Transanal Mass in an Infant
A 5-month-old boy was referred from a chronic care facility for evaluation of blood in his diaper, lethargy, and two episodes of nonbilious emesis. He had a significant past medical history of trisomy 18, but he had no prior abdominal concerns or surgeries.
Upon presentation, the child was afebrile but irritable with abdominal distention. The rest of the physical examination findings were noncontributory. He had passed a small stool with obvious blood seen in the diaper.
During examination, while the infant was crying, a mass was seen emerging from the anus, which initially was thought to be a prolapsed rectum.
The mass was manually replaced but prolapsed again, with progressively more mucosa visible. The boy was taken to the operating room, where the diagnosis of transanal protrusion of an appendiceal intussusception was confirmed.
Intussusception is a common diagnosis in infants. It occurs when one segment of bowel invaginates into a more distal segment. The classic presentation is colicky abdominal pain, vomiting, and bloody stools, but this triad of symptoms is present in less than one-third of all patients with bowel intussusception. Younger infants often present with listlessness.
The diagnosis is confirmed with specific findings on radiography, ultrasonography, or contrast enema.1,2 Management is reduction with air enema, barium enema, or surgery.1,2
Appendiceal intussusception is uncommon, with only approximately 200 cases having been reported in the literature.1-4 Intussusception that progresses to protrusion through the anus is very rare.5 The combination of both intussusception of the appendix and prolapse of this mass made for an unusual diagnosis in this infant. Both of these two entities must be considered in atypical presentations of intussusception or in cases of apparent rectal prolapse.
References
1. Duncan JE, DeNobile JW, Sweeney WB. Colonoscopic diagnosis of appendiceal intussusception: case report and review of the literature. JSLS. 2005;9(4):488-490.
2. Eckert K, Radeloff E, Liedgens P. Intussusception of the appendix: a rare cause of acute abdominal pain in childhood [in German]. Chirurg. 2012;83(2):172-175.
3. Lipskar A, Telem D, Masseaux J, Midulla P, Dolgin S. Failure of appendectomy to resolve appendiceal intussusception. J Pediatr Surg. 2008;43(8):1554-1556.
4. Pohl J. Intussusception of the appendix. Video J Encyclopedia GI Endosc. 2013;1(2):377. http://www.sciencedirect.com/science/article/pii/S2212097113701663. Accessed April 1, 2014.
5. Dunavant D, Wilson H. Intussusception of the appendix, with complete inversion of the appendix and protrusion from the anus. Ann Surg. 1952;135(2): 287-288.