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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 lethargy

may 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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1979;64;93

Pediatrics

Jonathan Singer

Altered Consciousness as an Early Manifestation of Intussusception

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