intussusception newbornintussusception in thenewborn by v. c. talwalker* fromthehospitalfor sick...

INTUSSUSCEPTION IN THE NEWBORNBY

V. C. TALWALKER*From The Hospital for Sick Children, Great Ormond Street, London

(RECEIVED FOR PUBLICATION AUGUST 23, 1961)

Intussusception is a rare condition during theneonatal period. Isolated cases have been men-tioned in many of the large series reported fromvarious centres, but only a few cases are describedin detail. The purpose of this paper is to describeone such case, report nine new cases and reviewthe literature on this subject.

* Present address: 394 Lamington Road, Bombay 4, India.

Case ReportThis female infant, the second child of normal parents,

was born on January 4, 1960, weighing 7 lb. 10 oz.(3-46 kg.). She started vomiting bile-stained fluid fromthe first day, some of these vomits being projectile.Meconium was passed on January 7, for the first time.She was admitted to the hospital on January 9. Onexamination there was some epigastric distension, butno masses were palpable. There was a large gush ofsoft, jelly-like dark-red meconium after a rectal examina-tion. Plain radiographs of the abdomen showed asmall quantity of gas in the stomach and the duodenum.There was no gas anywhere else in the abdominal cavity.As the appearances were not typical of any common formof intestinal obstruction, it was felt that further investi-gations were justified. A tube was passed into thestomach and 40 ml. of air was injected. Another seriesof plain films revealed that the gas passed round theduodenum into the upper jejunum. The terminal partof the gas shadow tapered down into a cone (Fig. 1).Although this appearance was not typical of smallbowel atresia, it was obvious that some form of intestinalobstruction was present and laparotomy was performedon the same day. There was an irreducible intussus-ception about 15 cm. from the duodeno-jejunal flexure.This was resected and an end-to-end anastomosisperformed. The baby made an uneventful recoveryand was discharged home on January 18. Histologicalexamination showed (Fig. 2) that the apex of the intus-susception was formed by an adenomatous polyp about2 cm. in length. There was necrosis of the muscle

}.. ..

FIG. I.-Antero-posterior view of the abdomen after the injectionof 40 ml. of air into the stomach.

*.. I ..I I I l.

FIG 2.-Resected specimen of jejunal intussusception, showing apolyp at the apex.

203

---%~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

on April 24, 2020 by guest. P

rotected by copyright.http://adc.bm

j.com/

Arch D

is Child: first published as 10.1136/adc.37.192.203 on 1 A

pril 1962. Dow

nloaded from

http://adc.bmj.com/

Cu*-o >

0~~~~~~~0So0." 0 Cu

0 0

(Au ~ 0 0

C.0

vCu 4) a a o

'C0 cd 06-3. K

Cu.o

Cuo C>C 0o

Cu

.20E .Q.0 .2 .2

4.

0 0

0 .0

$-

to

> E

0d C Cu

oa E

°uY4) D °0X.0

u20 Ca 0.0 o- C600

0

0 0. o~.0 0. 4) 4)~ 0.2002Eo e'10 Cu 04) 0 2(A4)

0'-~~~~~~~~~~~~~~~~ .0 ~~~~~~~~~~~~~~~o ~~~~~ WtW) 0 do* e~~~~~4O0.~~~~~~ 4)~~~~~ ~~~ ~

0G . .c 00

E 0 0U=4) 4

0 be 0 . to0 0 C

*C4 0 o00 o 4j4)-

;N

0C~~~. 000..cu j 0' '0

C~-20 . Cru 4u Oc la..4)

