Case Presentation: A 5 month old boy born at 39 weeks presented with vomiting and lethargy. On the day of presentation, the patient took his morning bottle but refused baby food, then had an episode of non-bilious emesis. Over the course of the day the patient was less interactive and sleeping more. The last bottle was taken at noon. There was one small bowel movement and decreased wet diapers. At 7:30 PM the patient had an episode of non-bilious projectile vomiting. Due to new projectile vomiting, lethargy, and dehydration concerns, parents brought the child to a local emergency department for evaluation.In the ED, there was another episode of projectile vomiting. Additional history included a pediatrician visit five days prior to admission where the patient received vaccinations including for rotavirus. An x-ray of the abdomen showed dilated loops of bowel suggestive of obstruction, therefore he was transferred to the children’s hospital for further management.On admission, the patient was non-toxic appearing with a soft abdomen that did not appear distended and bowel sounds were present. An ultrasound was obtained which showed ileocolic intussusception with a 1.1 cm echogenic mass lesion acting as a lead point. Pediatric surgery was consulted and operative management was recommended. Intraoperatively the intussusception was determined to in fact be ileoileal with a Meckel’s diverticulum acting as a lead point, which was resected. The proximal small bowel was dilated and when the diverticulum was opened the small bowel contents were noted to be fecalized and malodorous, but all bowel was viable. The patient was separately noted to have malrotation, and a Ladd’s procedure was performed.Post-operatively the patient did well. He was initially managed with TPN awaiting return of bowel function, but was tolerating full feeds and ready for discharge on post-operative day 8.
Discussion: As the most common cause of obstruction in young children, pediatric hospitalists are very familiar with the presentation and management of intussusception. This case illustrates several teaching points. Despite an x-ray with significant bowel distention and intraoperative findings suggesting chronicity of the obstruction, the patient’s physical exam on admission was benign without significant abdominal distention apparent. A high index of suspicion is therefore needed, particularly in younger infants who may present with isolated vomiting and inconsistent signs of pain. Although historically the rotavirus vaccine has been associated with an increased incidence of intussusception, the risk is very low with current formulations. The presence of a Meckel’s diverticulum, the most common pediatric lead point, makes it unlikely that the vaccine contributed to this patient’s presentation. Finally, this patient was found to have both a Meckel diverticulum and intestinal malrotation. This has been previously described in small case series but is generally uncommon.(1,2) Malrotation is more strongly associated with other congenital defects including omphalocele, gastroschisis, congenital diaphragmatic hernia, heterotaxy, and intestinal atresia.
Conclusions: Clinicians must maintain a high index of suspicion for abdominal emergencies such as intussusception in younger infants whose signs and symptoms may be more subtle. This case highlights a previously described but uncommon association between intestinal malrotation and Meckel diverticulum.