UMEM Educational Pearls

Category: Pediatrics

Title: Abdominal pain and fever

Keywords: Intussusception, abdominal pain, fever (PubMed Search)

Posted: 11/10/2013 by Jennifer Guyther, MD (Emailed: 11/15/2013) (Updated: 11/16/2013)
Click here to contact Jennifer Guyther, MD

Question

Case: A 3 year 9 month female presents with fever to 39.4 C and intermittent abdominal pain worsening over 2 days.  The patient had been tolerating food and had no change in her bowel habits.  Based on the imaging below, what is your diagnosis and treatment?

Answer

Answer: Intussusception.  This patient failed air reduction enema and was taken the OR.  No bowel ischemia was found.  The ilium was inside of the colon at the ileocecal valve.  There was significant mesenteric lymphadenitis noticed.  The patient recovered and was discharged later that day.

The x-ray above shows a soft tissue mass under the liver projection in the RUQ that can be suggestive of intussusception in the appropriate case.  The second x-ray done during attempted air reduction shows air surrounding a dense area on the right side.  Ultrasound, however, has become the gold standard.  The ultrasound image shows the classic target sign of hyperechoic compressed loop of bowel telescoping within a hypoechoic edematous outer loop of bowel.

A few other important facts:

The median age of presentation is 32 months, with many presenting before 12 month.  

Abdominal pain and/or crying was seen in 95% of cases.  66% had vomiting, 28% had fever, and 27% had bloody stools.

Causes included 29% with enlarged mesenteric lymph nodes (followed by GJ tube obstruction and meckels diverticulium)

30% have concurrent infections (URI and gastroenteritis being most common)

91% 1st time success rates with air contrast enema

*The above percentages were taken from the article referenced, which is a retrospective review done at a tertiary pediatric center.

References

Lochhead et al.  Intussusception in children presenting to the emergency department.  Clinical Pediatrics 2013 52:1029.


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