Primary ileoileal intussusception without a lead point simulating appendicular mass in a 4-year-old girl.

To cite: Patel RV, Shepherd G, Kumar H, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-203390 DESCRIPTION A 4-year-old girl presented with a 4-day history of right-lower quadrant and suprapubic abdominal pain, vomiting and low-grade fever. On examination, she was found pale, tachycardic and with intermittent pain. Abdominal examination revealed a palpable tender but mobile mass in the suprapubic area. A clinical diagnosis of appendicular mass secondary to pelvic appendicitis was made. Urine dipstick and microscopy tests were normal. Full blood count was normal but C reactive protein was 30 mg/L. As there was no clinicopathological correlation, an urgent abdominal ultrasound scan was performed. It showed an ileoileal intussusception with classic target/doughnut/bull’s eye sign not amenable to air enema reduction (figure 1). She underwent exploratory laparotomy at which a primary ileoileal intussusception was found, which was very difficult to reduce, and had no lead point but a small segment of terminal ileum was non-viable and resection and primary end-to-end anatomosis was performed uneventfully. She was discharged home on third postoperative day and histology did not show any lead point. She presented again in 4 months’ time with features of acute adhesive intestinal obstruction for which she underwent laparoscopy, adhesion lysis with segmental resection of terminal ileum with end-to-end ileoileostomy uneventfully. She is well and asymptomatic at 2 years of follow-up. Primary ileoileal intussusception is rare at 4 years of age; it may simulate appendicular mass and an adult case has been reported, but none in children. An inflammatory pseudotumour may present with intussusception and a normal appendix may form a lead point of an intussuception. 3 Our case illustrates that barium enema reduction of intussusception is obsolete and in fact contraindicated; there are still some cases in which an open traditional emergency surgery has some indications, although, at present, pneumatic air enema reduction is a gold standard, ultrasound-guided and laparoscopyguided reductions are gaining favour recently.