Bored Review – The Tale of the Telescoping Bowel

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?
  • Intussusception
  • Appendicitis
  • Incarcerated hernia , specifically inguinal hernias given his age.
  • Testicular torsion
  • Gastroenteritis

 

2. What is Intussusception?
  • A word that might get you first place on a medical spelling bee or is difficult to say many times very fast.
  • Also, it’s when a portion of the proximal bowel slides into a more distal portion, almost like a telescope, that causes a momentary obstruction. It usually resolves, and then occurs again, explaining the colicky pain that can occur. It usually occurs in the ileocolic region.(1)
  • That obstruction can cause bowel wall edema and inflammation, which can lead to perforation and peritonitis. Thus, intussusception is a medical emergency.
  • Most cases are idiopathic, but other etiologies may contribute by causing “lead” points in the bowel, often through inflammation. Some contributing factors are thought to be viral illness, intestinal infections, and other medical conditions such as Henoch-Schonlein purpura (HSP), inflammatory bowel disease, hemolytic uremic syndrome, or Meckel’s diverticulum. HSP, in particular, is associated with ileo-ileal intussusceptions.(1)

 

3. What is the age range in which intussusception occurs?
  • It occurs most often between the ages of 3 months and 3 years.

 

4.How does intussusception present?

The classic triad is colicky abdominal pain, “red-currant jelly stools”, and a palpable sausage shaped mass, usually in the right upper quadrant.

  • This triad is not often seen, so it shouldn’t be relied upon.
  • Children often present with colicky or crampy abdominal pain, often occurring every 15-20 minutes, as the bowel obstructs and returns to its normal position. The mass may at times be palpated during this time as well. The child may have a normal exam, especially in between painful episodes.
  • Intestinal inflammation and necrosis can lead to “red-currant jelly” stools.
  • There may be episodes of bilious vomiting, especially when the obstruction does not reduce on it’s own.
  • Edema and ischemia can lead to acidosis, sepsis, lethargy, and ultimately death if not corrected.

 

5. What should be your next step?
  • Early diagnosis is key, and pediatric surgery should be contacted as soon as possible for reduction if intussusception is suspected.
  • Most importantly, as always, you should stabilize your patient making sure their ABC’s are intact. Make sure you adequately resuscitate a lethargic child and work up your differential diagnoses with bloodwork and imaging as needed.
  • Both X-Rays and ultrasound can be used to aid diagnosis, but if intussusception is strongly suspected, neither test is definitive if negative.
  • Abdominal X-Rays might show dilated small bowel and a lack of gas in the cecum or a mass-like impression within the colonic gas. A prospective experimental study by Morrison et. al evaluating the use of abdominal X-Ray’s for diagnosis of intussusception, showed a sensitivity of 48% and specificity of 21%, when interpreted by pediatric emergency medicine physicians.(2) Although radiographs may have a low sensitivity and specificity for diagnosis, they can still aid in the work-up of suspected intussusception. They may be helpful in looking for free peritoneal air, or ruling out other considerations in the differential.

  • Ultrasound is an excellent tool for diagnosis and should be ordered if the diagnosis is in question.

 

6.What do you see on your ultrasound? What’s the sensitivity and specificity of ultrasound for diagnosis?
  • Ultrasound often shows a mass with a swirled appearance, with alternating hyper and hypoechoic areas representing the loop of bowel within another. This is called a “target” sign.
  • Ultrasound has been shown to reach diagnostic accuracy approaching 100% in experienced hands in some studies, and other studies have shown a sensitivity of 98-100%, reducing the amount of false negatives, and a specificity ranging from 88-100%.(3)

 

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?
  • All children should have an IV placed, adequate fluid resuscitation, and an NG tube placed for decompression. Ultimately, the intussusception needs to be reduced, either surgically or non-surgically.
  • The previous gold standard was a barium enema, which can be diagnostic and therapeutic. However, risks include peritonitis, infections, adhesions, and radiation exposure. Contraindications to non-operative treatment with a therapeutic enema include perforation and peritonitis.(4)
  • Ultrasound-guided pneumatic reduction—AKA an “air enema”—and pneumatic reduction with fluoroscopic guidance has also been shown to have successful reduction rates. Currently, reduction with an air enema is the preferred treatment for a stable child, when trained personnel are available.(4)
  • Ultimately, if none of these techniques are successful, surgical management is needed.

 

8. What is your patient’s disposition?
  • After appropriate resuscitation, pain control, and diagnostics, your patient should be admitted, with pediatric surgery on board, to watch for recurrence or need for further definitive management.

 

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

PGY2 Clinical Monster in Training

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