Indian J Surg DOI 10.1007/s12262-013-0820-9
IMAGES IN SURGERY
Post-traumatic Jejunojejunal Intussusception Haitham Rejab & Ahmed Guirat & Aymen Trigui & Mizouni Abdelkader & Mohamed Issam Beyrouti
Received: 3 April 2012 / Accepted: 15 January 2013 # Association of Surgeons of India 2013
Abstract Intussusception is a well-known cause of acute abdomen in the pediatric population. Traumatic intussusception is exceedingly rare, with only 22 cases reported in the English language literature. We report a case of jejunojejunal intussusception that happened after blunt trauma to the abdomen in a 10-year-old boy. The patient presented with clinical presentation of small-bowel obstruction. Through this case and brief review of the literature, we try to focus on the etiology of this rare condition, the clinical particularities, and treatment modalities. Keywords Intussusception . Small bowel . Trauma . Hematoma . Child
Introduction Intussusception is a well-known cause of acute abdomen in the pediatric population. Traumatic intussusception on parietal duodenal hematoma is exceedingly rare; it may present as a challenge for diagnosis. We present a case of jejunojejunal intussusception in a 10-year-old boy that happened after blunt trauma to the abdomen.
Case Report A 10-year-old child presented with left upper quadrant pain, associated with vomiting. The pain rapidly spread to involve H. Rejab (*) : A. Guirat : A. Trigui : M. Abdelkader : M. I. Beyrouti Department of General and Digestive Surgery, Habib Bourguiba’s Teaching Hospital, 3029, Sfax, Tunisia e-mail: [email protected]
the whole abdomen. There was a history of blunt abdominal trauma in the form of multiple blows with closed fists to the abdomen, a day prior to presentation. Physical examination revealed an elevated temperature and severe tenderness in the left upper abdomen. Digital rectal examination was normal. There was no palpable mass. Laboratory studies revealed a white blood cell count of 10,500/mm3 and hemoglobin of 10.6 g/dL. The abdominal radiograph was normal. Because of the history of abdominal trauma, a computed tomography (CT) was performed, which showed a non-enhancing peritoneal collection in the left upper quadrant, measuring 6×3×7 cm (Fig. 1). The patient underwent an emergency laparotomy, which revealed a 200-cc serous collection and intussusception at the level of the second loop. This coincided with the parietal hematoma (Fig. 2). A manual reduction of the intussuscepted segment revealed a non-viable jejunal loop. The patient underwent resection of 20 cm of the gut and end-to-end anastomosis to establish continuity. The post-operative course was uneventful, and the patient remains well after 18 months of follow-up.
Discussion Intussusception is a well-known entity in the pediatric age group [1–3]; however, traumatic intussusception is rare with only 22 cases reported in the English language literature [4, 5]. Intramural hematoma has been reported in 4 of the 22 reported cases of traumatic intussusceptions [5, 6]. In some cases, the mechanism of post-traumatic intussusceptions is unknown. In other cases, it seems to be related to disorder of peristalsis, local spasm, and bowel edema [4, 5]. Although an intramural hematoma appears to be a clear explanation for intussusception in our case, other factors may also have
Indian J Surg
Fig. 1 Peritoneal collection on the level of the left side, which does not enhance after injection of product of contrast
contributed. CT, done in the presence of a history of trauma associated with clinical signs of small-bowel obstruction, provides an early diagnosis [1, 3, 5]. Manual surgical reduction is sufficient if the gut is viable; otherwise, resection and anastomosis has to be done as was done in our case [5, 6].
Conclusion Jejunojejunal intussusception after blunt trauma in childhood is a rare entity, and pediatricians and surgeons should keep it in mind. Early diagnosis is needed to give appropriate management. Emergent surgery remains the treatment of choice.
Conflict of interests
None.
Fig. 2 Intramural jejunal hematoma after manual reduction
References 1. Ko SF, Tiao MM, Hsieh CS, Huang FC, Huang CC, Ng SH, Lee SY, Chen MC (2010) Pediatric small bowel intussusception disease: feasibility of screening for surgery with early computed tomographic evaluation. Surgery 147:521–528 2. Koh EP, Chau JH, Chui CH (2006) A report of 6 children with small bowel intussusception that required surgical intervention. J Pediatr Surg 41:817–820 3. Parikh M, Samujh R, Kanojia R, Sodhi KS (2010) Does all small bowel intussusception need exploration? Afr J Paediatr Surg 7:30– 32 4. Stockinger ZT, McSwain N (2005) Intussusception caused by abdominal trauma: case report and review of 91 cases reported in the literature. J Trauma 58:187–188 5. Lu S-J, Goh P-S (2009) Traumatic intussusception with intramural haematoma. Pediatr Radiol 39:403–405. doi:10.1007/s00247-0091158-0 6. Erichsen D, Sellström H, Andersson H (2006) Small bowel intussusception after blunt abdominal trauma in a 6-year-old boy: case report and review of 6 cases reported in the literature. J Pediatr Surg 41:1930–1932
IMAGES IN SURGERY
Post-traumatic Jejunojejunal Intussusception Haitham Rejab & Ahmed Guirat & Aymen Trigui & Mizouni Abdelkader & Mohamed Issam Beyrouti
Received: 3 April 2012 / Accepted: 15 January 2013 # Association of Surgeons of India 2013
Abstract Intussusception is a well-known cause of acute abdomen in the pediatric population. Traumatic intussusception is exceedingly rare, with only 22 cases reported in the English language literature. We report a case of jejunojejunal intussusception that happened after blunt trauma to the abdomen in a 10-year-old boy. The patient presented with clinical presentation of small-bowel obstruction. Through this case and brief review of the literature, we try to focus on the etiology of this rare condition, the clinical particularities, and treatment modalities. Keywords Intussusception . Small bowel . Trauma . Hematoma . Child
Introduction Intussusception is a well-known cause of acute abdomen in the pediatric population. Traumatic intussusception on parietal duodenal hematoma is exceedingly rare; it may present as a challenge for diagnosis. We present a case of jejunojejunal intussusception in a 10-year-old boy that happened after blunt trauma to the abdomen.
