© 2004 by the American Institute of Ultrasound in Medicine
J Ultrasound Med 23:1659-1661 • 0278-4297
Double Intussusception in a Child
The Triple-Circle Sign
Ahmet Kazez, MD,
S. Kerem Ozel, MD,
Ercan Kocakoc, MD and
Adem Kiris, MD
Departments of Pediatric Surgery (A.K., S.K.O.) and Radiology (E.K., A.K.), Firat University Faculty of Medicine, Elazig, Turkey.
Address correspondence and reprint requests to Ahmet Kazez, MD, Department of Pediatric Surgery, Firat University Faculty of Medicine, 23119 Elazig, Turkey. E-mail: akazez{at}firat.edu.tr.
Abbreviations: CT, computed tomography • DI, double intussusception
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Introduction
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Intussusception is a common surgical problem in childhood and is defined as a prolapse of a part of the intestine into the lumen of an immediately adjoining part.1–3 Double intussusception (DI) in children is a very rare entity, and its diagnosis is made during surgical interventions. In classic cases, the displacement of 1 segment of bowel is defined, whereas, very rarely, 2 separate segments can prolapse into the same distal segment, giving rise to DI.4,5 To our knowledge, 3 DI cases in the pediatric age group have been reported in the English literature to date.4,5 A target sign is a typical finding of classic intussusception on sonography and computed tomography (CT).6,7 The sonographic and tomographic findings in an 8-year-old patient with DI were evaluated retrospectively, and the "triple-circle" sign was noticed, which was different from the classic target sign and which, to our knowledge, has not been defined previously.
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Case Report
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An 8-year-old girl had been followed up in a medical center with the diagnosis of amebiasis and symptoms including abdominal pain, vomiting, and bloody stool for 7 days. She was sent to our hospital because of continuation of her symptoms. During the last 2 days, her symptoms had increased, and her stool was totally bloody. Her general condition was stable, and she was noted to be lethargic at admission. Her vital signs were normal; her abdomen was normal on inspection; and bowel sounds were hyperactive. Tenderness in the left lower quadrant and a partially mobile mass extending toward the pelvis were found on physical examination. In a rectal examination, the rectum was empty, but blood was noticed on the examining finger. Plain abdominal radiography revealed a large air-fluid level that might have been in the ascending colon. Aeration in the small bowel was found to be increased. Sonography revealed a mass of 53 x 54 mm in size, which was composed of multiple concentric circles with anechoic fluid and hyperechoic mesenteric fat tissue inside in the left lower quadrant, occupying a 15-cm bowel segment (Figure 1 ). During an emergency CT examination without oral or intravenous contrast agents, a mass of 15 cm in length, 6 x 5 cm in size, with an appearance of a triple circle, inside of which hypodense mesenteric fat tissue could be seen, was found in the left lower quadrant (Figure 2). The preoperative diagnosis was a late intussusception.
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Figure 1. Triple-circle appearance on sonography; 1 indicates the proximal prolapsed segment; 2, the distal prolapsed segment; and 3, the distal intestinal segment.
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Figure 2. Triple-circle appearance on CT; 1 indicates the proximal prolapsed segment; 2, the distal prolapsed segment; and 3, the distal intestinal segment.
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An emergency laparotomy was performed, and intestinal dilatation in the ascending and transverse colon with reactional free fluid in the abdomen was observed. A colocolic intussusception in the descending colon was found and manually reduced. However, after reduction of the first segment, a second colic segment of intussusception was also noted proximal to the first one. This second segment was also manually reduced. There was no sign of a leading point on the colon. The postoperative course of the patient was uneventful, and she was discharged after a 7-day hospital stay. A leading point was not seen during a barium enema study of the colon 1 month after the operation.
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Discussion
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Intussusception in children is a common surgical problem, but DI is a very rare entity; its diagnosis was possible during surgery in previously reported cases.3,4 However, to our knowledge, radiologic findings have not been discussed before.
The target sign is one of the findings on sonography and CT that has been described in classic intussusception.6,7 In this finding, the outer circle shows the distal intestinal segment, and the inner circle shows the prolapsed proximal bowel (Figure 3).6 In our case, a third circle was noticed after the intraoperative, sonographic, and tomographic findings were evaluated retrospectively (Figures 1 and 2). The outer circle was the distal segment; the middle second circle was the second prolapsed segment; and the inner third circle was the first intussusception (proximal prolapsed segment).
This case emphasizes the triple-circle sign as a descriptive finding on sonography and CT in patients with DI.
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Footnotes
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Received June 20, 2004, from the Departments of Pediatric Surgery (A.K., S.K.O.) and Radiology (E.K., A.K.), Firat University Faculty of Medicine, Elazig, Turkey. Revision requested August 9, 2004. Revised manuscript accepted for publication August 17, 2004.
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References
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- Bisset GS III, Kirks DR. Intussusception in infants and children; diagnosis and therapy. Radiology 1988; 168:141–145.[Abstract/Free Full Text]
- Fallat ME. Intussusception. In: Ashcraft KW, Murphy JP, Sharp RJ, Sigalet DL, Snyder CL (eds). Pediatric Surgery. Philadelphia, PA: WB Saunders Co; 2000:518–526.
- del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in diagnosis and enema reduction. Radiographics 1999; 19:299–319.[Abstract/Free Full Text]
- Kiyan G, Tugtepe H, Iskit SH, Dagli TE. Double intussusception in an infant. J Pediatr Surg 2002; 37:1643–1644.[Medline]
- Him FP, Weng YK, Hoi CW. A case of double compound intussusception in an infant. Singapore Med J 1980; 21:540–541.[Medline]
- Lee HC, Yeh HJ, Leu Y. Intussusception: the sonographic diagnosis and its clinical value. J Pediatr Gastroenterol Nutr 1989; 8:343–347.[Medline]
- Sorantin E, Lindbichler F. Management of intussusception. Eur Radiol 2004; 14:L146–L154.
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Introduction
Case Report