>CoE .C,2C.C~~~~~~ - E- >C'*0 0''C

~~~.~~~~~0 o~~~.~ Or- o2 > 40 Oa0 ~ 44

cc EE,00 -C~ .C0 u' .0S.cCC4.-.uC-.~~~22~~~ .-02~~c Eu) E00C

>(A 0 - Cdo~o02.oo'to

W) u> >0-E - 0. 00 0Cu Cu

CU 44440 44 c0 0 C C 4 C

Cd0 '' C',u 00 c t0. cdE.o

Eu0.44 C.4-4 es > ' Eu>,-10 - =C.0 .- 4

4) >CEE0. 00 ..2 '0- 20 >00

0

0 C. .0~~~~~~~U a-r.0 0) ' .- cu

~40 'C C '0.0 ~~~~~~~~~~~~~~~~~~~~~a~~~ ~ ~c

*-..E . E0 'o C, 0 S.2 to.E2 lo' E cu0 Mouc *...0 0

E o "W~~~ Co m 2- .2 -'-C, 0-0LO,0 .2 0

-0 r~040 S.CWV ed2o

4) ~~~~~4N - '44040~.0 .

ri0 en

Q

1-

en

ena0

0.

0

ON

en

r.

cW002'0

en0

.0-C)o.o

0s 0

4) 4)

.. 40Q

4) 4) 4m ~ c~ 4

-O. -. u< 0I

1-

0

4

I..

E0

0

U

-

0

0 o._ ^ -

.'0

x0

0-

w

Hj

0

E

F-

00.E

00CA

Ccen

00

0.0.

Cd0

0

0

'0

-

2

'0-

3Q

1-

8o1-

*.



j.com/

Arch D


pril 1962. Dow

nloaded from

http://adc.bmj.com/

6. - 4) ed A bo a 0

>0 >t o

> E E > To Km 4m

0 E >

U 0 0 Z0 0 0 4u 04 r. 006 E,; 0 m EE 0 >.5 0 00 0 0 E= 00 0 0 m -0 .: E 0 u 0tj 06 m be o o d0 co-q _'0 0 0 E -z: 0ti Ca co 8 0

- C, 0 0u 0 0 0 a 11,06 -

00 4'-) 0 4) 0a e

0-0 a , - 0 1.4 4 04) E C r en00 0

-Z:to0 o o r.M.z o ci, 1. v.o 0 0 M

r. - 0Z 0-0 0 0. co'A.- C co

v 0 0 10 o0

> > > > > > >r. la 0 O.Z: co -0 r.

0. rA4) u V

0 41,

4) 0 Z, 0C.= o 0 > - M.-.0 0 0 00 .0 rA rA

00>,M cdm-C m- .14rA E

00 Co IU - -= 0 Gn 0 M 0O,z 0 o (A M 020 0 r.

r. - 8 or

0 00 Gn 0

M - 0 E!9 Xv 'A M -5C,, rA06 E'Z: E E rA='O 0M rA0 r r. Z rA

M co x ..M M 0 W.sC 1. >, 0 r.rA o eu .0 vmen :M .0 -_ u0 -14 > - 0 .- Ch E

I..= la 0 .: "O06 E 4,10 ti-2

..O 0 0 co 411. :u 0E= m >

0 X ME E 00 O= Z0 ECd

rA M U0 >,M E EW E 0 E E E E E E la0 E 0 0 0 0o oto or. Os or.-0 Z 0 C - 0 .. 0v C-1 M M Z0 0 0 0 0 a 0 0Oe,-.2 0 0

&. - W I..S. 'A 1. EE Ev &' a E E0 -a 0 m 0 v M cc M M M

o E E 061, 0.

04 0.4 Z 04

s M 0 r. C.;=M M 8m eg

06 M OZ a: Z 0 o Ela r. 0 Et" .0 M -0 0 1W.- 0 o

ea0.0 Ol- 0 10

r. r- to o x010 0 M 0 u

E X-A 0 > M co v0a0 E.2 cli -a m E 010 0 M MW I.. E m C,I 4 r. S- 0 rA uCl. E z 0 W u

.. 0 %Z 1. E o 0 :6.0 Cdr.4.; C .-O - I.. I..> 0 0 00.0 0 0 0'O 0 0

M 0 r ..v0 >, P6.0 ..O 0M .0 mE 0 to r. 'A r. w E 0 0 0

.104 r. 0 r. Er tE Z .9 11

00 CL .t , .: 0-00>.0C8.0 I...C

.2 U3.5 -0 .0 0 r. M 0 0 >>.V C r. C zE to

.. r. =M.:: 0 'a 0 .0 r' Er- X 0 0 S.--- '; to 0Z r. 0 cv'o

t: OZ: Z Om 'oj E 0 UU M 0 0. Z o C14 X.- E 0

r. 0E' 0 O=M 0

U- "to V w 0 r. C),> Gn - 0 'a to= 060 0 o cd C, 0 --.0 0 -0 LA 0 EC-0 = 0 - .- E--r. 0M 0 cd M M Z to bb,= r. r.0 0 EC , M 0 0 0 wboZZ 0 -O WM r. S- to r.0

= 0.r. x cli0 cd 0 5 C Z 0 m-0 ;..,a V.U E a: . >,a U. 0 0 0la 0 0 co Mr. q o E;z 0

...Q -!. , m U0, E u v 0 = Z 0 Z 2 w E ro- R co' E0 O. la 0 v 0 C M la4) 0 0 U

0 0 0 0 -U -U -0

O _OO 0-:$ -OW)

44 6. ON

S ir. SC arZ CZ0 0 0 00 bo 0 be 0 bo rA 0 0x 02 x 'A Z rA O'0 010 r.

M M co . r. r. 00 O

O4) Cd .0 1; 0 0> "t , "t $_ ;N4) W) 4) W) 4) WI a .O >, CF CF e 4) C. 10 .2

CZ -001, -0 as -0 -0 ON 0 r. 0 0

la la

E E E:E E E0 0 0. 0 0 0 0. O U O U 0 U 0 U OU

CZ U. 6. U. U. S. W U.Z



j.com/

Arch D


pril 1962. Dow

nloaded from

http://adc.bmj.com/

ARCHIVES OF DISEASE IN CHILDHOODcoat in the covering layer of the intussusception andatrophy -of the mucosa at one point.

Review of LiteratureA search through the literature up to the end of

1960 was made. Only those cases in which thediagnosis was confirmed either at operation or atautopsy were selected for review, though a fewcases which did not qualify are mentioned separatelyas they are of some interest. With these criteria,a total of 16 cases was found. In addition therecords of three British hospitals provided ninefurther cases, none of which had been reported.These, together with the case described in thispaper, provide 26 cases for analysis. The mostrecent review of the subject was by Rachelson,Jernigan and Jackson (1955). All their casescould not be included in the present review assufficient information was not available in everycase (Table 1).

