It’s about 12am on a Tuesday, and you’re almost done cleaning up that post-dinner rush in the pediatric ED. You scuttle that last fever with a rash out the door, stickers in hand, when another one pops up on your board: Three-year-old male, here with abdominal pain. Oh, those little buggers. They just won’t leave you alone.

You notice the child is squirming in pain and you go right in to see him. You note that his vital signs are within normal limits. As you are talking to his mother, you notice he stops squirming and is suddenly still, cooperative, and playing with his toy. Strange, huh?

Here’s what you get from mom:

3-year-old male, who is previously healthy and has had abdominal pain for the last day. He woke his mom up this morning clutching his stomach and crying, but after he was given Pepto-Bismol and ate a piece of toast, his pain went away. He later had four more episodes of similar pain, lasting about 10-15 minutes, and then disappearing. At around 8pm, he had two episodes of emesis with a slight green tinge and had two episodes of loose stool without blood throughout the day. He hasn’t eaten or drank since the episodes of emesis. Mom chalked it up to a stomach virus, as he had eaten some questionable fast food the night before. But after the last episode, which woke him up from his sleep, she brought him in.

By the time you examine him, the child’s pain has already stopped. His physical exam is really only notable for some very mild tenderness, difficult to localize, but mainly in the periumbilical region. There are no peritoneal signs. You think you may feel a small mass in the right upper quadrant, but you aren’t too sure. You have him jump a little with you, to see if he has any “hop pain”, and he has a jolly old time.

What could be going on here?

1. What is your differential? 2. What is Intussusception? 3. What is the age range in which intussusception occurs? 4.How does intussusception present? 5. What should be your next step? 6.What do you see on your ultrasound? What’s the sensitivity and specificity of ultrasound for diagnosis? 7. Your patient’s ultrasound is positive, and identifies a lead point in the ileo-cecal region. What’s your next step and how do you fix it? 8. What is your patient’s disposition?

References:

(1): Horowitz R. Pediatric Abdominal Disorders. In: Emergency Medicine. Elsevier; 2013.

(2): Morrison J, Lucas N, Gravel J. The Role of Abdominal Radiography in the Diagnosis of Intussusception When Interpreted by Pediatric Emergency Physicians. The Journal of Pediatrics 2009;155(4):556–9.

(3): Applegate KE. Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module. American Journal of Roentgenology 2005; 185(3_supplement).

(4): Intussusception Treatment & Management [Internet]. Intussusception Treatment & Management: Approach Considerations, Nonoperative Reduction, Surgical Reduction. 2017 [cited 2017 Jul 11]; Available from: http://emedicine.medscape.com/article/930708-treatment

(5): Imaging in Child Intussusception [Internet]. Overview, Radiography, Computed Tomography. 2016 [cited 2017 Jul 9]; Available from: http://emedicine.medscape.com/article/409870-overview#a1

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Delna

PGY3 Clinical Monster in Training

Delna

PGY3 Clinical Monster in Training

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