18-month-Old Boy With Abdominal Pain and Rectal Bleeding

Background
The parents of a 18-month-old boy bring him to the emergency department (ED) owing to recent
lethargy and an 18-hour history of pain that his parents believe stems from his abdomen. He is a
previously healthy and well-nourished boy without any significant medical history. He was born
at term via vaginal delivery, and his neuromotor de0velopment is adequate for his age. His
vaccinations are up to date.
Four weeks ago, he developed a common cold, with runny nose, low-grade fever, and sneezing,
which subsided in 3 days with symptomatic treatment (acetaminophen, hydration, and physical
measures). The afternoon before arrival to the ED, he appeared to be in significant pain,
accompanied by inconsolable crying and drawing up his legs toward the abdomen. Between
painful episodes, the child behaved relatively normally and free of pain; he was even able to fall
asleep before waking again with pain. Since then, he has vomited gastric contents four times.
Two hours before admission, he became lethargic, just waking up to cry during the colic
episodes.

Physical Examination and Workup

Upon physical examination, the boy is a well-nourished and well-hydrated infant. His vital signs
show a heart rate of 180 beats/min, a respiratory rate of 32 breaths/min, systolic blood pressure
of 110 mm Hg, and temperature of 98.6°F .

Figure 1.

Figure 2.

Figure 3.

Between episodes of cramps, he sleeps tiredly and his abdomen is soft; during the acute pain
phases, he cries inconsolably and draws his legs toward the abdomen, with rigid abdominal
muscles. Peristalsis is augmented and high-pitched. No masses are felt, and no rebound
tenderness is observed. He passes a small amount of mucous bloody stool (Figure 1). A complete
blood cell count demonstrates mild leukocytosis, with a left shift. Electrolytes and the rest of the
chemical panel are normal. Plain abdominal radiography and ultrasound images are shown
(Figures 2 and 3).

Discussion
Intussusception is the most common abdominal emergency in children younger than 2 years, and
is the most common cause of intestinal obstruction in those aged 6-36 months. The term refers to
a segment of intestine (the intussusceptum) that telescopes or invaginates into the lumen of
another, immediately adjacent distal segment called the "intussuscipiens" (Figure 4).[1]Early
diagnosis with fluid resuscitation and treatment results in a mortality rate of less than 1% in
children. However, if left untreated, intussusception is uniformly fatal in 2-5 days.

Figure 4.

Acute gastroenteritis in children is most often viral, thus showing lymphocytosis rather than an
elevated neutrophil count. It is also commonly preceded by an upper respiratory tract infection.
Low-grade fever may be present, but the pain is persistent. Episodes of colicky pain with the
patient crying inconsolably and drawing the legs upward toward the abdomen, intermingled with
periods of rest and calm, are characteristic of intussusception.
Meckel diverticulum is usually found in older children and is mostly asymptomatic, except in
cases complicated with diverticulitis. Meckel diverticulum is often confused with
acute appendicitis, and the rectal bleeding is fresh and profuse. Currant-jelly stools are also
characteristic of intussusception.
Intestinal polyps are often asymptomatic, except in complicated cases that present with rectal
bleeding, and are mostly painless. A family history may be recorded.
Intestinal volvulus is an acute surgical emergency in babies with malrotation. These individuals
present extremely sick, with hemodynamic instability and severe electrolyte imbalance, a
scaphoid and sometimes discolored abdomen, and vomit that is characteristically bilious (green).

Most intussusceptions are idiopathic; only 2%-8% of cases are caused by an underlying disease

or condition that creates a pathologic lead point for the intussusception. Although the cause of
intussusception is unknown in 90%-95% of children, a viral etiology is suspected because of the
seasonal predisposition for intussusception to occur in spring and autumn, as well as a higher
incidence of adenoid hypertrophy in children with intussusceptions. Although diarrhea is a
common symptom preceding intussusception, recent studies have failed to prove statistical
significance of a specific viral infection as a cause for intussusception.
Older children with intussusception may have lead points as the cause of the condition. These
include Meckel diverticulum, cocaine abuse, laxatives, and antibiotic use. It has also been
described in patients with parasites, particularly Ascaris lumbricoides, and Henoch-Schönlein
purpura, where mucosal hematomas are thought to act as the lead point. Acute appendicitis in
patients with Burkitt lymphoma has also been reported as an etiology.
 Figure 5.

Peutz-Jeghers syndrome, familial polyposis coli, and juvenile polyposis can also cause
intussusceptions. A vermiform appendix may occasionally cause the disease (Figure 5). Familial
cases of intussusception have been described. Intestinal lymphomas should be suspected in all
children older than 6 years with intussusception.

