Distinguishing intussusception from necrotizing enterocolitis in a preterm infant: a case report
Case Report

Distinguishing intussusception from necrotizing enterocolitis in a preterm infant: a case report

Pei Pei Lim1 ORCID logo, Hamiza Hassan2, Ahmad Hazwan Roodzi3

1Department of Paediatrics, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia; 2Department of Paediatrics, Tuanku Mizan Military Hospital, Kuala Lumpur, Malaysia; 3Department of Biomedical Imaging, University Malaya Medical Center, Kuala Lumpur, Malaysia

Contributions: (I) Conception and design: PP Lim; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: PP Lim; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Dr. Lim Pei Pei, MBBS, MRCPCH. Department of Paediatrics, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kem, Sungai Besi, 57000 Kuala Lumpur, Malaysia. Email: limpeipei@upnm.edu.my.

Background: Neonatal intussusception is a rare condition, particularly in preterm infants, and poses a significant diagnostic challenge due to its clinical similarity to the more common necrotising enterocolitis (NEC). Delayed or incorrect diagnosis may result in significant morbidity or even death. While similar cases have been reported, this case is noteworthy for its early onset, atypical clinical course, timely diagnosis and successful non-surgical management.

Case Description: We report a case of a preterm infant born at 35 weeks of gestation who developed multiple episodes of rectal bleeding beginning at 78 hours (day 4) of life. An initial diagnosis of NEC was made, as it is the most common cause of rectal bleeding in premature infants. Enteral feeds were withheld, and intravenous antibiotics were given. However, over the subsequent 14 hours, the infant’s clinical condition remained unusually stable for a typical NEC presentation. The abdomen was soft and non-distended, and laboratory investigations did not reveal typical findings such as thrombocytopenia, raised inflammatory markers or metabolic derangements. This atypical clinical course prompted reconsideration of the diagnosis, and intussusception was suspected. An abdominal ultrasound performed at 97 hours (day 5) of life confirmed an ileocolic intussusception. The condition was successfully managed with gentle pneumatic reduction within 6 hours of diagnosis at 103 hours of life- an uncommon but effective non-invasive approach in this age group.

Conclusions: This case highlights the importance of maintaining a high index of suspicion for intussusception in preterm neonates presenting with rectal bleeding but lacking typical features of NEC. Uniquely, this case involved a rare ileocolic intussusception in a preterm infant that was successfully managed non-surgically—a strategy not commonly reported in this population. Early identification and recognition of subtle clinical differences can significantly alter management and improve outcomes.

Keywords: Preterm; neonatal intussusception; necrotising enterocolitis (NEC); pneumatic reduction; case report

Received: 11 May 2025; Accepted: 28 August 2025; Published online: 18 December 2025.

doi: 10.21037/pm-25-62

Highlight box

Key findings

• This case represents a rare instance of ileocolic intussusception in a preterm infant, diagnosed early and successfully treated with pneumatic reduction without complications.

What is known and what is new?

• Rectal bleeding in preterm infants is commonly attributed to necrotising enterocolitis (NEC), which is highly prevalent in this population.

• Early diagnosis of neonatal intussusception among preterm infants is possible by high index of suspicion, especially if the infant is presenting with atypical features for NEC, such as the absence of systemic signs, minimal abdominal distension, and isolated rectal bleeding.

What is the implication, and what should change now?

• Although neonatal intussusception is traditionally managed surgically, early diagnosis may allow for non-surgical intervention, such as image-guided enema reduction, in carefully selected cases.

Introduction

Intussusception involves an invagination of the proximal bowel into the distal bowel, is the second most common cause of intestinal obstruction in childhood, primarily affecting children aged 6 to 18 months (1). Its occurrence in neonates is rare, and even more so in preterm infants, who account for only 0.3% of reported cases (2). Owing to its rarity and overlapping clinical features, gastrointestinal symptoms in preterm neonates are often misattributed to necrotising enterocolitis (NEC), in which inflammation of the intestine leading to mucosal damage and necrosis. This diagnostic overlap complicates timely recognition. No radiographic finding is pathognomonic for intussusception (3), and while ultrasonography can aid diagnosis, it is highly operator dependent. As a result, diagnosis is frequently delayed, with most cases identified intraoperatively rather than preoperatively (3).

Knowledge gap

Clinicians must maintain a high index of suspicion when assessing preterm infants with gastrointestinal symptoms to avoid missing a diagnosis of intussusception. While surgery remains the standard of care (2), non-invasive approaches—such as image-guided pneumatic or hydrostatic enema reduction—may be appropriate in carefully selected cases. These typically involve ileocolic intussusception in clinically stable infants without haemodynamic compromise, perforation, or peritonitis (3). Such procedures, performed under fluoroscopic or ultrasound guidance, are well established in older infants and children (4). However, to date, no published cases have documented successful non-surgical management in preterm neonates, likely due to the predominance of ileo-ileal intussusception in this group (5), which is less amenable to enema reduction. Furthermore, delayed recognition often precludes timely non-operative intervention.

