Said Al Mazroui

On 11/10/09

5 months child presented with 5 days history of loose motion

for 3-4 times daily (normal 1-2 times/day). the diarrhea was associated with low grade fever ( not ducomented ) 2 times vomiting only

the fever was of low grade in nature, on/off with no sweating, rigors/chills, abdominal pain, respiratory distress, LOC or seizures. Mother noticed blood in the stool at 11:30pm h/o increased crying. perinatal history is not eventful

Examination:

looks lethargic and dehydrated. No pallor, jaundice, cyanosis, LN. HR=140/mint, RR=30/mit, t=36.9 C, O2 sat=98%, BP: 86/62 wt:8 kg Abdomen: soft, no distention , tenderness, no mass. Other systemic examination: nad.

DD

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Plan:
Start I.V.F Send CBC, U&E, Urine dipstix Observation

UREA AND ELECTROLYTES

sodium 136 mmol/l

potassium
chloride Carbon dioxide urea creatinine

4.4 mmol/l
102 mmol/l 22 mmol/l 1.8 mmol/l 17 umol/l

CBC
hemoglobin hematocrit 11.4 34 g/dl %

Mean cell volume

Mean cell hg RBC dist. width Platelet count

4.58
74.2 16.5 253

fl
pg x10pwr9/1

White cell count

neutophils lymphocytes

9.8
5.2 3.8

x10pwr9/1
x10pwr9/1 x10pwr9/1

Urine dipstick:

ketone 3+

After 4 hrs
became playful and active No crying throughout observation

R u happy to d/c ???

d/c on ORS it was fully explained for the parents if the patient developed fever, bloody diarrhoea or vomiting to bring her back to the A&E or nearest local health center

On 13/10/09
h/o vomiting x several times, poor oral intake persisting loose watery stools / mixed with blood ? red current jelly stools No excessive (Inconsolable) crying

Examination:
afebrile, tachycardic 158/min, rr 28/min looks mod-sev dehydrated with dry mucus membrane, mild sunken eyeballs and ant fontanelle. chest: clear sat 100% P/A: soft, non tender, + bs, no mass

Plan

US abdomen: (13/10)
There was a donut sign seen in the right mid abdomen suggestive of intusseption. After manipulation is resolved spontaneously.
The spleen, liver, GB and both kidneys are normal.

No free fluid in the pelvis or abdomen. \ Spontaneous resolution of Colico-colic intusussception

Admitted for observation -NPO -start IVF 0.18 DNS 30 cc/hr -ceftriaxine 170mg IV OD

Why she was admitted??

Definition

telescoping of one segment of bowel into an immediately adjacent segment

Classification.
Enterocolic(90%) Colocolic Enteroenteric

Causes of intussusception
Idiopathic(90%) Nonidiopathic. (hypertrophied Peyer patches secondary to infection, adenovirus infection, foreign bodies, parasitic infestation polyps, lipomas, Meckel's diverticulum, intestinal duplication, Henoch-Schnlein purpura, lymphomas, (

EPIDEMIOLOGY
2 per 1000 live births. male-to-female ratio is 3:1. Most common between 3-9 month most common cause of intestinal obstruction between 6 and 36 months of age Most episodes occur in otherwise healthy and well-nourished children

Approximately 60 percent of children are younger than one year old, and 80 percent are younger than two

Intussusception is rare before three months and after six years of age

Most patients recover if treated within 24 hours. Mortality with treatment is 13%. If left untreated, this condition is uniformly fatal in 2-5 days. Recurrence is observed in 3-11% of cases. Most recurrences involve intussusceptions that were reduced with contrast enema

History

Abdominal pain(80-95%) : The child appears to have intermittent abdominal pain( manifest as episodic bouts of crying) which is colicky, severe and may be accompanied by pallor and drawing up of the legs (guarded position) Episodes typically occur 2-3 times/hour. Infant may sleep or may appear lethargic or playful between episodes of pain.

Vomiting (75%) is usually a prominent feature Initially nonbilious but may progress to bilious Bowel motions

blood and/or mucus classic red currant jelly stool is a late sign (60%)

Diarrhea is quite common and can lead to a misdiagnosis of gastroenteritis .(can be an early sign of intussusception ) Lethargy is a relatively common presenting symptom with intussusception There may be a preceding respiratory or diarrheal illness

Classic triad(21% all three, 72% have two) 1-Intermittent abd. Pain(80-95%) 2-Bilious vomiting(75%) 3-Currant-jelly stool(60%)

Examination
Abdomen:

Abdominal mass(65%) - sausage shaped mass in RUQ or midabdomen variably tender Abdomen may be soft, nontender or distended and tender

Peristaltic wave may be present. Absence of bowel contents in RLQ ( Dance sign) PR: may revealed blood or mass. (PR unnecessary if good evidence of intussusception).

Investigations

Blood tests

FBC, U&E Blood group and cross -match Blood glucose

Plain abdominal Xray

Performed

to exclude perforation or bowel obstruction A normal AXR does not exclude intussusception radiographic signs of intussusception are subtle Signs of intussusception on a plain Xray include :

1-Target sign - two concentric circular radiolucent lines usually in the right upper quadrant 2-Crescent sign : intussusceptum protruding into a gas filled pocket, which often results in a crescent shaped gas pocket. 3-Signs of obstruction.

Ultrasound scan :

Useful if there is a suggestive history but no mass palpable or signs on plain AXR Sensitive and specific. Its use is limited by diagnostic and therapeutic use of air enema Donut sign: hyperechoic core surrounded by hypoechoic rim

Hydrostatic reduction( air or barium)

This intervention is both diagnostic and therapeutic Diagnostic investigation of choice if high level of suspicion

Complications:
Intestinal hemorrhage Intestinal obstruction and dehydration. Bowel infarction leading to bowel resection Bowel perforation Peritonitis Sepsis and shock recurrence

Prognosis Prognosis is excellent if diagnosed and treated early; otherwise, severe complications and death may occur.

Differential diagnosis
Gastroenteritis Enterocolitis Infantile colic Incarcerated inguinal hernia meckels diverticulum HSP others: polyps, appendicitis

Management

Initial stabilization: Secure IV access Most children will require fluid resuscitation with normal saline 20mls/kg IV Keep nil orally nasogastric decompression Surgical consultation.

Hydrostatic reduction
Sucuss

rate is 80% in <24h of intrassusception. Only 32% if >24h., recrrence is 10%(most within 24 hr post reduction) CI: peritonitis, perforation, shock Complications: perforation, reduction of necrotic bowel.

Surgical reduction: indicated in: 1-suspected bowel gangrene or perforation. 2 -failure of hydrostatic reduction 3-multible recurrence.

Clinical pearls
Intussusception is the most common cause of intestinal obstruction between 3 months and 2 years of age. high index of suspicion is essential 60% of Intussusception are initially misdiagnosed( GE is commonly confused with it)

Colicky abdominal pain is the major symptom Bilious vomitous and currant jelly stool are late finding Profound Lethargy can be the sole presenting symptom (up to 10%) , which makes the diagnosis challenging Morbidity and mortality increased with delayed diagnosis.

THANX