INTUSSUSCEPTION

A Reading Presented to the

Faculty of the Nursing Department
San Pedro College
Davao City
MR. MARC JADE ADLAWAN, RN

In Partial Fulfillment of
The Requirements in NCM 216-RLE
GASTROINTESTINAL / METABOLISM NURSING ROTATION

BY:

CLARISSA S. TORRES, ST.N.

March 30, 2021

TITLE: Intussusception in an infant as a manifestation of COVID-19
BIBLIOGRAPHY: Moazzam,Z., Salim,A., Ashraf,A., Jehan,F. & Arshad,M.
(2020). Intussusception in an infant as a manifestation of
COVID-19. Journal of Pediatric Surgery Case Reports.
https://doi.org/10.1016/j.epsc.2020.101533

SUMMARY:
COVID-19, which has caused the loss of countless lives and financial
damage, was first reported as cluster of patients having the symptoms of severe
pneumonia with symptoms ranging from mild, including fever, dry cough,
dyspnea, myalgia, vomiting and diarrhea, to potentially fatal respiratory distress.
Thus, it can be said that respiratory symptoms are the most common. COVID-19
is also less likely to occur in children, and if infected, they tend to have milder
symptoms. In this study, it was stated that SARS-CoV-2 infection may have
possible gastrointestinal complications as the authors presented a case of a 4
months, 25 days old baby boy who was diagnosed with intussusception and was
subsequently diagnosed to be SARS-CoV-2 positive. The baby boy had a two-
day history of acute onset, intermittent, severe, crampy abdominal pain,
accompanied by inconsolable crying and drawing up of the legs towards the
abdomen and reluctance to feed, with episodes becoming prolonged and severe
with the passage of time. Intussusception was confirmed with ultrasound of the
abdomen, who was resuscitated in the emergency room with the performance of
reduction of intussuscepted bowel. After the successful operation, the patient
was admitted for further observation, and because of the protocol, he was
screened for SARS-CoV-2 which was positive. He had no history of contact and
did not receive treatment for COVID-19 because the patient was asymptomatic.
He did not develop any respiratory symptoms throughout the hospital course and
was recovering. The authors stated that this would be the first reported incidence
of intussusception as a manifestation of SARS-CoV-2 infection, with no
respiratory symptoms. Thus, researchers of the study concluded that there is a
need to conduct further studies on the gastrointestinal complications associated
with COVID-19.
REACTION:
This pandemic brought a lot of damages to the lives of many, may it be
financially, mentally or their physical health. It has affected millions of people
from all ages, although it was believed that infants or young children are less
likely to be affected by the virus, there are a lot of undergoing studies that may
prove otherwise especially with the possible complications brought about by
SARS-CoV-2 infection. That’s why, I believe that this study has provided not just
a basis for further research, but through this, new questions arise regarding the
mode of transmission and the possible signs and symptoms healthcare providers
must take note when assessing patients aside from the respiratory symptoms
that are more common with COVID-19 positive individuals as they present
themselves in the emergency room.

When I was searching for an article regarding the topic of my reading,

which is intussusception, I expected to find articles regarding its management or
case studies on people with this diagnosis. I did not expect that I’d find articles,
not just 1 but more than 5 articles, which relates intussusception to our current
situation, which is the COVID-19. Aside from this study, which focused on a case
last June 2020, I also found the same study which focused on 2 cases of children
both aged 10 months old with intussusception. Instead of a nasal swab test, they
utilized a rectal swab test, which turned out positive after more than 2 attempts.
Thus, the researchers concluded that there may be a fecal-oral route as a mode
of transmission for the virus, and also concluded the same thing with the authors
of this case study, which stated that there may be possible gastrointestinal
complications associated with patients positive for the virus, which some of them
even presented in the hospital without respiratory symptoms.

Reading this case study has provided me a lot of knowledge and even
made me form a lot of questions not just about intussusception, but with its
association to COVID-19. I was astounded how varied and uncertain the
symptoms and complications are because of this threatening virus. With this
information and appreciation I have for this study, I will be able to utilized these
during my clinical practice, especially on assessing patients. The nursing practice
will benefit from this when it comes to being a competent nurse providing quality
care to patients, and finding the right nursing interventions for patients who
present themselves in the emergency room with symptoms of intussusception.
Also, it provided additional information with regards to the caution nurses must
consider during assessment especially that these patients may be positive with
the virus. Moreover, ward management will be easier with the right assessment,
diagnosis and treatment for these patients if early detection is done, especially if
patients doesn’t have respiratory symptoms, the same way with the case in this
study.

