Thursday, April 12, 2007

Pain in the Belly

Another case of mine that involves a relatively uncommon but significant diagnosis...

CC: Abdominal pain
HPI: 2 yo male presents w/ three day h/o abdominal pain. Patient has had an unremarkable PMHx, but for the last three days has had intermittent episodes of abdominal pain. Per parents he's been very fussy and irritable. He'll be fine and then seems to go over to the corner, get on fours "like a dog" and cry and grab his belly. Nothing seems to precipitate these events, they last for a couple minutes and then resolve on their own. He was seen in an UC three days earlier and had x-rays performed that were "negative". Parents were instructed that if symptoms persist, they should come to the ED.

He has no prior surgical history and still have normal BM's. Parents deny fevers, nausea/vomiting, travel, recent Abx use, GI hx, excessive weight loss, trauma, etc. No family h/o pyloric stenosis, but per parents, the UC doc informed them that if symptoms persist, then he should get an U/S. When the pain comes on he seems to grab at his epigastric/periumbilical region. Stools at the U/C were negative for fecal leuks, but parents admit to "foul-smelling" flatus.

PMHx: GERD as infant (no further trx)
Meds: Deny
SHx: Lives w/ parents and one sib
ROS: Negative except for HPI

V/S: HR: 79 RR: 22 Temp: 99.6 Sats: 98% (RA)
PE: (pertinent findings)
Gen: Non-toxic, but fussy and irritable.
Abd: Soft and NT, no obvious HSM. During the exam, he curled up and cried excessively w/ a tense, hard abdomen

Comments: This is a pretty classic presentation for what he ultimately was found to have. Two year old w/ intermittent episodes of crampy, inconsolable abdominal pain has to make you consider this diagnosis and order a specific test that can be both diagnostic and therapeutic...

In the mean time labs had been ordered and were relatively unremarkable.

Labs: WBC: 10.7 Polys: 44% Bands: 3%
Electrolytes, urine all unremarkable

So late on a Saturday night (when he presented), I bugged one of our dear radiologists to come in and perform a barium enema (their choice- the newer literature shows that air enema's can work just as well) to r/o intussusception.

If you've never seen a BE study performed, they can be painfully boring until you get to the end of it (as in this one). For the first 50 minutes, the general excitement was getting the patient adequately sedated enough to tolerate the test and lay still. But once the ileocecal junction was getting closed, the diagnosis was made. There it was found that the contrast would not pass and even more importantly, the bowel was not reducing. It appeared as if he had suffered from an non-reducible intussusception.

The patient was quickly transferred to PCH for surgical evaluation.

So let's review some of the key features of intussusception...

Remember, that it involves any part of the GI tract telescoping into another segment. It's the most common cause of bowel obstruction in children from 3 months - 5 years. Over 60% of the cases are diagnosed in the first year of life. There is a male:female predominance of 4:1.

There is a seasonal incidence after the viral season. Other causes include a Meckel's diverticulum, polyp, HSP, tumors or FB's. Ileocolic intussusception are the most common (as was the case in this child).
As the upper part of the bowel enters into the lower part, it brings along the mesentery. This causes venous engorgement. Later on bowel edema, bleeding and sloughing can produce the classic "currant-jelly stools". However, this is a late-finding and if found the patient is already extremely sick.
The classic story is a child from 6-18 months old who will be fine and then suddenly drop or ball up and be inconsolable. Vomiting is usually rare. If you're lucky, you might feel a "sausage-shaped mass" in the right quadrant during an attack, but again, these children are usually so inconsolable, that I wouldn't rely on this finding.
I've made this diagnosis probably 3 or 4 times in my career and every time it's strictly based on history. The examination is difficult at best. Imagine if your bowel was incarcerated as a two year old. Would you lay back and allow some doctor w/ cold hands to push on your belly? Hence, this is one of those diagnoses where history is extremely important. Usually the parents provide all the info. The story is pretty classic and if they're giving you this type of story, I will refuse to send the child home until some sort of definitive testing is done. These are not the type of cases you can send home and chalk it up to "colic" or a "virus". Just like in this child, if it was allowed to persist, he could of ended up w/ dead bowel and even worse. Therefore, like meningitis, if you consider the diagnosis, you probably have to do the test to rule it out.
With regards to diagnosis, our radiologists still prefer BE's. Air enemas have shown to be just as effective in diagnosis, less radiation and with better rates of successful reduction. Do not perform an enema on a patient with signs of peritonitis, perforation or hypovolemic shock. These patients should obviously go straight to the OR. Ileo-ileo intussusceptions are much more difficult to diagnose and reduce.
All patients who have had a successful reduction should be admitted for observation. Recurrence happens in 0.5-15% of patients. Even after laparatomy, recurrence rate can be 2-5%.
If you have any questions or comments let me know.

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