A baby boy cried every ten minutes for six hours and vomited at least five times during that time. When he was finally admitted to hospital, an initial examination revealed a mass in his right upper abdomen. He had to undergo an ultrasonography, which confirmed an intussusception. This was treated with a procedure known as air reduction. The child recovered well and was discharged three days later. What had happened?
For first-time parents Evan and Elise Chng, a similar harrowing experience happened just a week after their son’s first birthday. “When we got Ethan to the A&E department at the hospital, a scan confirmed the doctor’s suspicion that it was indeed an intussusception. Their first course of action was to pump air through his rectum,” recounts Evan.
“They held him face-down during the procedure and tried doing it three times. Each time, he tensed up and screamed – it was really heartbreaking, especially when the doctor said that they would have to try the next option, which was a keyhole scope surgery (laparoscopy). Thankfully, that worked, so no open surgery was required.”
Elise added, “He was admitted at the A&E at 5 pm on Wednesday, the surgery was done at around 2 am and by Friday, he was already back to his usual, active self, jumping around in his cot. The doctor declared a clean bill of health and Ethan was discharged at noon on Saturday.”
We asked Professor Phua Kong Boo, a Senior Consultant at the Gastroenterology Service in the Department of Paediatrics at KK Women’s and Children’s Hospital (KKH), to tell us more about intussusception.
What is Intussusception?
Intussusception is a condition where a portion of the intestine pushes into a neighbouring part of the intestine, like how parts of a telescope retract into each other. When this happens, the blood supply to the loop of intestine that has telescoped will be compromised and with delay, will eventually become not viable, says Prof Phua.
Most of the time, the cause of intussusception is not known. One theory offered is that the lymph node in the intestinal wall enlarges for some reason, resulting in the telescoping of the intestine.
Prof Phua adds, “Upper respiratory infection, gastrointestinal infection, and introduction of new food proteins have also been postulated as probable causes. Occasionally, it can also result from intestinal polyp, Meckel’s diverticulum, inverted appendix stump and/or intestinal duplication cyst.”
No matter the cause, if recognised early and if the child is given prompt treatment, the prognosis is generally good and very rarely fatal.
Who is susceptible?
Intussusception is most common among babies between four and nine months of age, although it can also occur in toddlers and young children up to five years of age. It rarely occurs in older children as the occurrence decreases with age.
Not being very common, most parents aren’t aware of this condition – until it happens to their child or someone they know. In Singapore, the incidence of intussusception varies, but affects about one in 2,400 to 3,400 infants yearly. It is seen twice as often in boys as in girls.
How is Intussusception treated?
If the condition is diagnosed early, Prof Phua explains, reversal of the telescoping can be attempted by introducing air into the intestine via the anus. This is known as an air reduction, and is successful in more than 80 per cent of cases.
If the air reduction fails, or if severe obstruction and possible leakage of intestinal content into the abdominal cavity has taken place, surgery is required. The surgeon will gently pull on the intestine to reduce the telescoping.
If the condition has progressed to where the intestine is not viable, the section of intestine that is affected will be resected – cut out – and the two ends surgically joined together. This is why intussusception must be diagnosed and treated promptly, or things could deteriorate fast.
If everything goes well, feeds will be gradually introduced over the next day or two. When the child can feed normally, he is deemed to be sufficiently recovered and ready to go home.
Can it recur?
Unfortunately, intussusception can recur even after successful treatment and complete recovery. This happens in five to 10 per cent of patients. The symptoms are similar and treatment follows the same path.
However, parents should understand that it is nothing they may or may not have done. As Prof Phua explains, recurrence – or occurrence, in the first place – cannot be prevented, nor are there lifestyle changes that can lessen the risk of intussusception.
What are the tell-tale signs?
According to Prof Phua, symptoms of intussusception are as follows:
• A previously well child suddenly develops attacks of severe abdominal pain
• Legs are drawn up, knees to the chest
• Cries and screams
• Turns pale
• Starts to vomit and may have bile-stained vomitus
• (Less often) passes stool that contains blood and mucus described as “currant jelly stool”
• Palpation of the abdomen may reveal a sausage-shaped mass on the right side of the abdomen
“Ethan hadn’t been eating well the day before. Around lunch time the next day, he suddenly began crying quite badly, screaming from time to time, and pulling his knees up to his chest,” relates Evan. “When my wife changed his diapers, she saw a red jelly-like substance in loose stools. He also vomited, so we brought him to the A&E.”
Seven months on, Elise is relieved her son has recovered well and is as happy and healthy as he was before the episode. So if your perfectly healthy child suddenly develops abdominal pain, cries inconsolably seemingly without rhyme or reason, and vomits, intussusception could be the reason. Waste no time in taking your child to the nearest children’s emergency department.