Aside from the nursing practice, I’ve mentioned earlier its contribution to
my knowledge as a student nurse, so it will definitely help the nursing education
as with providing new information regarding the disorder. While it also helps
student nurses like me be knowledgeable of intussusception itself, we can also
learn a timely and relevant topic that was also given emphasis in this case study
as it is associated with the viral infection. Furthermore, as a student nurse who
will be graduating soon, it will help me in preparation for the work environment
that I’ll be dealing with.

Finally, as with the goal of authors and researchers, this study hopes to
provide a basis for further research to be done particularly on the possible
complications of SARS-CoV-2 in relation to intussusception or other
gastrointestinal complications. Also, this study raised a question if screening of
SARS-CoV-2 infection is necessary in children who require admission to the
hospital with gastrointestinal symptoms. With this, further research should be
done to confirm its association with the virus especially that there were only a
number of cases that were studied, where patients have intussusception and
turned out to be positive for the virus.

Therefore, it is really significant to understand intussusception, the

management and assessment to be done. While also considering what we have
learned in this study and the COVID-19, we must be cautious in assessing
patients who present themselves with gastrointestinal symptoms but with no
respiratory ones. Thus, being knowledgeable, aware and competent will help us
prepare for these situations that may arise in our care as student nurses and as
healthcare professionals in the future.
Journal of the Pediatric Infectious Diseases Society
CASE REPORT
Intussusception in 2
Children With Severe Acute
Respiratory Syndrome
Coronavirus-2 Infection
Heidi Makrinioti,1,a Alexander MacDonald,2,a Xiaoxia Lu,2,a Susan Wallace,1,a,
Mathew Jobson,3 Furong Zhang,2 Jianbo Shao,2 Jonathan Bretherton,3
Tariq Mehmood,3 Elizabeth Eyre,1 Adelene Wong,1 Lorna Pakkiri,1,a
Amulya Saxena,3,a Gary Wong4,a
1
West Middlesex University Hospital, Chelsea, and Westminster Hospital NHS
Foundation Trust, London, United Kingdom; 2Wuhan Children’s Hospital, Wuhan,
Huazhong University of Science & Technology, Wuhan, China; 3Chelsea and
Westminster Hospital, Chelsea, and Westminster Hospital NHS Foundation Trust,
London, United Kingdom; and 4Department of Paediatrics, Prince of Wales Hospital,
Chinese University of Hong Kong, China
We note that intussusception was likely associated with severe
acute respiratory syndrome coronavirus-2 infection in 2 infants
in Wuhan and London. The intussusception was reduced by en-
emas in Wuhan; the outcome was fatal. The intussusception was
not reduced by enemas in London and required surgery; the
outcome was favorable.
Keywords.  case report; gut; gastrointestinal; intussuscep-
tion; SARS-CoV-2
Based on the data to date, severe acute respiratory syndrome co-
ronavirus-2 (SARS-CoV-2) infection in children runs a milder
course with lower reported mortality rates [1, 2]. Both Chinese
and Italian epidemiological studies have shown that approx-
imately 10% of children present with gastrointestinal symp-
toms, and the presence of these symptoms is associated with
increased disease severity [3]. However, as the definition of sus-
pected cases does not include presentations with only gastroin-
testinal symptoms, there is still no clear answer to the question,
Should we screen for SARS-CoV-2 infection in children who
require admission to the hospital with gastrointestinal symp-
toms? The current advice from Public Health of England points
against screening (https://www.gov.uk/government/publications/
wuhan-novel-coronavirus-initial-investigation-of-possible-cases/
investigation-and-initial-clinical-management-of-possible-cases-
Received 4 May 2020; editorial decision 24 July 2020; accepted 4 August 2020; Published
online August 8, 2020.
a
H.M., A.M., S.W., L.P., A.S., and GW contributed equally to this work.
Correspondence: Heidi Makrinioti, (heidimakrinioti@gmail.com)
Journal of the Pediatric Infectious Diseases Society   2020;9(4):504–6
© The Author(s) 2020. Published by Oxford University Press on behalf of The Journal of the
Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail:
journals.permissions@oup.com.
DOI: 10.1093/jpids/piaa096
504 • jpids 2020:9 (September) •  Heidi et al
of-wuhan-novel-coronavirus-wn-cov-infection). In addition to the
fact that most presentations of infection in children are atypical,
there is recent evidence that shows that the highest viral shedding
takes place 2 to 3 days before symptom onset (https://www.nature.
com/articles/s41591-020-0869-5). This evidence could potentially
add to existing stress experienced by front-line pediatricians not
only related to diagnosis and timely management but also their pro-
tection from contracting the disease. There is mounting evidence
of an increase in the number of deaths in healthcare professionals
[4]. Therefore, data that clarify the definition of suspected cases are
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eagerly anticipated. Case studies could be valuable in providing this
