Pediatric Case of the Week 15: "Little Ball of PAIN!"

You enter another morning shift at a local EMERGENCY/URGENCY center and find yourself reminiscing over the recent "tummy bug" season, and glad to be entering spring.   You begin your day by cursing the ER Gods who seem to unceasingly torture you with a deluge of unnecessary patient visits.  After venting this to the open air, you cheerily proceed to see your first patient: an 18 month old male (little Davey Pickleson) whose chief complaint is six hours of stomach pain.

His mom reports that he awoke in the middle of the night crying.  She picked him up and pulled him into bed with her. He settled down after a short while, then fell back asleep. Over the next 3-4 hours he awoke intermittently crying, "curling up into a little ball of pain!"

His appetite has been poor over the past day.   Over the past day he has also been less playful and mom notes that he would "occasionally bend down crying." There is no vomiting or diarrhea. His last stool yesterday was normal.  No other sick contacts, but he is in daycare..."so everything is possible."  Additionally mom denies any fever and there is no report of abdominal trauma.

VS:       T37.6      P 118       R 24     BP 85/55      Wt 11 kg

Physical Exam: He is awake, alert, and being carried by mom. His skin is pink with good perfusion and brisk capillary refill. His oral mucosa is pink and moist. There are no ulcers in the posterior pharynx. His tympanic membranes are normal. Heart regular rhythm and normal rate. Lungs are clear with good aeration. His abdomen is soft and not distended, with normoactive bowel sounds, and no masses noted. It is difficult to determine if any abdominal tenderness is present. His genitalia are normal (no scrotal/testicular swelling or tenderness). His distal extremities are warm and the distal pulses are strong. He is responding to mom appropriately.

What do you want to do for this little trooper?

Before you order any tests, you faintly make out one word of gibberish from the young boy's mouth, "EV--I--DENCE???"

You pause, scratch your head, and wander back to your computer wondering what tests, if any, you should get?



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WEEKEND UPDATE

Intussusception presents most commonly between 3-12 months of age.  The Illeo-colic junction is the most common site, but ileoileal "telescoping" is also freqeunt. Colonic intussusception is rare in kids.

Less than 1/3 of intussusception cases will present with the classic triad of abdominal pain, vomiting, and bloody stools.  LESS THAN ONE THIRD.  The classic description of bloody stool as "currant jelly" is a LATE FINDING; and I think any report of blood should raise your suspicion.



It seems that every good talk I've ever heard about intussusception notes an association with increased "lethargy." Additionally, the colicky nature of 'little Davey's pain is pretty classic for a bowel that is intermittently "telescoping."  Ouch.

Other things to consider:

- Appendicitis
- Occult Trauma
- Colic
- Gastroenteritis
- Hernia
- Testicular Torsion
- Volvulus



 
















History: Ask parents about recent viral illnesses that may have lead to enlarged Peyer's patches (different than cabbage patches but interesting nonetheless) that can act as a LEAD POINT for the intussusception.  Also ask about family history of intussusception which can increase risk by 15-20 times!

Physical exam: You may palpate a "sausage like" mass in the right upper quadrant or you may appreciate a scarcity of content in the right lower quadrant (Dance's sign.)  However, in reality your physical exam will be more of a ritualistic show than a meaningful inquiry.  Don't feel bad.


Get an ultrasound and redeem yourself.  Some institutions may be fond of the 3 view series abdominal film, but most start with ultrasound.  It is non-invasive, safe, and has a sensitivity of 95-99% with specificity of 88-98%. 

Finally, a barium or air contrast enema is both diagnostic and therapeutic.  (Choose air if you have the choice because no-one wants barium to spill over into this little fella's peritoneum.) This test should be performed where-ever a pediatric surgeon hangs their coat.  (Perforation or failure is certainly possible and you will want those tiny little pediatric surgeon hands ready to do business if needed.)

These patients are admitted (even after successful reduction) because they can develop recurrance within the first 1-2 days.

Also...worth noting: Previously an increased rate of intussusception was associated with oral RSV immunization.  It was an unfortunate side effect and cause for pause amongst public health officials.  Bottom line, we studied this and produced safer vaccines.  I'm still very PRO-IMMUNIZATION, but for those of you who are skeptics, the history of rotavirus and intussusception may unfortunately add adrenaline to your fear.

Here are some additional resources if you are interested in learning more:

http://www.cdc.gov/vaccines/vpd-vac/rotavirus/vac-rotashield-historical.htm

http://www.nejm.org/doi/full/10.1056/NEJM200102223440804

http://www.nejm.org/doi/full/10.1056/NEJMoa052434

http://www.nejm.org/doi/full/10.1056/NEJMe1105302

http://pediatrics.aappublications.org/content/126/6/e1499.long


Blog References: 

Bachur R; Abdominal Emergencies, Chapter 121; Textbook of Pediatric Emergency Medicine 6th ed.

Christian-Kopp S; Intussusception is a "Cannot Miss" Diagnosis...Know How To Diagnose And Manage These Patients.  Avoiding Common Errors In The Emergency Department. 2010.

Blanco F, Cuffari C; Intussusception. emedicine; http://emedicine.medscape.com/article/930708-overview 

Young L;  Intussusception Chapter X.4; Case Based Pediatrics for Medical Students and Residents; University of Hawaii: http://www.hawaii.edu/medicine/pediatrics/pedtext/s10c04.html