8mo male brought in by his mother hysterical for bloody bowel movements. Pt is up to date with vaccinations and was born at 35wks via vaginal delivery w/out any complications. Over the past 5 days, mother states child has not been feeding as well and has been tired with periods of fussiness and crying. Pt has had 4 episodes of NBNB vomiting over 2 days. Vitals on presentation 90/60BP, 100HR, 27RR@100%, 98.7F. During your exam, you take off the pt’s diaper to see this.
1. What do you see? How would you describe this? Bloody stools, one would say this looks like currant jelly
2. What do you think this patient has? Classically, this vignette is describing intussusception.
3.Describe the pathophysiology.
Intussusception occurs when a portion of intestines invaginates or telescopes into the adjacent intestinal lumen which can cause obstruction. This can happen idiopathically or there can be a lead point causing disorganized peristalsis and ultimately telescoping of bowel. Once there is intussusception of bowel, the following can occur
- Lymphatic drainage is impaired leading to edema formation and increased pressure around the bowel wall ->
- Venous drainage will be obstructed ->
- Arterial flow can cause bowel obstruction and ischemia ->
- Shedding of mucosal layer and blood ->
- CURRANT JELLY STOOL (blood mixed with intestinal mucous)
Lead points: Disruption or abnormalities in the intestinal wall predisposing patients to intussusception. If a lead point is found in a patient, they are less likely to be amenable to nonsurgical treatment.
- Enlarged lymph node
- Meckel diverticulum
- Submucosal hematomas which can occur in patients with Henoch Schonlein Purpura
- Tumors (adults)
4.What labs/ imaging would you order?
- Labs: Not necessary to diagnosis intussusception, but surgery labs may be drawn if you suspect your patient may require surgery.
- Ultrasound: One study with pediatric patients showed that the sensitivity of US for detecting intussusception was 97.9% and specificity was 97.8%. Target sign and kidney signs are pathognomonic for intussusception.
- CT: Target sign can also be seen in CT studies.
5. What is the definitive treatment?
- Nonoperative treatment options include barium and pneumatic enema usually performed by a radiologist. Barium enema is both diagnostic and therapeutic
- Operative reduction may also be required, especially if a lead point is found to be the cause of intussusception
Further Reading:
http://radiopaedia.org/articles/intussusception
KCH EM Image 