Intussusception in a premature newborn: A case report

Intussusception is a common cause of abdominal pain and intestinal obstruction in infants between 6 to 18 months, with an incidence of 1-4/2000.[1] Only 0.3 % of cases occur during the neonatal period. It represents 3% of all the causes of neonatal intestinal obstruction. About 70-80 cases of neonatal intussusception have been published worldwide over the last 42 years.[2] We report the first case in Ecuador of a premature, born at 33 weeks of gestation with intussusception, who was treated surgically with a favorable clinical outcome.


INTRODUCTION
Intussusception is a common cause of abdominal pain and intestinal obstruction in infants between 6 to 18 months, with an incidence of 1-4/2000. [1] Only 0.3 % of cases occur during the neonatal period. It represents 3% of all the causes of neonatal intestinal obstruction. About 70-80 cases of neonatal intussusception have been published worldwide over the last 42 years. [2] We report the first case in Ecuador of a premature, born at 33 weeks of gestation with intussusception, who was treated surgically with a favorable clinical outcome.

CASE REPORT
A female newborn with a birth weight of 1970 grams was delivered at 33 weeks of gestation, by cesarean section due to premature rupture of membranes. Mother had a positive history of substance abuse (opioids). The baby developed type I respiratory failure at birth and was given intratracheal phospholipids. The baby was transferred to our hospital on mechanical ventilation on day 8 of life. At presentation, the baby had a heart rate of 152/minute, a temperature of 36.9℃, blood pressure of 69/45 mm Hg, and O2 saturation of 94%. The abdomen was soft on examination, without any palpable mass, with bilious aspirates from the orogastric catheter. A plain abdominal x-ray revealed dilated bowel loops. An upper gastrointestinal (GI) series with hydro-soluble contrast was normal. Laboratory investigations showed a white blood cell (WBC) count of 18.9 x 103/L, C -reactive protein (CRP) 0.75 mg/dl, procalcitonin (PCT) 0.25 ng/dl, and a positive fecal occult blood test. After 24 hours of observation, the baby still had bilious aspirates and 2 currant-jelly stools. An abdominal ultrasound was suggestive of intussusception ( Fig.1). She underwent laparotomy that revealed a 10 cm long edematous, erythematous intussusceptum segment in the jejunum, 35 cm distal to the angle of Treitz (Fig.2). It was reduced manually without any signs of perforation. The baby was kept nil per os in NICU for 2 days and was started oral feeds from postoperative day 3 after resolution of gastric aspirate. The baby was discharged and is gaining weight at 2 months of follow-up.

DISCUSSION
Intussusception is unusual in premature neonates accounting only for 0.3% of all reported cases. [1] Premature neonates are at an increased risk of developing intestinal hypoperfusion, causing intestinal stasis and dysmotility, which may lead to intussusception. [3] The index case is the first report in Ecuador of intussusception in a premature newborn.
The etiology of intussusception is idiopathic in the majority of cases, with pathologic lead points identified in less than 25% of pediatric cases. [4] Other underlying causes mentioned in the literature are intestinal duplication, Meckel diverticulum, hamartomas, mesenchymal tumors, jejunal atresia, congenital infantile fibrosarcoma, polyps, and neoplasms. [5] In our case, there was no pathological lead point.
Adult literature describes opiates causing intestinal dysmotility due to the affection of the μ-receptors in all three intestinal layers. Opiates decrease gastrointestinal neuronal activity, reducing peristaltic activity and delaying the passage of contents through the intestines. The use of narcotics may increase the risk of intussusception in the user [6], however, we could not find any study that describes the link between maternal narcotic use and risk of intussusception in the newborn. In older children, ileocolic intussusception is most common, and treatment consists of pneumatic or hydrostatic reduction under imaging or fluoroscopy. In neonates, intussusception usually involves the small intestine, and perforation risk is high. So, the reduction under imaging is not indicated and managed with laparotomy or laparoscopy depending on the surgeon's expertise and available resources. Table 1 shows the characteristics of few reported cases in the literature.
In conclusion, intussusception in premature babies should be considered in the differential diagnosis of intestinal obstruction during the neonatal period. Early diagnosis and intervention can prevent bowel gangrene and hence the need for intestinal resection/diversion.