Abdominal Pain Intussusception. Author: Philip Wolfson, M.D. Jefferson Medical College Revision Editor: Linda Barney, M.D. Joseph Iocono, M.D. Emme Hall. Your patient in the ER is a 14-month-old female with a 12 hour history of irritability and abdominal discomfort. History.
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Philip Wolfson, M.D.
Jefferson Medical College
Linda Barney, M.D.
Joseph Iocono, M.D.
What other points of the history do you want to know?
Consider the Following
Unable to verbalize but discomfort seems intermittent, in spasms
Has become more pronounced in past 4 hrs
Much less active than usual, irritability with the pain alternating with periods of lethargy
Associated Signs & Symptoms
Vomited 3 X, initially clear but now yellowish; had a watery bowel movement with a mixture of blood and mucus
Born at 37 weeks’ gestation. Otitis media at age 8 months. Upper respiratory infection 2 weeks agoHistory, Emme Hall
What would you look for on physical examination?
Auscultation – bowel sounds present but diminished
Percussion – tympanitic; elicits tenderness in RLQ and RUQ
Palpation - generally soft, but + RUQ and RLQ tenderness
Remainder of examination is within normal limits
What studies would you obtain?
The hemoglobin is normal. The white cell count is moderately elevated, suggesting an infection or inflammation. The serum electrolytes are normal. The abdominal x-rays suggest the possibility of an intestinal abnormality, but the findings are nonspecific.
What would you do now?
Sequential images with arrows demonstrating reducing lead point of intussusception
The air passes up through the large intestine until it reaches the right side of the transverse colon where it encounters a filling defect. The radiologist is able to reduce the “mass” up to the proximal right colon but no further.
What does this mean?
What should be done next?
A right lower quadrant incision is made, and the ascending colon is delivered. There is an intussusception of the ileum half-way up the right colon.
Using manual pressure on the colon above the intussusception, the ileum is reduced. The bowel is pink and viable; no pathological “lead point” is seen. An appendectomy is also performed.
Intussusceptionis a telescoping of one portion of the intestine into another, and typically affects children between the ages of 6 to 18 months. The ileum usually invaginates and advances a variable distance into the colon. It often follows a nonspecific viral illness and may be due to hypertrophy of Peyer’s patches; rarely is there a pathological lead point in the intestinal wall. The patient presents with intermittent bouts of pain where they may draw their knees up to the chest; in between episodes they may be irritable or lethargic. Vomiting is common and as the condition progresses there may be blood and mucus (classically the “current jelly”) in the stools as the mucosa becomes ischemic. Physical examination may be fairly normal initially but there may be irritability, somnolence, fever, and right sided abdominal tenderness; occasionally a right upper abdominal mass can be palpated. Abdominal x-rays may appear normal or show a paucity of air in the right lower quadrant and some dilatation of the small intestine.
Intussusception is considered to be an emergency, as the intestine can become necrotic. If the diagnosis is suspected, a contrast enema will be diagnostic and often therapeutic. Radiologists are increasingly utilizing air rather than barium because of the greater success with contrast reduction and lower morbidity if there should be a perforation. Some advocate administration of intravenous fluids and broad spectrum antibiotics at the time of the x-ray studies, especially if the child is ill. Successful radiographic reduction is confirmed if there is reflux of contrast into the ileum, in which case the child is admitted to the hospital for 24 hours of observation. If contrast reduction is unsuccessful, surgery is mandatory to reduce the intussusception manually. The appendix is usually removed. If the intestine is necrotic, a resection is necessary. Recurrence of intussusception occurs in approximately 5% of children.
The diagnosis of intussusception must be considered in any patient between 6 months and 2 years with unexplained abdominal pain, and a contrast x-ray usually is obtained. There may also be a role for ultrasound as a screening test.