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Case of the Month

March 2009

Patient Data: 5 year old boy

Clinical Info: Pain and cramps in the abdomen. An ultrasound examination was requested to rule out an appendicitis or intussusception.

Transverse image of a target shaped lesion in the left upper abdomen. The multilayered lesion represents an intussusception.

The same lesion in a longitudinal plane shows the typical bowel in bowel configuration of an intussusception.

374.swf Cineloop 1 is made in the transverse plane of the lesion and shows peristaltic movements within the intussusception confirming that it is a small bowel intussusception.

375.swf Cineloop 2 is made in the longitudinal plane of the lesion and also shows the peristaltic movements in the intussusception.

Color Doppler shows normal vascularization of the bowel walls in the intussusception

In the right lower abdomen a normal appendix was found in a normal position. This eliminates an abnomal position of the cecum, confirming that the intussusception found in the left upper abdomen is not an iliocolic intussusception.

Image of 2 mesenteric lymph nodes. The presence of mesenteric lymph nodes in children is non specific. No peritoneal fluid or bowel dilatation was found. The intussusception did not resolve during the time of the ultrasound examination. Because small bowel intussusceptions usually resolve spontaneously. It was decided to wait. A couple of hours later the cramps had disappeared and a repeat ultrasound examination was performed.

Image of the left upper abdomen only shows normal small bowel.

Small bowel intussusceptions can be found incidentally in asymptomatic children and in symptomatic pediatric patients like in this case.
There is a difference between the small bowel intussusception and the ileocolic intussusception. The ileocolic intussusception nearly always needs hydrostatic or even surgical treatment . The small bowel intussusception in many cases is a self limiting disease. It is important to look for signs that help differentiating the self limiting small bowel intussusceptions from the ones that need surgical treatment.
Transient small bowel intussusceptions resolve during the examination or are resolved during a short term follow up examination.

Signs to look for in a small bowel intussusception are
Length of the intussusception
Wall thickness
Vascularity of the bowel wall
Identifiable lead point
Signs of obstruction
Signs of peritonitis

Signs found in intussusceptions that need surgical treatment are
Longer length of the intussusception (usually more than 3,5 cm.)
Bowel wall thickening
Identifiable lead point
Small bowel dilatation
Free peritoneal fluid
Signs of peritonitis

Signs found in intussusceptions that can be followed up are
Shorter length
No bowel wall thickening
Normal vascularity
No signs of obstruction or peritonitis

For more examples of intussusception see

Park NH, Park SI, Park CS, Lee EJ, Kim MS, Ryu JA, Bae JM. Ultrasonographic findings of small bowel intussusception, focusing on differentiation from ileocolic intussusception
Br J Radiol. 2007 Oct;80(958):798-802

Mateen MA, Saleem S, Rao PC, Gangadhar V, Reddy DN. Transient small bowel intussusceptions: ultrasound findings and clinical significance.
Abdom Imaging. 2006 Jul-Aug;31(4):410-6.

Munden MM, Bruzzi JF, Coley BD, Munden RF. Sonography of pediatric small-bowel intussusception: differentiating surgical from nonsurgical cases.AJR Am J Roentgenol. 2007 Jan;188(1):275-9.

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