Abdomen Case 2

9 month old white male presents with his mother. She states that he was playing earlier today when suddenly he began screaming in pain, followed by an episode of calmness. This has recurred multiple times over the past few hours.

History & PhysicalT: 99.4 P 110 RR 30 BP: 90/60Gen: normal appearing . NADHEENT: PERRL, NCAT, oropharynx clear CV: RRR, no m/r/gPulm: CTABAbdomen: sausage-shaped mass in RUQ, NT, NDExt: 2+ pulses, No c/c/e

Abdominal X-Ray

Intussusception1- Crescent Sign: intussusception lead point into gas filled lumen2- Target Sign: Mass in RUQ forms shape of target, sometimes just appears as a mass.3- Absent RUQ bowel gas4- Signs of small bowel obstruction

IV & IV fluidsIf H&P convincing for Intussusception:

Air Contrast EnemaNotify Surgery prior to study due to risk of

perforationThis can be both diagnostic and curative

If H&P is not convincing but still in differentialUltrasound 1st then Air contrast enema if

indicatedThis is done as a less invasive method to look for

intussusception and other causes of abdominal pain.

Admit to hospitalRecurrence rate of intussusception is 5-10%

ED Management

Most common intestinal obstruction between 3 months and 6 years of age

“Currant Jelly Stool” is a late manifestation that is only present in 50% of cases ; (75% have heme-positive stool)Should raise concern for intussusception if

present but should have no bearing on decision if absent.

Air contrast enema is both diagnostic and curativeAir is preferred over contrast b/c if perforation

occurs no barium introduced into peritoneum

Pearls:

Additional Images of Intussusception

In Left image, Note the outline of bowel telescoping proximally.

King, Lonnie. Pediatrics, Intussusception. http://emedicine.medscape.com/article/802424-overview

Tintanelli’s Emergency Medicine: A Comprehensive Study Guide. Chapter Chapter 127 Pediatric Abdominal Emergencies

Wahba, Mark. The Pediatric Abdomen: Intussusception. www.remergs.com. Oct 9, 2003

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1172.htm

References