Neonatal ileo-ileal intussusception without a lead point: a case report

Background Ileo-ileal intussusception is an extremely rare cause of intestinal obstruction in neonates, particularly in the absence of a lead point. Its clinical and radiological presentation can closely mimic necrotizing enterocolitis (NEC), posing a significant diagnostic challenge. Case presentation A 36-week gestational age male neonate, born via spontaneous vaginal delivery with a birth weight of 2400 g and Apgar scores of 10/10, was transferred from the maternity ward to the neonatal surgery unit on day of life (DOL) 3 due to abdominal distension, paroxysmal crying, mild vomiting, and failure to pass stool spontaneously. Prenatal care had not been obtained due to difficult socioeconomic circumstances. On admission, physical examination revealed abdominal distension with audible bowel sounds and a temperature of 36.8 °C. Laboratory investigations showed no significant leukocytosis or thrombocytopenia. Plain abdominal radiography in the upright position and a contrast study were performed. Abdominal ultrasound at this time demonstrated free peritoneal fluid without a target sign or pseudokidney sign, leading to an initial diagnosis of suspected NEC. The patient was managed conservatively with bowel rest, nasogastric decompression, parenteral nutrition, and intravenous antibiotics (amikacin and metronidazole). Despite treatment, the patient's condition gradually deteriorated. On DOL 5, repeat ultrasound — performed to evaluate for pneumatosis intestinalis and portal venous gas — identified two target signs in the right iliac fossa measuring 3 cm in width and 5.2 cm in length, consistent with ileo-ileal intussusception. Given the small bowel location and prolonged symptom duration, non-operative reduction was contraindicated. The patient underwent midline laparotomy, which revealed an ischemic, hemorrhagic, and edematous bowel segment. Manual reduction was achieved using the traditional milking technique; following application of warm saline-soaked gauze, intestinal pulsations were restored and the bowel was deemed viable, precluding resection. The postoperative course was uneventful. The patient spent one day in the neonatal intensive care unit, resumed breast feeding on postoperative day 1, and was discharged on postoperative day 5. At six-month follow-up with serial abdominal ultrasound, no recurrence was detected. Conclusion Ileo-ileal intussusception, although rare, must be considered in the differential diagnosis of newborns who develop an intestinal obstruction.

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