information while epidemiological data are being gathered.
Here, we describe 2 cases of intussusception in infants found
to be positive with SARS-CoV-2. The first case was reported
at Wuhan Children’s Hospital, China, with a lethal outcome.
The second case was reported from West Middlesex-Chelsea
and Westminster Hospital in London, United Kingdom, with a
favorable outcome.
DESCRIPTION OF CASES
Case 1: Wuhan, China
On 2 February 2020, a previously healthy 10-month-old girl
was brought to the emergency department (ED) of Wuhan
Children’s Hospital. She presented with a history of 30 hours
paroxysmal crying, vomiting, and passing red currant jelly–like
stool. Ileocolic intussusception was confirmed by ultrasound ex-
amination 2 hours after admission, and pneumatic reduction was
successful. An abdominal X ray after pneumatic reduction did
not reveal any evidence of perforation. Two days later, due to de-
velopment of progressive respiratory distress, a chest computed
tomography (CT) scan was performed that showed small, dense
infiltrates in both lower lung fields. Her throat swab and antibody
testing were positive for SARS-CoV-2. The infant’s clinical con-
dition continued to deteriorate with progressive distention of the
abdomen and absence of bowel sounds. Abdominal CT showed
signs of peritonitis, ascites, and swelling of the small intestinal
wall. Two days later, a laparotomy was performed with placement
of a defunctioning ileostomy. Despite maximum support with
antibiotics, inotropes, and mechanical ventilation, her condition
deteriorated further. With development of disseminated intravas-
cular coagulation, the infant passed away on 8 March.
The infant had no other underlying disease. However, her
father had fever and cough 5 days prior to her presentation and
had recovered without having any specific investigations.
Case 2: London, United Kingdom
On 30 March 2020, an otherwise fit 10-month-old girl pre-
sented to the ED of the West Middlesex Hospital in London
in poor condition. She had been unwell for 2 weeks with in-
termittent coryzal symptoms and bilateral conjunctivitis fol-
lowed by abdominal symptoms for which she had visited the
ED twice before the latter presentation. She presented with
2  days of bilious vomiting and red currant jelly–like stool.
During her last presentation, she was lethargic, had poor pe-
ripheral perfusion, and was unresponsive to pain (including
interosseous access). Following resuscitation and suspi-
cion of intussusception, she was transferred to Chelsea and
Westminster Hospital. Due to failure of air enema reduction
management, a surgical reduction was undertaken during
which a malrotation was identified and a Ladd’s procedure was
performed. After full recovery, the infant was discharged on 5
April. Her nasopharyngeal and throat swabs on 30 March and
4 April tested positive for SARS-CoV-2. An extended virus de-
tection panel by polymerase chain reaction assay did not re-
veal coinfection with other viral agents.
In the patient’s history, mother was shown to have a flu-
like illness 3 weeks earlier. The family isolated per Public
Health of England advice, but the mother was never tested
for SARS-CoV-2 due to unavailability of mass testing in the
United Kingdom. One week after onset of the mother’s illness,
the patient’s sibling also became unwell with mild respiratory
symptoms and fever.
Figure 1.  A, Timeline of events in case 1 (Wuhan, China) and case 2 (London, United Kingdom). B, Ultrasound images showing similarities in intussusception
for case 1 (left) and case 2 (right). Abbreviations: CT, computed tomography; ED, emergency department; IgM, immunoglobulin M; PCR, polymerase chain
reaction; PICU, pediatric intensive care unit; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Cases 1 and 2
Figure 1 shows the timeline of events for both cases and provides
ultrasound pictures of the intussusception site in both children.
Blood work performed on admission for both patients was
not suggestive of any abnormalities, consistent with epidemio-
logical data described in most children in the Chinese cohort [1].
Inflammatory markers were not raised (C-reactive protein level
was 13.8 mg/L in case 1 and below 5 mg/L in case 2; white cell
counts level was 5.68 × 109/L for case 1 and 13.2 × 109/L for case
2). There was no derangement in results of renal and liver investi-
gations. Lymphopenia, which has been described in children who
deteriorated and required extracorporeal membrane oxygena-
tion, was not noted in either case [5]. The absolute number of
lymphocytes was 4.57 × 109/L in case 1 and 5.6 × 109/L in case 2.
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DISCUSSION
Here, we describe 2 infants with intussusception and SARS-CoV-2
infection. A  case report that highlights a similar association
was recently published (https://journals.lww.com/pec-online/
Citation/2020/06000/COVID_19_Infection_Is_a_Diagnostic_
Challenge_in.24.aspx). The first case developed respiratory
symptoms during hospitalization and underwent a chest CT
scan that revealed changes, while the second case had preceding
BRIEF REPORT • jpids 2020:9 (September) • 505

