Image of the Month
A 6-year-old boy was investigated for iron-deficiency anemia refractory to oral supplementation. He did not have a history of abdominal pain or gastrointestinal bleeding, and stool microscopy was normal. Gastroscopy and colonoscopy were normal. To exclude an occult cause of gastrointestinal bleeding, a small-bowel capsule endoscopy (CE) was undertaken.
The image/video (http://links.lww.com/MPG/A42) is a luminal view of a nonobstructive intussusception occurring at 1 hour 30 minutes into the small-bowel CE. It was asymptomatic and was not associated with any visible mucosal irregularity or blood in the lumen. No lead point such as a polyp was visualised during the study, and further investigations included a normal barium contrast follow-through study. No cause of his anemia has been identified to date.
Gastrointestinal obstruction is a contraindication to performing a CE and should be excluded with imaging or the use of a degradable, radio-opaque patency capsule except in certain circumstances. Several studies have looked at the diagnostic yield of small-bowel CE in pediatrics, and the capture of an intussusception on CE is a noteworthy event because it is a rare occurrence (1).
It is not possible to verify whether an intussusception is antegrade or retrograde unless one is absolutely certain of the capsule's orientation (the capsule lens can spin). In the present case the capsule passed through the intussusception with minimal delay, possibly reducing it with its passage. The smooth, moist surface suggests that there may be a bubble contributing the sheen seen in the image.
The present case is a useful teaching point because it visually demonstrates an intussusception occurring as a normal physiological occurrence. In younger children, intussusception is thought to be caused by lymphoid hyperplasia. In older children and adults pathological lead points may be responsible for triggering the intussusception (2). Intussusceptions can present with abdominal mass, pain, bloody stool, and vomiting. Symptomatic intussusceptions can be treated pneumatically or surgically. Further investigations may be necessary to exclude a lead point such as adenitis, Peutz-Jeghers polyp, and carcinoma, if clinically indicated.
1. Thomson M, Fritscher-Ravens A, et al. Wireless capsule endoscopy in children: a study to assess diagnostic yield in small bowel disease in paediatric patients. J Pediatr Gastroenterol Nutr
2. Moyer S, Warner B. Surgical disorders 17.1 Intestinal obstructions. In: Kleinman RE, Goulet OJ, Mieli-Vergani G, et al., eds. Walker's Pediatric Gastrointestinal Disease: Physiology, Diagnosis, Management
. Vol 1. Hamilton, ON: BC Decker; 2008: 349.