Role of Nutritional Rehabilitation in Managing Prolapsed Intussusception in A Malnourished Child in Northwest Nigeria: A Case Report

We present a case of H.A., who was a 20-month-old boy of Hausa ethnicity, and of Muslim parents, who was managed at Federal Teaching Hospital, Birnin Kebbi. He was presented (by parents) on account of anal protrusion of five hours duration, and abdominal pain of two hours duration. About five hours prior to presentation, his mother noticed him to be having a protrusion from the anus while going to bath the child in the early hours of the morning. The protruding mass was pushed inside manually after defaecation, but was later noticed few minutes afterwards. It progressively worsened and could not be reduced manually by the mother again, resulting in continuous extrusion of the swelling. This presenting episode was the fifth, as the child has been experiencing similar episodes within the previous two months.

Abdominal pain was colicky, appeared to be lower, as the child was holding his lower abdominal region, with associated crying. There was inability to defaecate in the previous 24 hours (constipation), with associated bilious vomiting. There was no associated fever, and reduction in abdominal size. No yellowness of the eyes. Stool was intermittently stained with blood and child cries during the episode. There was history of recurrent vomiting and diarrhea before the onset of the index symptom. There was no prior respiratory tract infection, no current history of immunization. He was the second child of mother in a monogamous setting. Parents had no formal education.

Examination revealed a young child, ill-looking, moderately pale, anicteric, afebrile, and moderately dehydrated. He was not cyanosed, had no significant peripheral lymph node enlargement, and no pedal oedema. His OFC was 45cm (92% of expected). Weight was 10 kg (83% of expected) and Height was 76cm (93% of expected). Pulse rate was 130 bpm, and blood pressure was 90/60 mmHg. Heart sounds were the first and second only. Respiratory rate was 26 cpm, Chest had vesicular breath sound. Abdomen was flat, moved with respiration, with visible peristalsis, but no dance sign. There was no area of tenderness. Bowel sound was hyperactive. Digital ano-rectal examination showed prolapsed bowel through the anus, which finger could be insinuated within the mucocutaneous junction leading to an indefinite and cleft. Prolapsed bowel was oedematous, with area of hypopigmentation, Inner lumen of bowel was appreciable at the peak of the prolapse (Figure 1 & 2). Examining gloved finger was stained with bloody mucoid discharge.

An assessment of Prolapsed Intussusception in a malnourished child was made.

Management involved counseling parents for exploration and repair of lesion. He was placed on nil per orals. Warm saline-soaked gauze was applied to protect and reduce swelling. Nasogastric tube was inserted. Urethral catheter was placed. Intravenous fluid 4.3% Dextrose saline 300 ml 8 hourly; IV Paracetamol 120 mg 8 hourly; IV Ciprofloxacin 80mg 12-hourly; and IV Metronidazole 120mg 8-hourly were commenced. Place patient in Trendelenburg position. Full blood count (FBC), Electrolyte, Urea, and Creatinine (EUCr), and Serum protein were requested. Full blood count showed: WBC 27.28 X 106/ul; Lym 74.8%; Gra 8.9%; Plt 231 X 106/l; PCV 25.5%; Hgb 8.5g/dl. EUCr showed Na 130mmol/l, K 4.8 mmol/l, Cl 90 mmol/l, Ur 5.5mmol/l, Cr 30mmol/l. Retroviral screening, HBsAg and HCV were all non-reactive. Abdominopelvic Ultrasound scan revealed features of dilated bowels, and no mass of fluid collection was noticed in the abdominal cavity.

Within 48 hours, child had trial of Koch’s procedure in Trendelenburg position which failed as the distal aspect of the protrusion was gangrenous. He then had exploratory laparotomy via a transverse supraumbilical incision, dipping through subcutaneous tissue, rectus sheath, rectus abdominis muscle and into the peritoneal space. Operative findings were long segment ileocolic intussusception; gangrenous terminal ileum (about 10cm), caecum, appendix, ascending colon, and mid-transverse colon and proximal descending colon; dilated proximal small bowel. Multiple inflamed mesenteric lymph nodes and serous ascitic fluid. Subsequently, per rectal ileo-colic resection was done which was then brought out as stoma in the right iliac fossa. Fascia and skin of the primary were closed in layers. Histology of the resected segments showed features of gangrenous tissues.

The post-operative period was smooth, as the patient was placed on parenteral antibiotics, food and fluid therapy, strict fluid input – output charting, and vital signs’ monitoring. Patient was discharged two weeks later and mother was taught above stoma care. He was scheduled for clinic follow up on a monthly basis. He subsequently had Reversal of ileostomy (Ileostomy closure and minimal adhesiolysis) under stable conditions done eight months later. Patient recovered completely and regained normal bowel movements subsequently.