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Intussusception is one of the most frequent causes of intestinal obstruction in early childhood, especially within the first 2 years of life. The classic clinical presentations are colicky paroxysmal abdominal pain with vomiting, a palpable abdominal mass, and bloody stool. The most common type, ileocolic, accounts for 85% of cases, and the incidence of pathological leading points (PLPs) in pediatric patients ranges from 1.5 to 12%. The recurrence rate following fluoroscopy-guided air enema reduction is 5.4–15.4%.
We present the case of a 3-year-old boy with dull abdominal pain for two days. However, he did not present with fever, diarrhea, vomiting, episodic irritable crying, or red, currant jelly stool. Abdominal ultrasonography performed in our emergency department showed one target lesion over the left upper quadrant; fluoroscopy-guided air reduction was performed successfully. The complete blood count revealed microcytic anemia (hemoglobin, 5.2 g/dL; MCV, < 50 fL) with a low ferritin level (1.1 ng/mL), a low iron level (5 μg/dL), and a relatively elevated total iron binding capacity (430 μg/dL). The patient had no family history of thalassemia. The patient was discharged after symptomatic relief, with follow-up for the cause of anemia in the outpatient department.
The patient had two episodes of intussusception with bloody stools within the next 10 days. Abdominal ultrasonography revealed similar target lesion in the left upper quadrant (Fig. 1A). Because intussusception over this quadrant is unusual, we referred to the initial X-ray and fluoroscopy. We observed a mass-like lesion in the left upper quadrant and suspected colocolic intussusception (Fig. 1B). Abdominal computed tomography (CT) confirmed colocolic intussusception with a large tumor (Fig. 1C). A colonoscopy was then performed, and a large pedunculated polyp (Fig. 1D), measuring 3.5 cm in diameter, was identified in the descending colon near the splenic flexure. We successfully performed an endoloop-assisted polypectomy. Pathological examination revealed a juvenile polyp. Four months post-treatment, his abdominal pain and bloody stool subsided and hemoglobin and ferritin levels reached 11.8 g/dL and 48.8 ng/mL, respectively.
PLPs are more common in neonates and children over 5 years of age; the most common causes are inverted Meckel's diverticulum and intestinal polyps.
The colonic juvenile polyp caused lower gastrointestinal bleeding in our patient, resulting in profound iron deficiency anemia. In our literature review, cases of intussusception due to colonic polyps and successful endoscopic resection mostly involved 4- to-10-year-old patients.
We report a case of this extremely young patient with a relatively large juvenile polyp (3.5 cm in diameter).
In summary, PLPs should be considered if there are more than three recurrent episodes of intussusception or atypical initial presentations, such as extraordinary age, unusual symptoms/signs, uncommon location of intussusception, or difficulty in air enema reduction. Colonoscopic polypectomy is a safe, effective, and less invasive treatment for PLPs, such as colonic polyps, in toddlers.
Declaration of competing interest
No conflict of interest exists in the submission of this manuscript.