EXPERIENCE AND REASON 93
hood, ed 2. Springfield, IL, Charles C Thomas, 1969,
pp 232-258
3. Milhorat TH: Intracerebral hemorrhage, acute hy-drocephalus, and systemic hypertension. JAMA 218:
221, 1971
4. Epstein FJ, Hochwald GM, Wald A, et al: Avoidance
of shunt dependency in hydrocephalus. Dev Med
Child Neurol [Suppl] 35:71, 1975
5. Salmon JH: The collapsed ventricle: management
and prevention. Surg Neurol 9:349, 1978
Altered
Consciousness
as an
Early
Manifestation
of
Intussusception
Many reviews of intussusception in the last
cen-tury have included the salient features of the
clini-cal spectrum of intussusception. Few reports during
this period have been devoted specifically to
atyp-ical presentation of the illness. This paper reviews
the recognized symptoms of intussusception,
high-lighting altered consciousness as a presenting
com-plaint.
Usually intussusception is a readily diagnosed
disease as the clinical pattern is typical most of the
time. ‘Typically a child less than 2 years of age who
has previously been in good health suffers a sudden,
violent abdominal pain.2 The paroxysm of pain,
which at the onset is uninterrupted for a few
mm-utes, is followed by a period of relief. Between
attacks, the child may go to sleep or may be playful
and without complaint. The healthy appearance at
this time may lead the clinician to disregard the
history.’ Nausea and vomiting may occur either
simultaneously with the pain or soon thereafter.
Concurrent with vomiting, the child usually has one
or more bowel movements which vary from thin
liquid to formed stools.2 After an interval, the child
will again cry-out, writhe, and vomit only to be
suddenly well and afflicted again in 15 to 20
mm-utes.4 Within several hours, apathy or even lethargymay ensue in the intervals between the colicky
abdominal pain.5 Within 12 hours’ or 24 hours,3
mucus, or blood, or both may be passed together
with thin bowel movements. Vomiting may become
feculent.2 With the passage of time and increased
obstruction, pallor, and restlessness are found as
the child approaches a state of shock.6 Terminally,
the child will be pale and listless,7 and may have a
convulsion.2
Early diagnosis is essential because the duration
of intussusception before treatment bears a close
relationship to the reducibility of the
intussuscep-tion by whatever means, and in the days when
Reprint requests to (J.S.) Children’s Hospital Research Foun-dation, Elland and Bethesda Aye, Cincinnati, OH 45229.
deaths caused by intussusception were not rare, the
death rate was directly proportional to the duration
of symptoms.5
Several obstacles to early diagnosis have been
described. Diagnostic obstacles include inexplicable
diagnostic errors on the part of physicians such as
the failure to recognize the typical history or failure
to perform a rectal examination; ‘ a prolonged
his-tory in conjunction with well being of the child;4
atypical age at the time of presentation or absence
of pain;7 and the presence of an underlying disease
state.8 Also, atypical presentations with marked
variations from the classic picture have caused
di-agnostic delay. As examples: bright red rectal
bleed-ing,8 anorexia, constipation, diarrhea, abdominal
distension, and fever as prodromal symptoms
pre-ceding clear-cut symptoms of mtussusception have
occurred in isolated as4 In all of these cases,
the diagnosis was obvious only in retrospect. The
following case reports are perhaps as obvious when
reviewed retrospectively.
CASE REPORTS
Case 1
A.G., a previously healthy 8-month-old male infant,
was evaluated for progressive lethargy. After an
unevent-ful night and two hours postprandially, the infant
sud-denly became irritable, vomited, and passed a normal
stool. He rapidly became unarousable. There was no
history of ingestion of any medication.
On arrival at the emergency department, he was
flac-cid, responsive only to noxious stimuli by purposeful
withdrawal. The temperature was 37 C, pulse 100,
respi-ratory rate 30, blood pressure 94/66. The pupils were
miotic and slowly responsive to light. The abdomen was
soft, nontender without masses or abnormal bowel
sounds. The rectal examination revealed guaiac positive
stool. There was no evidence of cardiorespiratory
depres-sion or focal neurologic abnormality.
