Hot Seat #57: 15 mo old with abd pain for 10 days
Posted on: May 26, 2015, by : Katie Donnelly MD
by Katie Donnelly, Children’s National
with Jamil Madati, Children’s National
The Case
15 month old female presenting with abdominal pain for 10 days. Patient initially started off with NBNB vomiting and diarrhea, these symptoms resolved in the past 3 days. She had 2 days of fever during this illness but has not been febrile in the past 4 days. Her Tmax was 101F. Throughout the entire illness she has had abdominal pain. The pain “comes in waves” and she will “crunch up and pull her legs to her chest” or if she is sitting she will “bend over her legs.” The pain is intermittent, and she can go a couple of hours without having pain. She attempts to nurse but stops and cries with what the family believes is pain. The family does not believe this pain has changed at all since the start of the illness 10 days ago. They report no blood in the stools. She is passing flatus and her last bowel movement was two days ago.
ROS: currently afebrile, no cough, no congestion, no rhinorrhea, abdominal pain as above, all others noncontributory
PMH: Negative
PSH: Negative
Vaccinations: Up to date
FHx: Unremarkable
PE: HR 138, BP 98/56, RR 32 O2 sat 100% on RA
General: Alert. Unhappy and cries through most of exam but is comfortable in parent’s arms.
Skin: Warm. Dry. Pink.
Ears, nose, mouth and throat: Tympanic membranes clear. Oral mucosa moist.
Cardiovascular: Regular rate and rhythm. No murmur.
Respiratory: Lungs are clear to auscultation. Respirations are non-labored. Breath sounds are equal.
Gastrointestinal: Soft. Non distended. No organomegaly. Difficult to assess tenderness as patient cries throughout. No specific location causes maximal discomfort.
Questions for you:
Other = AXR- upright/flat
Re-examination
CBC: WBC 13 Hgb 10 Hct 32 Plts 317
Chem: Na 135 K 4.4 Cl 100 HCO3 21 BUN 10 Cr 0.3 Glucose 77 Total protein 7.1 Albumin 3.7 ALT 26 AST 14 ALK 112
CRP: 3.2 ESR 53
Amylase: normal Lipase: normal
KUB: (please highlight text to reveal!)
Rounded intraluminal density is visualized in the right upper quadrant, consistent with intussusception. No free intraperitoneal air. The bowel gas pattern is nonobstructive.
US: (please highlight text to reveal!)
1. Findings are consistent with an intussusception extending from the cecum to the hepatic flexure.
2. Appendix not visualized. No evidence of free fluid or other secondary inflammatory changes within the right lower quadrant.
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.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
Who goes to the OR for open reduction of intussusception? Patients with an unsuccessful enema reduction, signs of peritonitis, prolonged course with suspected necrotic bowel or toxic appearance, signs of shock, suspected pathologic lead point, or non-ileocolic intussusception. Although this child had a prolonged course, she did not have clinical concern for necrotic bowel and was well appearing. Thus, I think it would be reasonable to attempt once with air-contrast enema in radiology before going to OR.
Agree with Dewesh, kid does not sound toxic and it is reasonable to attempt reduction by air contrast enema first. Also per this abstract duration of symptoms alone did not affect success of pneumatic reduction (http://www.ncbi.nlm.nih.gov/pubmed/21259012). Finally, Alyssa Abo nicely pointed out last week during sign-out rounds that ultrasound evidence of trapped fluid within the intussusception (crescent shaped usually, which our patient had) is a predictor of poor success with pneumatic reduction.
Patient’s symptoms have been going on for at 48-72 hours if not longer. Concern that rushing to air contrast enema might result in bowel perforation due to ischemic gut. Of note, patient is super tachycardic (138). Sure it could be dehydration, or pain, or the patient is crying. But if the patient is this tachycardic at rest and afebrile, it makes me concerned that there is some other process going on (bowel ischemia/acidosis? sepsis?). In short, (I clicked ‘other’ for my response to last question) I’m no expert about the best approach for this patient BUT given the duration of symptoms, I would definitely have a discussion in conjunction with my surgical and radiology colleagues about the best approach. Would definitely not rush to air contrast enema WITHOUT letting surgery know in case this patient needs to be taken to the OR emergently for bowel perforation. Serum HCO3=21 not too bad. Any utility for a lactic acid level (as marker of bowel ischemia) to help guide the decision process? Any signs that the patient has bacteremia or translocation of bacteria through the intramural wall? (fever? intramural air/pnematosis intestinalis on KUB?). Just thinking out aloud here. Definitely fluid resuscitate (NS bolus, re-check vital signs particularly BP and HR), prior to surgery or air contrast enema.
A small detail. A KUB is a single view of the abdomen with the patient laying supine. It is not a useful test to address this child’s symptoms. The radiographic test to order, either before or after the US, is a 2-view of the abdomen; the teaching has long been that a L lateral decubitus view is added to the supine view to look for air in the ascending colon which, if present, can be a reassuring sign that there is no intussusception.