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Virtual Pediatric Hospital: Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology: Case 10

Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology

Case 10

Michael P. D'Alessandro, M.D.,
Steven J. Fishman, M.D.,
Deborah E. Schofield, M.D.

Peer Review Status: Internally Peer Reviewed
Chief Complaint:
Three week old male with bloody stools and emesis.

Clinical History:
The patient was a three and half week old male who was diagnosed soon after birth with supraventricular tachycardia. On the day of admission he had 3 grossly bloody stools and 3 episodes of emesis.

Clinical Physical Exam:
The patient was pale with a soft, distended abdomen.

Clinical Labs:
White blood cell count was 20,000 with 77% polys and no bands.

Clinical Differential Diagnosis:
Small bowel obstruction due to intussusception

Imaging Findings:
An abdominal film obtained on the day of admission showed a small bowel obstruction. A water soluble enema was then performed and encountered an intussusception at the splenic flexure which could only be reduced to the transverse colon. An air enema was then performed and the intussusception was reduced to the level of the hepatic flexure, at which time a spontaneous perforation occurred, with spillage of air and contrast into the peritoneal cavity. The air enema was terminated.

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Two AP films taken after perforation demonstrate free intraperitoneal air around the liver and outlining both the inner and outer walls of the small bowel.

Imaging Differential Diagnosis:
Intussusception with spontaneous perforation

Operative Findings:
The patient was taken emergently to the operating room to repair the colon perforation. During anesthesia induction there was difficulty with the maintenance of the patient's airway resulting in some patient respiratory instability. An Angiocath was placed into the patient's abdomen to decompress the pneumoperitoneum to improve venous return and ease ventilation. The abdomen was entered through a midline incision. Only minimal soilage of the peritoneal cavity was seen with no gross fecal contamination. The ileocolic intussusception was seen, in place up to the hepatic flexure. The right colon was necrotic in appearance. No attempt was made to reduce the intussusception. A blow out of the transverse colon was seen just distal to the midpoint of the transverse colon, measuring 1.5 cm in length. A right hemicolectomy was performed along with a primary ileocolic anastomosis.

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Pathological Findings:
Examination of the surgical specimen revealed intussusception with hemorrhage and gangrene of the intussuscipiens. There was intussusception with transmural necrosis of the right colon and reactive and inflammatory changes of remaining intestine. Etiology of the intussusception was uncertain. A transmural recent hemorrhage was noted at the distal resection margin, consistent with a history of recent perforation.

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Final Diagnosis:
Neonatal Intussusception, perforation occurred during enema

Follow-up and Prognosis:
The patient developed swelling of the right scrotum one week post-operatively, and an ultrasound of this region (not provided) demonstrated a complex fluid collection in the right scrotum which was felt to represent an abscess, which was treated with antibiotics and resolved.

Similar Cases:
Case 5, Case 9


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