Symptoms. Vomiting and blood in the stoolswere almost invariably present (Table 2). Evidenceof abdominal pain and the palpation of an abdomi-nal or rectal mass seem to be uncommon findings.

TABLE 2

Symptom Recorded Not Present No Mention

Vomiting .. 20 2 1As first symptom .. 14Bile staining .. 9

Blood in stools .. 17 2 4As first symptom .. 11

Screaming .. 5As first symptom ..4As only symptom ..

Mass felt per rectum .. 2Mass felt abdominally .. 4

Symptoms have not been recorded in three cases.

Many cases presented with blood in the stools asone of the first symptoms. In the three cases inwhich vomiting was either absent or not recorded,blood in the stools was the first symptom. In oneof these it was the only symptom, and diagnosiswas made only at autopsy. In another, althoughblood in the stools was the only symptom, a diag-nosis was made by the help of barium enema.In the third case, all other clinical features werepresent and a clinical diagnosis was made.Many infants exhibited symptoms soon after

birth (Table 3). Three of these were said to bepremature. One of them was said to be two monthspremature and died soon after birth. Autopsyfindings suggested that the intestinal obstruction

TABLE 3

Age at First Symptom Number

Up to 48 hours .15Up to I week. 5Up to I month. 4

Total .24

Died soon after birth .. 1Unusual presentation .. 1

was of about one week's duration. The intussus-ception had obviously occurred in utero. All thesix cases in which a causative lesion was presentshowed first symptoms within the first 48 hours.

Diagnosis. A pre-operative clinical diagnosis ofintussusception was made in six cases; four of thesehad a palpable mass. In 13 cases the abdomenwas opened with the diagnosis of obstruction madeon clinical grounds either with or without the helpof plain radiographs. In two cases a barium mealexamination was undertaken to diagnose obstruc-tion. In one case a barium enema demonstratedan intussusception, but the barium also succeededin reaching the peritoneal cavity through a per-foration in the splenic flexure near the apex of theintussusception. Diagnosis of intussusception wasmade at autopsy in four instances.

Treatment. Apart from the four cases diagnosedafter death all others were operated on (Table 4).

TABLE 4

Total Alive Dead

Resection 12 6 6Reduction .. 10 7 3

Simple reduction was done in nine cases. One ofthese recurred four months later at the same siteand was treated again by simple operative reduction.Reduction and ileo-colostomy were done in oneinstance. Out of the 12 cases which needed resectionof bowel, one needed another laparotomy for lysisof adhesions three weeks later.

Pathology. The commonest site of intussus-ception was in the ileo-caecal region (Table 5). Theproportion of cases with jejunal intussusception,however, is much higher than would be expectedin a series of older infants. The incidence of under-lying pathology is also higher in the jejunal group.Out of the eight cases of jejunal intussusception,six were treated by resection. In one case in which

206



j.com/

Arch D


pril 1962. Dow

nloaded from

http://adc.bmj.com/

INTUSSUSCEPTION IN THE NEWBORNTABLE 5

Typeof

Intussusception

Ileo-caecalJejunal ..

IlealColic ..

Site not mentioned

simple reduction was successful, enterotomy hadto be done to remove an 'enteric cyst'. Three casesshowed interesting associated lesions. Meconiumileus was present in one, diaphragmatic hernia inanother and an exomphalos in a third. The lasttwo had the corrective operations for their lesionssix days and three days previously. Whether theresulting increase in the abdominal contents andpressure had any relation to the aetiology of theintussusception is open to speculation.

