by Katie Donnelly, Children’s National
with Jamil Madati, Children’s National

The Case
The case is a 15 month old female presenting with abdominal pain for 10 days. The challenge of this case was how to best determine the cause of her abdominal pain and the appropriate treatment of her found intussusception.

Here’s How You Answered Our Questions

Other = AXR- upright/flat
Other = Surgery should be present for attempted reduction via air contrast enema by rads.
Notify surgery about the length of time of symptoms. Have a discussion best way.

Denouement
The patient was taken to radiology for attempted reduction.  An initial air contrast enema, followed by a barium enema, and a repeat air contrast enema were tried without success.  The patient had no adverse events from these procedures.  Surgery was consulted prior to the enemas.  In discussion with surgery, they elected to take to the patient to the OR for a laproscopic reduction instead of reattempting enema reduction.  The patient tolerated the surgical reduction well and was discharged home on post-op day 1.

Teaching Points

1.  Given the unusual history of this patient, a 2 view abdominal XR would be almost as important as US to evaluate bowel gas pattern. With low concern for perforation, our group prioritized US over XR

2. The US sign of fluid surrounding the intussussceptum is a poor indicator for success of interventional radiology reduction.  Intussusception in children: current concepts in diagnosis and enema reduction. 

3. Criteria for immediate surgical intervention, as Dewesh pointed out, would be sepsis, peritonitis, concern for necrotic bowel or concern for perforation.  Our group was willing to allow an attempt at enema reduction before a surgical intervention.

4. Everyone agreed that this was a case that deserved early discussion with radiology and surgery to come up with a plan together for moving forward.