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30. Pediatric Intussusception: Not Galileo’s Telescope
Keywords
IntussusceptionTransient intussusceptionPediatricUltrasoundCase 1
Constipation and Abdominal Pain
Pertinent History
A 5-year-old female presents to the emergency department (ED) with constipation for the past month, as well as abdominal pain for the past 3 days that worsened on the day of arrival. The patient is unable to pinpoint an exact location of the pain. The pain is sharp and intermittent, often coming in waves. The patient last had passed a small, hard stool 4 days ago. She has not had any fevers, vomiting, diarrhea, dysuria, cough, or rashes. There has not been any recent trauma.
Pertinent Physical Exam
BP 118/87, Pulse 142, Temp 98.1 °F (36.7 °C), RR 21, SpO2 98% on room air
Except as noted below, the findings of a complete physical exam are within normal limits.
Cardiovascular:
Tachycardia with regular rhythm, normal heart sounds with no murmurs, rub nor gallop appreciated. Distal pulses including femoral and radial pulses are intact and symmetric. Capillary refill is less than 3 seconds.
Abdomen:
Abdomen is soft and nondistended with normoactive bowel sounds. There is mild tenderness to palpation diffusely. No hepatosplenomegaly is appreciated.
Past Medical History
Constipation
Up to date on immunizations
Family History
Paternal grandfather: Hodgkin lymphoma
Pertinent Test Results
Test | Result | Units | Normal range |
|---|---|---|---|
WBC | 6.02 | K/μL | 3.8–11.0 103/mm3 |
Hgb | 11.9 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Lactate | 0.2 | mmol/L | <2.0 mmol/L |
AST | 32 ↑ | IU/L | 6–21 IU/L |
ALT | 31 | IU/L | 8–32 IU/L |
Abdominal Plain Radiograph
Mild stool retention without signs of obstruction or impaction.
Limited Abdominal Ultrasound (US)
Ileocolic intussusception noted without any identifiable lead points, no free air appreciated.
ED Management
Once the US was obtained, the patient subsequently underwent a pneumatic enema reduction of her ileocolic intussusception. This procedure was successful with resolution of the intussusception, and there were no complications.
Updates on ED Course
After the successful reduction of her intussusception, the patient had resolution of her abdominal pain. After a period of observation, she continued to remain asymptomatic and tolerated an oral food challenge without complications. She was subsequently discharged home in stable condition with outpatient follow-up.
Case 2: Lethargy in an Infant
Pertinent History
A 10-month-old male presents to the ED with lethargy that started on the day of presentation. The patient’s mother notes the patient slept later than usual this morning and continued to be abnormally tired throughout the day. He has taken several prolonged naps despite usually only taking one short afternoon nap. She denies any recent fevers, vomiting, diarrhea, or rashes. There has been no known trauma. She denies concern for accidental ingestion, with the only medications in the home being acetaminophen and ibuprofen.
Pertinent Physical Exam
BP 105/84, Pulse 158, Temp 98.1 °F (36.7 °C), RR 21, SpO2 97% on room air
Except as noted below, the findings of a complete physical exam are within normal limits.
General Appearance:
Patient is tired, although easy to arouse. He is well nourished, well appearing, and in no acute distress with normal color.
Musculoskeletal:
He is moving all extremities; there are no obvious deformities, swelling, lesions, or bruising.
Neurologic:
Sleeping. Arouses with mild stimulation but continues to fall back asleep throughout examination. Anterior fontanelle is open, soft, and flat. Strength and sensation are intact throughout. There are no obvious focal neurologic deficits.
Past Medical History
The patient was born at full term via spontaneous vaginal delivery. There were no complications with the pregnancy or delivery. The patient is up to date on immunizations.
Social History
The patient lives with his mom, dad, and four-year-old brother. He attends daycare 3 days a week and is occasionally babysat by his maternal grandmother.
Family History
Mom, vitamin B12 deficiency
Pertinent Test Results
Laboratory work-up including a complete blood count, comprehensive metabolic panel, hepatic function panel, and urinalysis was normal. A urine drug screen was negative.
EKG
Normal sinus rhythm, with no concerning findings
CT Non-contrast Head
Unremarkable
Limited Abdominal US
Ileocolic intussusception noted without an identifiable lead point and with no free air appreciated.
ED Management
After the US findings were discovered, the patient was taken for a pneumatic enema reduction. This was successful and completed without complications.
Updates on ED Course
After the successful reduction of his intussusception, the patient was awake and acting appropriately. After a period of observation, he continued to remain asymptomatic and tolerated an oral food challenge without complications. He was discharged home in stable condition with outpatient follow-up.
Learning Points
Priming Questions
- 1.
What is intussusception, and what are the common and uncommon clinical manifestations of intussusception?
- 2.
How can the diagnosis of intussusception be made?
- 3.
What are the different treatment options for intussusception, and what clinical circumstances would preclude each?
Introduction
- 1.
Intussusception is one of the most common causes of acute intestinal obstruction in children [1, 2].
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