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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e3181c15f19
Image of the Month

Small Bowel Intussusception in Celiac Disease: Revisiting a Classic Association

Fishman, Douglas S MD*; Chumpitazi, Bruno P MD*; Ngo, Peter D MD; Kim, Heung Bae MD; Lightdale, Jenifer R MD

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*Section of Pediatric Gastroenterology, Nutrition and Hepatology, Texas Children's Hospital, Baylor College of Medicine, Houston, USA

Floating Hospital for Children at Tufts University School of Medicine, USA

Division of Pediatric Gastroenterology and Nutrition and Department of Pediatric Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.

Address correspondence and reprint requests to Douglas S. Fishman, 6701 Fannin St, Texas Children's Hospital Clinical Care Center, 1010.20, Houston, TX 77030 (e-mail: dougfishman@gmail.com).

The authors report no conflicts of interest.

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

A 4-year-old female presented with acute periumbilical pain, distension, and bilious emesis. She had an upper respiratory infection 2 weeks before admission, but was without prior gastrointestinal or cutaneous symptoms. Her examination was notable for a distended abdomen with diffuse epigastric tenderness. An abdominal radiograph suggested a small bowel obstruction, and a computed tomography scan (Fig. 1) confirmed multiple dilated loops of small bowel, ascites, and an enlarged, fluid-filled enhancing appendix. At exploratory laparoscopy, she had 6 discrete small bowel intussusceptions (Fig. 2) that were easily reduced and a normal appendix. Subsequent celiac serological testing (tissue transglutaminase >100) and endoscopic biopsies were diagnostic.

Figure 1
Figure 1
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Figure 2
Figure 2
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Intussusception is a common cause of bowel obstruction in children, and is often idiopathic. Children with cystic fibrosis, familial polyposis, Crohn disease, and celiac disease are at higher risk (1,2). Reported cases of intussusception in celiac disease suggest that it may be asymptomatic, transient, and limited to the small intestine, and rarely requires surgical intervention (3); however, enteropathy-associated T cell lymphoma should be considered in the differential diagnosis.

Proposed causes include diffuse inflammation and wall thickening, which lead to hyperperistalsis and increased dilatation of the proximal small bowel, or in combination with a focal lead point in lymphomas (4). As such, evaluation for celiac disease may be indicated in patients with single or multiple intussusceptions in the absence of another high-risk disorder.

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REFERENCES

1. Germann R, Kuch M, Prinz K, et al. Celiac disease: an uncommon cause of recurrent intussusception. J Pediatr Gastroenterol Nutr 1997; 25:415–416.

2. Mushtaq N, Marven S, Walker J, et al. Small bowel intussusception in celiac disease. J Pediatr Surg 1999; 34:1833–1835.

3. Martinez G, Israel NRB, White JJ. Celiac disease presenting as entero-enteral intussusception. Pediatr Surg Int 2001; 17:68–70.

4. Maconi G, Radice E, Greco S, et al. Transient small-bowel intussusceptions in adults: significance of ultrasonographic detection. Clin Radiol 2007; 62:792–797.

Cited By:

This article has been cited 1 time(s).

Bmc Gastroenterology
A large nationwide population-based case-control study of the association between intussusception and later celiac disease
Ludvigsson, JF; Nordenskjold, A; Murray, JA; Olen, O
Bmc Gastroenterology, 13(): -.
ARTN 89
CrossRef
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© 2010 Lippincott Williams & Wilkins, Inc.

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