Clinical Presentation
3yo Hispanic female without significant past medical or surgical history presented with her mother for bloody diarrhea and fevers for 2-3 days without recent travel, admissions, or antibiotics. Her older sister had similar symptoms, which resolved. The previous day, the patient saw her pediatrician, who recommended Pedialyte.
On exam, the patient was afebrile with a mildly distended abdomen and severe diaper rash. Abdomen was diffusely tender but non-peritoneal. Initially, no stool was noted.
DDx: HUS, c-diff, intussusception, Meckel’s, appy, volvulus
POCUS clips below. What is the diagnosis?
Diagnosis: Intussusception
Disposition: The patient was transferred to the local children’s hospital for successful air enema. Patient had an uneventful hospital course and was discharged home.
Discussion
Presentation
o Severe, intermittent colicky abdominal pain and diarrhea
o Non-bilious to bilious emesis
o Classic triad: colicky abdominal pain, vomiting, and bloody stools
Only present in 25% of patients
Currant jelly stools rare (see image)
Currant jelly stool
Epidemiology
o Male: female is 3-8:1
o 2/3 of cases <1yo
Etiology
o Idiopathic - most common
Ø Ileocolic junction
Ø Viral (adeno)
o Enteroenteral (jejunojejunal, jejunoileal, ileoileal)
Ø HSP
Ø Cystic fibrosis
o 2-12% pathologic lead points
Ø Meckel’s diverticulum, polyp, cyst, lymphoma
o Post-gastric bypass
Sonographic Diagnosis
o Diagnostic imaging modality of choice
Ø Linear probe (curvilinear for adults)
o Target, donut, or pseudokidney sign
o Sensitivity 98-100%; Specificity of 88–100%
o High risk findings (that may predict failure of enema)
Ø Trapped peritoneal fluid between the bowel walls
Ø Lack of color Doppler flow of bowel wall
Ø Free air
Treatment
o Fluid resuscitation
o Surgical consultation on all patients
o Pneumatic or hydrostatic enema (recurrence rate 10%) is preferred modality
@1% risk of perforation
o Surgery (recurrence rate 1%)
Complications
o Perforation, ischemia, obstruction
References
Applegate KE. Intussusception in children: evidence-based diagnosis and treatment. Pediatric radiology. 2009 Apr 1;39(2):140-3.
Harrington L, Connolly B, Hu X et al (1998) Ultrasonographic and clinical predictors of intussusception. J Pediatr 132:836–839.
Pracros JP, Tran-Minh VA, Morin de Finfe CH et al (1987) Acute intestinal intussusception in children. Contribution of ultrasonography (145 cases). Ann Radiol 30:525–530.
Shanbhogue RLK, Hussain SM, Meradji M et al (1994)Ultrasonography is accurate enough for the diagnosis of intussusception. J Pediatr Surg 29:324–328.
Verschelden P, Filiatrault D, Garel L et al (1992) Intussusception in children: reliability of US in diagnosis–a prospective study. Radiology 184:741–744.