Objective

We report a rare case of ileocolic intussusception in a clinically stable preterm infant, born at 35 weeks of gestation, who presented with multiple episodes of rectal bleeding on day 4 of life. Early diagnosis was achieved through abdominal ultrasound, and the condition was successfully managed within the same day with image-guided gentle pneumatic reduction. This case highlights the importance of early recognition in facilitating non-surgical management and achieving a favourable outcome. We present this article in accordance with the CARE reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-62/rc).

Case presentation

A female infant was delivered preterm at 35 weeks’ gestation via spontaneous vaginal delivery, with a birth weight of 2.3 kg. She was appropriate for gestational age. The mother was a primigravida with no known medical conditions, and the antenatal course was unremarkable apart from spontaneous preterm labour. There was no significant drug history aside from routine haematinic supplementation. Although the delivery was uneventful, the amniotic fluid was meconium-stained. Apgar scores were 9 and 10 at 1 and 5 minutes, respectively.

The infant was admitted to the neonatal intensive care unit (NICU) for respiratory distress and required non-invasive ventilation via nasal continuous positive airway pressure (nCPAP). She was kept nil by mouth and commenced on empirical intravenous (IV) ampicillin and cefotaxime for presumed listeriosis, given the unusual finding of meconium-stained liquor in a preterm birth.

On examination, she appeared pale, but had no bruising, petechiae, jaundice, or signs of external bleeding. The anterior fontanelle was normotensive, and cranial ultrasound showed no intraventricular haemorrhage. Initial haemoglobin (Hb) was 11 g/dL (reference: 14–18 g/dL), and although anaemic, she remained haemodynamically stable. At 15 hours of life, Hb dropped to 8 g/dL, prompting transfusion with 15 mL/kg of packed red cells, resulting in a post-transfusion Hb of 12 g/dL.

A full blood picture revealed normochromic anaemia with reticulocytosis, suggesting acute blood loss or tissue hypoxia. Fetomaternal haemorrhage was suspected, but confirmation was not possible due to the unavailability of the Kleihauer test. The infant was weaned off nCPAP by 24 hours and commenced on enteral feeding, which was well tolerated and gradually advanced to full feeds by day 3 of life.

At 78 hours of life (day 4), she passed several episodes of mucoid, blood-streaked stools (Figure 1) but remained clinically well, with stable temperature, no vomiting, and a soft, non-distended abdomen. No palpable abdominal mass was noted. NEC was suspected, and feeding was withheld. IV metronidazole 15 mg/kg was added to the ongoing antibiotic regimen. Laboratory investigations—including full blood count (FBC), venous blood gas, and C-reactive protein—were within normal limits. Abdominal X-ray did not show pneumatosis intestinalis or portal venous gas (Figure 2).

Figure 1 Infant passed out mucoid stool with blood streaks at 78 hours of life.
Figure 2 Plain abdominal radiograph shows paucity of bowel gas at right iliac fossa region. No bowel dilatation. No pneumoperitoneum. No pneumatosis intestinalis. No air outlining the liver to suggest portal venous gas.

Despite conservative management, rectal bleeding persisted over the next 14 hours, although the infant remained active and haemodynamically stable. Given the atypical features for NEC, an abdominal ultrasound was performed at 97 hours of life (day 5), revealing ileocolic intussusception (Figure 3). Owing to early detection and clinical stability, a non-surgical approach was pursued. Pneumatic reduction was successfully performed under sedation and fluoroscopic guidance within 6 hours diagnosis (Figure 4), resulting in complete resolution of the intussusception (Figure 5).

Figure 3 Sonographic images at right iliac fossa showing target sign (yellow arrow) with bowel loops. Evidence of internal vascularity within the target sign (green box) in keeping with an ileocolic (ileocaecal) intussusception.
Figure 4 Spot fluoroscopic images done during pneumatic reduction of the intussusception. (A) There is an initial filling defect (arrow) at ileocaecal region. (B) Free flow of air seen projected into the small bowel loops (arrow).
Figure 5 Complementary ultrasound image post pneumatic reduction shows no more target sign at right iliac fossa region.

The infant remained well post-procedure, with no recurrence of bleeding, and was discharged in good condition after one week of hospitalisation. A graphical timeline of the case evolution is presented in Figure 6.