Figure 1.  Continued.
mild respiratory symptoms and, therefore, did not undergo chest
imaging as per current standards of care. Abnormal CT find-
ings have been reported even in children with no respiratory
symptoms, but this did not alter their management course [6].
Although both infants presented with symptoms suggestive of in-
tussusception, their disease course differed. Case 1 had successful
reduction of intussusception but was troubled by respiratory and
nonrespiratory complications. The outcome for case 2 was favor-
able, though the infant had failure of air enema reduction and
required urgent surgery for reduction of the intussusception.
These cases describe a possible association between SARS-
CoV-2 infection and intussusception. Case 1 more closely
shows causality, as rectal swabs tested positive for SARS-CoV-2.
However, this finding needs to be reviewed with caution, as re-
cent data show that although SARS-CoV-2 can be detected up
to 9 days in stool samples, there is no potential for viral shed-
ding [7, 8]. Rectal swab testing for detection of SARS-CoV-2
was not part of the standard of care by the Chinese National
Health Service at that time of the pandemic. In case 2, the child
was incidentally found to have undiagnosed malrotation of the
bowel. Waugh’s syndrome has been described in toddlers who
present with signs of chronic intussusception and malrotation
of the bowel. In these cases, malrotation of the bowel is a struc-
tural risk factor rather than a trigger for intussusception [9, 10].
The suggested mechanisms that underly include either infec-
tion of gut epithelial cells with local reactive mesenteric adenitis
that can trigger intussusception or mesenteric adenitis secondary
to upper respiratory tract infection with SARS-CoV-2. The as-
sociation between adenovirus and intussusception was docu-
mented in 1992 [11]. Adenovirus-2 serotype, often described as a
respiratory pathogen, was the most frequently detected pathogen
in children with intussusception [12]. Angiotensin-converting
enzyme 2 (ACE2) receptor is the functional receptor for SARS-
CoV-2. Immunohistochemistry in human tissues has revealed the
surface expression of ACE2 protein on enterocytes of the small
intestine, functioning as a coreceptor for nutrient uptake, such
506 • jpids 2020:9 (September) •  BRIEF REPORT
as amino acid resorption from food [13]. This finding highlights
that the gut might be an important entry site for SARS-CoV-2
infection. However, there is no evidence of viral replication in
gut epithelial cells [14]. Currently, many asymptomatic patients
who undergo surgical procedures are found to be SARS-CoV-2–
positive; any association with the underlying problem (intussus-
ception, appendicitis) is unclear and requires further study [15].
In adults, evidence of asymptomatic infection on admission for
elective surgical procedures was associated with evidence of in-
creased inflammatory response and more adverse outcomes [4].
In conclusion, our aim in this brief report is to urge front-
line pediatricians to consider SARS-CoV-2 infection when
managing a child with intussusception and to consider taking
appropriate precautions, also being aware of any possible res-
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piratory deterioration. For future management and prevention
strategies, it is also crucial to determine if SARS-CoV-2 can in-
fect gut epithelial or endothelial cells and whether susceptibility
to gastrointestinal infection is associated with the host’s differ-
ential innate immune responses. Also a probabilistic assessing
the association between rotavirus vaccine and incidence of in-
tussusception would be particularly helpful [16].
Note
Potential conflicts of interest. All authors: no reported conflicts of in-
terest. All authors have submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest. Conflicts that the editors consider relevant to
the content of the manuscript have been disclosed.
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