Intestinal intussusception from a Meckel's diverticulum and intestinal malrotation: a case report

Most cases of pediatric intussusception are idiopathic, with a pathologic lead point identified in only 25 % of cases. Meckel's diverticulum (MD) is the most frequent pathologic lead point in children. The co-occurrence of intussusception and malrotation is known as Waugh's syndrome. The simultaneous presence of intestinal malrotation and intussusception due to a MD is a rare entity. A 5-month-old girl with no significant medical history was brought to the emergency room after one day of non-bilious, non-projectile vomiting, without any rectal bleeding. A two-view abdominal x-ray was performed, showing evidence of a small bowel obstruction without bowel wall thickening or free air. Due to the non-specific findings and symptoms concerning for intussusception, an ultrasound (US) was ordered. The US suggested an ileocolic intussusception. The patient underwent an attempted pneumatic reduction (PR) with air. After three unsuccessful attempts with persistent dilated loops of small bowel the patient was taken to the operating room for surgical reduction. We did initially a laparoscopy and found dilated bowel and no colon in the right lower quadrant, which rose concern for intestinal malrotation. We decided to convert the operation to a laparotomy. We found an ileocolic intussusception, and a more proximal ileo-ileal intussusception, with a MD as the lead point, and intestinal malrotation. We did a manual reduction of both intussusceptions, resected 25 cm of small bowel containing the MD due to its ischemic appearance, did an appendectomy, and a Ladd's procedure for the malrotation. The patient recovered well postoperatively and was discharged home on postoperative day four. Intestinal malrotation should be ruled out in patients undergoing surgical reduction of intussusception, as these two entities are occasionally associated and can present with non-typical symptoms.