Intussception From Emergency Medicine Cases #19 Part 2

The following is from EMC Episode 19 Part 2: Pediatric Gastroenteritis, Constipation and Bowel Obstruction [link is to the show notes and podcast]:


Prolapse of a segment of intestine into the lumen of an immediately adjacent part, and is the most common surgical emergency of the abdomen in children from 6mo to 6yo (peak at 18‐30mo)[emphasis added]
Classic triad of intermittent crying, bloody stools and sausage‐shaped mass in the abdomen seen in <40% of cases

History for Intussesception

Crying is often severe and different than usual crying, with the child dropping into fetal or knee‐chest position, and behaving normally a few minutes later
2 presentations: either vomiting (sometimes due to pain, and bilious only if prolonged) ± abdominal pain in older children, or lethargy with paleness (especially in younger infants, where parents might describe the child’s condition as “all the life got sucked out of them”)
May elicit a history of recent viral illness, given that intussusception often requires a lead point such as enlarged lymph glands (eg, Peyer’s patch), Meckel’s diverticulum, or mesenteric duct remnant
Classic currant jelly stool (loose stool with mucous and blood) is a LATE finding and only present in 10% of cases

Physical for Intussesception

The necessity of performing a rectal exam cannot be overstated, as fecal occult blood will appear before gross blood (by which time it is “too late” given that there is likely already bowel ischemia)
May feel an “empty” RLQ or a sausage‐shaped mass in the RUQ just below the liver
Examination should focus on ruling out inguinal hernia, testicular torsion, midgut volvulus (80% present in first year of life, where bowel turns around ligament of Treitz and causes bilious vomiting), as well as child abuse, sepsis, meningitis, bacterial gastroenteritis, UTI (intermittent crying when the child urinates due to irritation)

Investigations and management for Intussesception

Abdominal xray
Used mainly to rule out other or concomitant diagnoses (bowel obstruction or perforated viscus), but may see subtle target sign in RUQ (subtle just below last rib and to side of spine)

Lack of air in RLQ, or Crescent sign in LUQ – only 23% of cases have these signs

Ultrasound in Intussesception
Diagnostic test of choice, with sensitivity 99%
Less painful than enema, which is, however, also therapeutic

Treatment on Instussesception
Air or barium enema – center‐dependent; air may cause compartment syndrome in case of perforation due to high pressures, but barium may cause chemical peritonitis if it gets into the perineum
Direct to surgery in very young patients, prolonged symptoms (>15hrs), acidotic child, evidence of ongoing ischemia, gross blood per rectum getting worse, or hemodynamically unstable

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