Your patient is an18 months old female with intermittent abdominal pain for the last 4-5 days. She has history of constipation and soy allergy, seen at an outside hospital three days ago for the same. She had an xray and was discharged home with instructions for at home clean out with diagnosis of constipation.
Mother is bringing her to your ED because the pain is back. The laxatives helped somewhat, but her symptoms have returned. She reports that the patient cries spontaneously, lasting 1-2 minutes, then completely resolves. These episodes happen at multiple times during the day.
ROS: Decreased appetite and energy, but NO fevers, vomiting, diarrhea, bloody stool, abdominal distension, hematuria, or lethargy.
Intussusception classically presents with colicky abdominal pain, palpable mass, and currant jelly stools, but in less than 50% of patients. The clinical presentation of intussusception actually occurs on a spectrum. Children who present early in their course may look well with intermittent, unexplained crying episodes, while others may be febrile, dehydrated, with bloody stools, and be septic. The diagnosis can be missed in up to 60% of children presenting for initial evaluation. Identified risk factors include any syndrome or abnormality causing a lead point, ie Meckel's Diverticulum, Familial Polyposis, lymphoma and Henoch-Scholein Purpura, as well as GI infections, bacterial and viral, (Adenovirus, Rotavirus, and HHV6, etc.)
On exam, our patient's abdomen was soft but hard to evaluate due to behavior. Flat plate AXR demonstrated a circular hyperdensity in the RUQ, which on ultrasound, corresponded to a large ileocolic intussusception. She was successfully treated with air enema reduction, which in recent review has the lowest recurrence rate of intussusception.
Bottom Line -
In children with intermittent abdominal pain or unexplained crying episodes, consider intussusception on your differential, as more than half are missed on initial presentation, which can be subtle. Late presentations can include bowel perforation, peritonitis, sepsis, and shock. If diagnosed, arrange for enema reduction or transfer to a facility with this capability.
References:
Waseem M, Rosenberg HK. Intussusception. Pedi Emer Care. Nov 2008, 24(11): 793-800.
Gluckman S, Karpelowsky J, Webster AC, McGee RG. Management for intussusception in children. Cochrane Review of Systematic Databases. 2017; Issue 6.