Analysis of body fluids for medication, hypoglycemia,
electrolyte abnormality, bacteremia, and intracranial
in-fection were performed and were negative. There was no
clinical response to infusion of intravenous dextrose or
naloxone. The gastric contents were lavaged and the
patient was admitted to the intensive care unit with the
suspected diagnosis of ingestion or central nervous system
depression on the basis of sepsis.
Abdominal roentgenogram was obtained because bile
was obtained from a nasogastric tube. These showed
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94 PEDIATRICS Vol. 64 No. 1 July 1979
abnormal small bowel loops and a questionable left upper
quadrant mass. An ileocolonic intussusception
encoun-tered at the splenic flexure was reduced by barium
col-umn. Postreduction, the infant’s level of consciousness
returned to normal and he was discharged two days after
admission without recurrence of any symptoms.
Case 2
A.C., a previously healthy 7-month-old male infant
with a current history of upper respiratory tract
symp-toms and low-grade fever, was evaluated for increasing
lethargy. He awoke after an uneventful night in an
irri-table state. He was anorectic and vomited after taking
fluids. Fitful sleep, which retrospectively was associated
with transient flexion of the knees to the abdominal wail,
throughout the morning progressed to unresponsiveness
several hours later. He had vomited a second time and
had two loose stools by the time of his arrival in the
emergency department, nine hours after onset of the
altered sensorium.
He had generalized decreased motor strength and was
slowly responsive to painful stimuli. The temperature was
37 C, pulse 164, respiratory rate 42, blood pressure 110/
50. He had unilateral otitis media. A tender irregular
mass was palpable in the left suprapubic region. There
were decreased bowel sounds and guaiac positive stool.
There was no evidence of focal neurologic abnormality.
Intracranial infection, bacteremia, hypoglycemia, and
electrolyte abnormalities were excluded. Abdominal films
revealed small bowel obstruction. He remained lethargic
until laparotomy 14 hours after the onset of the altered
state of consciousness. A viable ileocolic intussusception
to the sigmoid colon was manually reduced. He recovered uneventfully.
DISCUSSION
In the above reported cases, there was not a
common predisposing cause, anatomical variation,
or environmental circumstance. In both cases, the
most common causes of altered sensorium were pursued and excluded. A cause and effect
relation-ship of the intussusception and the central nervous
signs is strongly suggested.
There have been isolated case reports of
prodro-mal alteration of central nervous function with
in-tussusception. Nervousness,’ restlessness, apathy,
and seizures4 have occurred individually. More
com-monly, however, altered consciousness correlates
directly with the duration of symptoms and the
degree of bowel viability. As examples: a
5-month-old infant with a 52-hour history of intussusception
during successful reduction by barium enema had
a generalized tonic clonic seizure.5 A 29-month-old
female infant with a history of intussusception for
an 18-hour interval was in “profound apathy” prior
to a successful intraoperative reduction.5 A
10-month-old infant whose intussusception was missed
and who had symptoms for greater than 24 hours
had an irreducible, nongangrenous bowel and was
“flaccid and almost completely unresponsive” prior
to operation.4 A 4-month-old infant with symptoms
for three days who had gangrenous bowel and died
had been “listless” preoperatively.2 A 5-year-old
child who died from disseminated tuberculosis and
a gangrenous bowel from an ileocolic
intussuscep-tion was “extremely drowsy” on presefltation.’
The majority of cases in which altered central
nervous system function has occurred have been in
moribund children who have a combination of
elec-trolyte and fluid imbalance, and blood loss, as well
as a compromised intestinal mucosal barrier.