Figure 6 Case report timeline. CRP, C-reactive protein; FBC, full blood count; Hb, haemoglobin; HoL, hour of life; IV, intravenous; NEC, necrotising enterocolitis; NICU, neonatal intensive care unit; nCPAP, nasal continuous positive airway pressure; VBG, venous blood gas.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Intussusception in preterm infants often involves the small intestine—most frequently the ileum or jejunum—and typically occur without an identifiable pathological lead point (2,5). Notably, small bowel involvement is observed in approximately 91.6% of cases among preterm neonates (6). In contrast, ileocolic intussusception such as in our case is extremely rare. Among ileocolic intussusception, pathological lead points—though uncommon—such as Meckel’s diverticulum, meconium plugs, and duplication cysts and caecal duplication had been reported (7,8). The exact aetiology of intussusception among neonates remains unclear; however, perinatal factors such as intestinal hypoperfusion, hypoxia, dysmotility, or stricture formation may contribute by creating functional lead points (7,9). In our patient, anaemia at birth raised suspicion of a prenatal onset, this may possibly lead to in utero intestinal hypoperfusion, which may contribute to the pathophysiology of intussusception presented in such as early postnaal age. However, this remains speculative in the absence of surgical exploration in this case.

Diagnosing intussusception in preterm infants is particularly challenging due to its significant clinical overlap with NEC. Shared features—such as abdominal distension, bilious vomiting or feeding intolerance, rectal bleeding, and, occasionally, a palpable abdominal mass—are commonly observed in both conditions (10,11). Given the higher incidence of NEC in this population, these signs are often misattributed, leading to conservative treatment and contributing to diagnostic delays. Reported intervals between symptom onset and definitive diagnosis range from 10 to 19 days (12), increasing the likelihood of intestinal necrosis and perforation.

Mooney et al. reported that more than half of their cases were initially misdiagnosed as NEC, with only 10% correctly identified before surgery (13). Similarly, Avansino et al. found that just 2 of 35 cases were diagnosed preoperatively, with the remainder identified intraoperatively or post-mortem (14). In our case, ileocolic intussusception was diagnosed within 24 hours of gastrointestinal symptom onset—significantly earlier than most cases reported in the literature (12). This timely diagnosis likely reflects a heightened index of clinical suspicion, guided by the consideration of multiple overlapping clinical features.

One of the key clinical distinctions is that intussusception may present in clinically stable preterm neonates, unlike NEC, which typically affects infants with a complicated early course and involves systemic deterioration (5,15). Wang et al. emphasised the need to suspect intussusception in neonates with presumed NEC but who remain unexpectedly stable (16).

Demographic factors and the timing of symptom onset can aid in differentiating between the two conditions. NEC primarily affects preterm infants born before 32 weeks of gestation and with a birth weight below 1.5 kg (17). It typically presents during the second or third postnatal week (18). In contrast, although the onset of intussusception is variable, it more commonly occurs earlier—within the first or second week of life (5,14).

Abdominal X-ray might play a limited role in diagnosing intussusception among preterm infants as the most common findings—dilated bowel loops and gas-fluid levels—are non-specific (14,18). However, presence of pneumatosis intestinalis or portal venous gas strongly suggest NEC (19). Ultrasound is a valuable, non-invasive modality for diagnosing intussusception. Classic sonographic features of intussusception include the “target” or “doughnut” sign on transverse views and the “pseudokidney” sign on longitudinal views. The “crescent” and “target” signs—representing concentric bowel loops with interposed mesenteric fat—are considered pathognomonic (20), as demonstrated in our patient. Nevertheless, several factors may influence the sensitivity of ultrasonography in neonatal intussusception. Notably, in a significant number of neonates, the sigmoid colon lies superficially on the right side, which, when combined with prominent abdominal gas, can obscure the intussuscepted segment and the caecal shadow (9). Additionally, the absence of colonic involvement in most preterm cases further reduces sonographic visibility. Moreover, the diagnostic accuracy of ultrasound remains highly operator dependent. To aid clinicians in differentiating neonatal intussusception from NEC, we have summarised key distinguishing features based on risk factors, timing of symptom onset, clinical presentation, laboratory parameters, and radiological findings in Table 1.