Case Report A 10-year-old child presented with left upper quadrant pain, associated with vomiting. The pain rapidly spread to involve H. Rejab (*) : A. Guirat : A. Trigui : M. Abdelkader : M. I. Beyrouti Department of General and Digestive Surgery, Habib Bourguiba’s Teaching Hospital, 3029, Sfax, Tunisia e-mail: [email protected]
the whole abdomen. There was a history of blunt abdominal trauma in the form of multiple blows with closed fists to the abdomen, a day prior to presentation. Physical examination revealed an elevated temperature and severe tenderness in the left upper abdomen. Digital rectal examination was normal. There was no palpable mass. Laboratory studies revealed a white blood cell count of 10,500/mm3 and hemoglobin of 10.6 g/dL. The abdominal radiograph was normal. Because of the history of abdominal trauma, a computed tomography (CT) was performed, which showed a non-enhancing peritoneal collection in the left upper quadrant, measuring 6×3×7 cm (Fig. 1). The patient underwent an emergency laparotomy, which revealed a 200-cc serous collection and intussusception at the level of the second loop. This coincided with the parietal hematoma (Fig. 2). A manual reduction of the intussuscepted segment revealed a non-viable jejunal loop. The patient underwent resection of 20 cm of the gut and end-to-end anastomosis to establish continuity. The post-operative course was uneventful, and the patient remains well after 18 months of follow-up.
Discussion Intussusception is a well-known entity in the pediatric age group [1–3]; however, traumatic intussusception is rare with only 22 cases reported in the English language literature [4, 5]. Intramural hematoma has been reported in 4 of the 22 reported cases of traumatic intussusceptions [5, 6]. In some cases, the mechanism of post-traumatic intussusceptions is unknown. In other cases, it seems to be related to disorder of peristalsis, local spasm, and bowel edema [4, 5]. Although an intramural hematoma appears to be a clear explanation for intussusception in our case, other factors may also have
Indian J Surg
Fig. 1 Peritoneal collection on the level of the left side, which does not enhance after injection of product of contrast
contributed. CT, done in the presence of a history of trauma associated with clinical signs of small-bowel obstruction, provides an early diagnosis [1, 3, 5]. Manual surgical reduction is sufficient if the gut is viable; otherwise, resection and anastomosis has to be done as was done in our case [5, 6].
Conclusion Jejunojejunal intussusception after blunt trauma in childhood is a rare entity, and pediatricians and surgeons should keep it in mind. Early diagnosis is needed to give appropriate management. Emergent surgery remains the treatment of choice.
Conflict of interests
None.
Fig. 2 Intramural jejunal hematoma after manual reduction
References 1. Ko SF, Tiao MM, Hsieh CS, Huang FC, Huang CC, Ng SH, Lee SY, Chen MC (2010) Pediatric small bowel intussusception disease: feasibility of screening for surgery with early computed tomographic evaluation. Surgery 147:521–528 2. Koh EP, Chau JH, Chui CH (2006) A report of 6 children with small bowel intussusception that required surgical intervention. J Pediatr Surg 41:817–820 3. Parikh M, Samujh R, Kanojia R, Sodhi KS (2010) Does all small bowel intussusception need exploration? Afr J Paediatr Surg 7:30– 32 4. Stockinger ZT, McSwain N (2005) Intussusception caused by abdominal trauma: case report and review of 91 cases reported in the literature. J Trauma 58:187–188 5. Lu S-J, Goh P-S (2009) Traumatic intussusception with intramural haematoma. Pediatr Radiol 39:403–405. doi:10.1007/s00247-0091158-0 6. Erichsen D, Sellström H, Andersson H (2006) Small bowel intussusception after blunt abdominal trauma in a 6-year-old boy: case report and review of 6 cases reported in the literature. J Pediatr Surg 41:1930–1932