Toxic metabolic products, although not defined,
have been shown to migrate transmurally through
obstructed bowel loops with compromised vascular
supply, causing systemic effects and death.9 The
anatomical derangement of the bowel created by
intussusception through a combination of bacterial
proliferation and tissue autolysis with time alters
the integrity of the mucosal barrier. Devitalized
bowel segments may then lead to a depressed
sen-sorium, especially when there are concurrent
pro-found changes in systemic vascular resistance and
effective plasma volume. It is unclear how altered
sensorium can be created at the initiation of the
intussusception when the mucosal barrier has not
been violated and hemodynamic changes have not
become significant.
Considering the possibility of intussusception in
a previously healthy child with sudden alteration of
consciousness, when known conditions of altered
consciousness have been systemically excluded, will
result in a reduction of diagnostic delay and a
facilitation of definitive treatment.
SUMMARY
Two children who had neurologic symptoms as
prodromal manifestations of intussusception are
presented. Previously described alterations in
cen-tral nervous system functioning with
intussuscep-tion are reviewed.
ACKNOWLEDGMENT
The author wishes to thank Margaret Straub for
sec-retarial assistance.
REFERENCES
JONATHAN SINGER, MD
Department of Pediatrics
Children’s Hospital Medical Center
Cincinnati
1. Kahle HR: Intussusception in children under two
years of age: An analysis of fifty-four cases from
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EXPERIENCE AND REASON 95
Charity Hospital of Louisiana at New Orleans. Sur-gery 29:182, 1951
2. Hess JH: Intussusception in infancy and childhood,
with collection of 1,028 cases, with statistics. Arch Pediatr 22:655, 1905
3. Ladd WE, Gross RE: Intussusception in infancy and
childhood: A report of three hundred and seventy-two cases. Arch Surg 29:365, 1934
4. Ravitch MM: Consideration of errors in the diagnosis
of intussusception. Am J Dis Child 84:17, 1952
5. Ravitch MM: Intussusception in infancy and
child-hood: An analysis of seventy-seven cases treated by
barium enema. N Engi J Med 259:1058, 1958
6. Gross RE, Ware PF: Intussusception in childhood: Experiences from 610 cases. N Engi J Med 239:646,
1948
7. Em SH, Stephens CA: Intussusception: 354 cases in
10 years. J Pediatr Surg 6:16, 1971
8. Cox J: The many faces of intussusception. Pediatric
Grand Rounds, Children’s Hospital Medical Center,
Cincinnati, August 26, 1975
9. Miller LD, Mackie JA, Rhoads JE: The
pathophysi-ology and management of intestinal obstruction. Surg Clin North Am 42:1285, 1962
OSTEOSARCOMA AND HEPATIC ANGIOSARCOMA AFTER CHILDHOOD
EXPOSURE TO THOROTRAST
From 1930 until 1950, Thorotrast, which contains radioactive thorium dioxide,
was used as an angiographic contrast agent in diagnostic radiology. A substantial
number of patients subjected to this procedure have developed hepatic
heman-giosarcomas or myelogenous leukemia. Osteosarcoma (OS) has been a rare
sequel, perhaps because most of the Thorotrast-exposed patients were adults.
OS has just been reported in two patients seen at National Cancer Institute,
in both of whom Thorotrast was used for cerebral angiography as a diagnostic
procedure for epilepsy during childhood. One, a male, exposed at 2 years of age,
developed OS at 24, and the other, a female, exposed at 16 years, developed the
tumor at 48, with a possible multicentric focus about two years later. The sites
were atypical for OS: the disphysis of the humerus in the man, and the
acetabulum and midhumeral shaft in the woman. An autoradiograph of the
man’s lymph node showed alpha particle tracks from the deposited radioactive thorium. The authors suggested that OS may be a late, late effect only now
becoming apparent among children treated several decades ago (Sindelar WF,
Costa J, Ketcham A: Cancer 42:2604, 1978).
Robert W. Miller, MD
National Cancer Institute-NIH, Bethesda, MD
From Childhood Cancer Etiology Newsletter #55, January 15, 1979.
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1979;64;93
Pediatrics
Jonathan Singer
Altered Consciousness as an Early Manifestation of Intussusception
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