Other Reported Cases. Three other cases arereported in considerable detail in the literature.These could not be included in the review as thediagnosis was not confirmed at operation or atautopsy. However, the histories of these cases areso suggestive of intussusception that it was decidedto mention these.

Becker's (1955) patient started vomiting at 10 days.He continued to vomit and to pass small amountsof stool until the seventeenth day, when a mass wasfelt in the right lower quadrant of the abdomen.Blood was noted on rectal examination. Surgerywas refused and the baby's condition continued todeteriorate until the twenty-fourth day when themass was still palpable. On the twenty-fifth daythe mass disappeared and some slimy necroticmaterial was passed with a little blood per rectum.This was followed by a rapid recovery.

Schiavone's (1936) case presented with screaming,constipation, bile vomiting, and a mass was feltin the left flank. Blood and mucus were found onrectal examination. A clinical diagnosis of intus-susception was made, but operation was refused.The patient died two days later aged 10 days.Autopsy was not allowed.

Perhaps the most interesting case was thatreported by Rachelson et al. (1955). The babypassed normal meconium at the age of 12 hours.At the age of 30 hours she passed a segment ofgangrenous tissue per rectum. Histology showedthat this was a segment of small intestine turnedinside out. Plain radiographs taken soon afterbirth had shown no evidence of intestinal obstruc-tion. Eight hours later she developed intestinal

obstruction. Laparotomy at 56 hours showed adistended ileum ending in a bulbous pouch whichwas sealed off. There was a V-shaped defect in themesentery. An end-to-end anastomosis was per-formed, and the patient recovered. The sketch ofthe operative findings is typical of intestinal atresia.Although the two radiographs are not published,nor is the histology of the intestinal segment, itseems reasonable to assume that this baby was bornnormally, developed an intussusception at the ageof 1 day, was cured by passing the segment ofgangrenous bowel, but was left with a gap in thesmall intestine. It is remarkable that both bowelends were sealed off in 26 hours.

DiscussionAlthough intussusception is rare in the newborn,

one may come across a case occasionally in centresdealing with many cases of neonatal intestinalobstruction. The four cases in Liverpool and thethree in Glasgow were seen in the past eight years.In the same period only one case was seen atGreat Ormond Street. Vomiting, often bile stained,and blood in the stool are the commonest symptoms.When vomiting is present it usually leads to thediagnosis of intestinal obstruction, but if blood-stained stools are the presenting symptom thediagnosis is likely to be delayed. Evidence ofabdominal pain and a palpable mass are uncommonfeatures, but when these are present a diagnosis ofintussusception can be made with confidence. Plainradiographs of the abdomen will demonstrateintestinal obstruction and the use of opaque mediais not necessary. When blood in the stools is thepredominant symptom and there is nothing elseto suggest the presence of obstruction a bariumenema may help. It should be performed cautiouslybecause there is a risk of perforating the colon.In most cases the final diagnosis of intussusceptionwill be made only at laparotomy.Laparotomy should be performed in all cases.

Reduction by enema is not advisable. Simplereduction should be attempted, though if there isany difficulty in reducing the intussusception or if

207



j.com/

Arch D


pril 1962. Dow

nloaded from

http://adc.bmj.com/

208 ARCHIVES OF DISEASE IN CHILDHOOD