Table 1

Diagnostic clues for differentiating intussusception from NEC

Characteristics Neonatal intussusception    NEC
Risk factors Presence of perinatal risk factors resulting in intestinal hypo-perfusion, hypoxia, dysmotility and stricture formation    Prematurity (especially <32 weeks gestation), low birth weight, small for gestational age, maternal chorioamnionitis, significant patent ductus arteriosus, sepsis, exchange transfusion, drugs, e.g., indomethacin, H2 receptor blockers
Symptoms onset Highly variable, although commonly reported within 1–2 weeks postnatally    Typical onset between 2–3 weeks of life post-delivery
Clinical features Symptoms are mostly confined to the abdomen in a relatively well neonate. General condition usually does not deteriorate unless perforation happens    General deterioration along with abdominal symptoms
Laboratory findings FBC may show normal white cell and platelet count; inflammatory marker (CRP) and blood gas are unremarkable (unless perforation happens)    FBC may show leukocytosis, thrombocytopenia, raised inflammatory markers, metabolic acidosis
Radiological findings AXR often show non-specific findings. Dilated bowel loops are the commonest finding    Pneumatosis intestinalis and portal venous gas on abdominal X-rays are highly suggestive of NEC
Ultrasonographic findings of “crescent” sign, an intussusception mass outlined by gas, and the “target” sign, resulting from layered bowel loops and intervening mesenteric fat, are pathognomonic    Pneumatosis intestinalis (hallmark), portal venous gas, bowel wall thickening, increased echogenicity of the bowel wall, absent or reduced bowel wall perfusion on Doppler imaging, intra-abdominal free fluid, decreased or absent peristalsis

AXR, abdominal X-ray; CRP, C-reactive protein; FBC, full blood count; NEC, necrotising enterocolitis.

Although surgery remains the standard treatment for neonatal intussusception, emerging evidence supports the use of non-operative techniques, such as pneumatic reduction, in selected cases (21). Non-operative enema reduction may be performed using various imaging modalities—typically fluoroscopy or ultrasonography, and with different reduction media, including air or liquid (22). Among these methods, pneumatic reduction under fluoroscopic guidance is the most widely utilised, as it is faster, more cost-effective, and associated with a higher success rate (approximately 83%) compared to barium enemas (21).

Historically, surgical intervention has been favoured in preterm neonates due to the predominant involvement of the small bowel (2,5), which contributes to lower success rates of pneumatic reduction (21). Moreover, delayed diagnosis in this population often renders non-operative management less favourable, given the increased risk of bowel compromise, morbidity, and mortality (2). Nevertheless, pneumatic reduction may be considered in selected cases—particularly when the intussusception involves the ileocolic region or is ileoileal in proximity to the ileocaecal valve (21), as demonstrated in our patient.

The American College of Radiology (ACR) endorses pneumatic reduction as the first-line approach for intussusception in appropriately selected cases, citing its favourable safety profile (22,23). In haemodynamically stable infants without evidence of perforation, peritonitis, or bowel ischaemia, image-guided pneumatic reduction provides a safe and minimally invasive alternative to surgery (23,24). However, the procedure carries a small risk of perforation and should be performed only by experienced personnel in centres equipped with immediate paediatric surgical support (25). Timely diagnosis is critical, as the success rate of non-operative reduction diminishes with increasing duration of symptoms (21).

In the present case, early recognition and supportive ultrasound findings—including a well-defined “target” sign, preserved bowel wall perfusion, and absence of free fluid—favoured a non-operative approach. Pneumatic reduction was successfully performed and resulted in complete resolution without complications.

Strengths and limitations

This report includes the early recognition of atypical features for NEC, which allowed for timely imaging, diagnosis, and successful non-surgical intervention. The case also demonstrates the feasibility of pneumatic reduction in a clinically stable preterm neonate—an approach not previously reported. However, there are several limitations to consider. As with any single case report, generalisability is limited. In addition, the diagnosis was based on imaging findings without surgical confirmation, which may leave some uncertainty regarding the underlying pathology. Ultrasound and fluoroscopic evaluations are also highly operator-dependent, which could affect reproducibility in different clinical settings. Nonetheless, this case underscores the importance of clinical vigilance and early evaluation in achieving favourable outcomes without resorting to surgery.

Conclusions

Intussusception in preterm infants is rare and often difficult to distinguish from NEC. A high index of clinical suspicion and early use of ultrasound are essential for timely diagnosis and intervention. While surgery remains the standard treatment, non-operative reduction may be successful in appropriately selected cases. Further research is warranted to elucidate risk factors and refine management strategies for this uncommon but serious condition.

Acknowledgments

We sincerely thank all the teams involved in the care of our patient for their concerted efforts to ensure our patient recovered in a timely manner and thank the patient’s parent for giving us this opportunity to share this unique learning opportunity including sharing the patient’s investigations.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-62/rc

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-62/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-62/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/pm-25-62
Cite this article as: Lim PP, Hassan H, Roodzi AH. Distinguishing intussusception from necrotizing enterocolitis in a preterm infant: a case report. Pediatr Med 2026;9:7.

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