fiagbedzi). https://doi.org/10.1016/j.radcr.2024.06.080 1930-0433/© 2024 The Authors. Published by Elsevier Inc. on behalf of U CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4 resembling currant jelly, episodes of vomiting, the presence of a mass in the abdomen, weakness, and diarrhoea [ 3–5 ]. In children, risk factors include cystic fibrosis, infections and in- testinal 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 stom- ach 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 competing financial interests or personal relationships that could niversity of Washington. This is an open access article under the .0/ ) https://doi.org/10.1016/j.radcr.2024.06.080 http://www.sciencedirect.com/science/journal/19300433 http://www.elsevier.com/locate/radcr http://creativecommons.org/licenses/by-nc-nd/4.0/ mailto:emmanuel2g4@gmail.com https://doi.org/10.1016/j.radcr.2024.06.080 http://creativecommons.org/licenses/by-nc-nd/4.0/ 4452 R a d i o l o g y C a s e R e p o r t s 1 9 ( 2 0 2 4 ) 4 4 5 1 – 4 4 5 6 Fig. 1 – A concentric lesion with rings of alternating hypoechoic and hyperechoic layers; a classical sonographic appearance of intussusception. process of diagnosing the condition [ 7 ]. Prompt identification is crucial for effective therapy [ 8 ]. Medical imaging plays a crucial role in diagnosing intus- susception; ultrasound is preferred in children, while com- puted 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 ]. Clinical presentation A 6 months old lethargic febrile female infant who was re- ferred to a regional hospital with a history of a palpable soft, firm and tender mass at the umbilical and left iliac fossa re- gion 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 Physi- cian she was sent for an ultrasound scan. Differential diagnosis In light of the clinical presentation, differential diagnoses such as merkel’s diverticulum, volvulus, lymphadenopathy, infan- tile hypertrophic stenosis were considered [ 12 ]. To confirm the diagnosis and rule out these conditions, further investi- gations, including ultrasound examination and intra opera- tive findings were perused. The differential diagnosis for a rare congenital defect known as merkel diverticulum is di- agnosed when a segment of the small intestine protrudes through a weak area in the abdominal wall [ 6 ,10 ]. It may mani- fest with symptoms similar to intussusception, such as vomit- ing, bloody faeces, and abdominal pain. However, it possesses sonographic characteristics like a short bowel connection to a blind-ending peristaltic loop [ 3 ,13 ]. Investigations and imaging findings The patient underwent an ultrasound examination. An ultra- sound 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 ob- tained 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 alter- nating hypoechoic and hyperechoic layers ( Fig. 1 ), giving a tar- get 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 aver- age size measuring 6.9 cm with homogeneous parenchymal echotexture, smooth surface, and sharp edge. No intra or ex- trahepatic 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 av- erage 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 intraab- dominal mass or intraperitoneal fluid collection seen. Abdom- inal organs displayed normal sonographic appearances ( Fig. 4 ). Treatment Due to the delayed detection of intussusception and the pres- ence of symptoms indicating possible bowel ischemia, the medical recommendation was to proceed with an urgent sur- gical intervention as seen in Fig. 5 (laparotomy with man- R a d i o l o g y C a s e R e p o r t s 1 9 ( 2 0 2 4 ) 4 4 5 1 – 4 4 5 6 4453 Fig. 2 – A concentric lesion with rings of alternating hypoechoic and hyperechoic layers with minimal flow on color doppler interrogation. Fig. 3 – Minimal peritoneal fluid (ascites). ual reduction) instead of attempting a nonoperative pneu- matic reduction. Patient mother was informed and coun- selled. Patient was then prepared and was taken to the the- atre for a laparotomy with manual reduction of bowel on May 23, 2023 after a consent form was issued by the med- ical officer and signed by the patient’s mother. Intra opera- tive findings was Ileo-caeco-colic intussuception with viable bowel. Outcome and follow-up The surgical procedure was successful. To support the baby’s recovery, a nasogastric (NG) tube was placed to facilitate en- teral 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 nasogas- tric (NG) tube in place, showing no signs of respiratory dis- tress or pain. The wound dressing was found to be clean and dry. The patient’s vital signs were stable, with a sat- isfactory oxygen saturation level (SPO2) of 100%. After the review, medications were switched to the oral route. Fol- lowing the successful recovery and continued improvement, 4454 R a d i o l o g y C a s e R e p o r t s 1 9 ( 2 0 2 4 ) 4 4 5 1 – 4 4 5 6 Fig. 4 – A ultrasound image of normal liver, right and left kidney and spleen. Fig. 5 – Intraoperative image of the rare case of intussusception. the patient was discharged from the hospital on May 26, 2023. Discussion Approximately 1-4 out of every 2000 children may have intus- susception within their first 3 years of life, with a median age ranging from 4 to 9 months. This condition is prevalent glob- ally. About twice as much affects the male sex. This is a pedi- atric 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 al- ways imprisoned within the downstream segment by a turn- ing 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 fac- tors frequently playing a role. In the case of our patient, no pathological lead point was seen (idiopathic). Idiopathic intus- susception takes place at the location of lymphoid hyperpla- sia, the ileo-colic junction. Rotavirus, herpes virus, and aden- ovirus all point to a viral origin. Tumors, appendicitis, diges- tive abnormalities, and a few general disorders are other local causes [ 16 ]. Ultrasound is the preferred diagnostic modality for intus- susception [ 10 ]. Although CT scans are not typically utilized to confirm a positive diagnosis of intussusception, they are nev- ertheless the preferred imaging modality when certain abnor- malities in the abdomen are present [ 2 ]. Treatment should be made available to the patient after di- agnosis; children who exhibit symptoms of shock, peritoni- tis, or perforation should have surgery right away. For most intussusceptions, noninvasive radiological technique is re- quired; 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 treat- ment is often used as the main approach in developing coun- R a d i o l o g y C a s e R e p o r t s 1 9 ( 2 0 2 4 ) 4 4 5 1 – 4 4 5 6 4455 tries, mostly because of the delayed manifestation and accu- rate 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 deter- mined 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, flu- oroscopic, pneumatic, or hydrostatic enema. Because there is a higher chance of recurrence in the first 24 hours, close su- pervision 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 intussuscep- tion is mostly accompanied with intestinal necrosis, neces- sitating surgical intervention. Surgical intervention is recom- mended in cases when enema reduction or careful surveil- lance proves to be ineffective, irrespective of the kind of in- tussusception. Delays in diagnosis and complications from in- tussusception have contributed to a decline in mortality over time [ 18 ]. Conclusion 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 in- dicators. A favourable diagnosis may be made by ultrasonog- raphy, and imaging plays a significant part in this process. 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