there is any doubt about the viability of the gutthe intussusception should be resected. Most ofthe jejunal intussusceptions seemed to require this,a fact which may be related to the high incidenceof a causative lesion in this group. End-to-endanastomosis should be performed to restore con-tinuity. Blood loss from the intussusception maybe large enough to need replacement in an occa-sional case.

Relation to Intestinal Atresia. Prenatal intus-susception has been suggested as one of the causesof intestinal atresia (Parkkulainen, 1958). Thoughthis theory lacks convincing proof, there is enoughevidence to suggest such a possibility. It seemscertain that intussusception can occur duringintrauterine life. If this is so, it is conceivable thatthe blood supply of the gut may be injured. Sincethis is known to cause intestinal atresia, prenatalintussusception may well be the aetiological factorin some of the cases of intestinal atresia. Thesequence of events described by Rachelson et al.(1955) appears to provide clinical evidence to supportthis theory.

Summary

A case of intussusception in the newborn isdescribed. A description of this condition as aclinical entity is attempted from the analysis of26 cases. The possible relation to intestinalatresia is mentioned.

I am grateful to Miss I. Forshall (Liverpool), Mr.W. M. Dennison (Glasgow), and Mr. D. J. Waterston(London) for permission to publish their cases and fortheir encouragement. I am specially indebted to Mr.J. E. S. Scott (Newcastle) for his help throughout thepreparation of the paper.

REFERENCES

Adamson, E. W. and Hild, J. R. (1939). Meconium ileus. J. Amer.. med. Ass., 112, 2275.Akerren, Y. and Pettersson, G. (1954). Intestinal intussusception

during the neonatal period. Acta chir. scand., 107, 550.Becker, J. (1955). Invagination bei einem 17 Tage alten Saugling

mit Selbstheilung. Kinderdrztl. Prax., 23, 264.Dowd, C. N. (1913). Resection of one-third of the colon for

irreducible intussusception in an infant five days old. Ann.Surg., 57, 713.

Feggetter, S. (1954). Intussusception at 70 hours. Brit. med. J.,2,1335.

Gelston, C. F. and Sappington, E. E. (1930). Acute intussusceptionin new born with report of case including autopsy findings.Arch. Pediat., 47, 185.

Jeffrey, F. W. (1946). Intussusception in the new born. Canad.med. Ass. J., 54, 271.

Lannin, B. G., Leven, N. L. and Tongen, L. A. (1955). Congenitalobstruction of small intestine and colon. A.M.A. Arch. Surg.,70, 808.

Lewis, J. H. (1939). Jejunal intussusception of newborn. Amer.J. Dis. Child., 58, 558.

Mayo, C. W. and Phillips, J. R. (1933). Acute intussusception inchildhood: report of 31 cases: tuberculous cyst of fallopian tube;femoral peritoneal cyst: report of case. Surg. Clin. N. Amer.,13, 995.

Noel, 0. F. and Beasley, L. A., Jr. (1957). Intussusception in thenewborn infant: a case report. Amer. Surg., 23, 352.

Parkkulainen, K. V. (1958). Intrauterine intussusception as a causeof intestinal atresia. Surgery, 44, 1106.

Prouty, M., Bruskewitz, H. W. and Schwei, G. P. (1949). Intussus-ception in a newborn infant. J. Pediat., 34, 487.

Rachelson, M. H., Jernigan, J. P. and Jackson, W. F. (1955). Intus-susception in the newborn infant with spontaneous expulsion ofintussusception; case report and review of literature. ibid.,47, 87.

Schiavone, G. A. (1936). Invaginacion intestinal en el lactante.Sem. med. (B. Aires), 43(1), 687.

Scott, E. P. (1943). Jejunal intussusception. J. Pediat., 23, 565.Shnitka, T. K. and Sherbaniuk, R. W. (195a,. Congenital intussus-

ception complicated by meconium peritonitis. Obstet. andGynec., 7, 293.

Swain, V. A. J. and France, N. E. (1954). Intestinal obstruction innewborn. Lancet, 1, 844.

Tweedy, E. H. (1906). Report of meeting of Section of ObstetricsRoyal Academy of Medicine in Ireland. Brit. med. J., 1, 1402.



j.com/

Arch D


pril 1962. Dow

nloaded from

http://adc.bmj.com/

intussusception newbornintussusception in thenewborn by v. c. talwalker* fromthehospitalfor sick...

Documents