Compression of the mesentery at the point of invagination leads to venous stasis and edema.
Goblet cells pour copious amounts of mucus into the intestinal lumen. The engorged hyperemic
intestinal mucosa seeps blood, which mixes with the mucus to form the currant-jelly stool that
occurs in 60% of patients (Figure 1). Tissue pressure eventually exceeds arterial pressure, and
necrosis ensues within 24 hours.
The peak age at presentation is between 5 and 10 months; it is more common in males. Less than
1% of intussusceptions are found in neonates. Early diagnosis and prompt treatment prevent
catastrophic complications. In 95% of cases, the intussusception is in the ileocecal area. Ileoileal
and colocolic intussusceptions are rare.
After nonoperative reduction, the recurrence rate of intussusception is usually less than 10% but
has been reported to be as high as 15%. Most intussusceptions recur within 72 hours; however,
some recurrences have been noted as long as 36 months later. If there is more than one
recurrence, a lead point is suggested. The onset of the same symptoms typically signals
recurrence. Treatment for a recurrence is similar, unless a lead point is strongly suggested, which
would indicate that surgical exploration is needed.

Intussusception causes a sudden onset of severe colicky abdominal pain. Children appear healthy
between paroxysms of pain. As the condition progresses, the child becomes progressively more
irritable and lethargic until shock develops. Vomiting occurs in the early phase of the illness and
is bilious in 30% of cases. Early in the course of the disease, stools are normal, but they rapidly
become bloody and mucoid within the first 12 hours.
The classic triad described for intussusception, which consists of colicky abdominal pain, a
sausage-shaped palpable abdominal mass, and currant-jelly stools, is actually found in only 20%
of cases. Patients may present with the Dance sign (empty right lower quadrant).

Figure 6.

Figure 7.

Figure 8.
Abdominal plain films may reveal the head of the intussusceptum projecting into the air-filled
colon and scattered air-fluid levels that suggest an ileus or partial obstruction (Figure 6).
Contrast fluoroscopy can be diagnostic as well as therapeutic. The classic sign is a coiled-spring
appearance caused by the tracking of contrast around the lumen of the edematous intestine
(Figure 7). However, air and water enemas are safer than and just as effective contrast
fluoroscopy.
Ultrasonography is the method of choice to detect intussusception in most institutions. A
"target," "bull's-eye," or "coiled spring" lesion is seen, representing layers of the intestine within
the intestine (Figure 8).

As was undertaken with this patient, the proper treatment for intussusception is to stabilize the
patient's airway, breathing, and circulation (ABCs) and replace large fluid losses. Administer
nothing by mouth and place a nasogastric tube to decompress the obstruction from above. The
use of antibiotics is appropriate for management of bacterial translocation.

For stable patients with radiographic evidence of intussusception and no evidence of bowel
perforation, nonoperative reduction of the intussusception is recommended rather than surgery.
The reduction can be guided by fluoroscopy or ultrasound, and either hydrostatic or pneumatic
enemas may be used.

The success rates and risks of these techniques are similar. Ultrasound-guided approaches have
the benefit of better identification of pathologic lead points and lower exposure to radiation.
Pneumatic reduction is currently considered an optimal first-line treatment. Most recurrences
occur during the first 72 hours.

Barium, water, or air enema reductions are appropriate after surgical consultation if the symptom
duration is less than 24 hours and the patient has no signs of peritonitis. If symptoms persist
longer than 24 hours, signs of peritonitis appear, or the intussusception cannot be reduced after
two enema attempts, or if it recurs, stabilize the child and transport him or her immediately to the
operating room, because untreated intussusception is almost always fatal. The recurrence rate is
higher after radiographic than after surgical reduction.

Surgical treatment is indicated as a primary intervention for patients with suspected

intussusception who are acutely ill or have evidence of perforation. Surgery may also be
appropriate when the patient is treated in a location where the radiographic facilities and
expertise to perform nonoperative reduction are not readily available. It is also necessary for
patients in whom nonoperative reduction is unsuccessful or for evaluation or resection of a
pathologic lead point.
Laparoscopy is currently considered a reasonable approach to pediatric intussusception, even
when bowel resection is necessary.

After two unsuccessful attempts to reduce this patient's intussusception, a transverse laparotomy
was performed, and the bowel was manually reduced by squeezing the intussusceptum with
warm moist towels. No evidence of bowel necrosis or perforation was found. A mild amount of
clear peritoneal fluid was washed out. Blood loss was minimal, and the patient recovered
uneventfully, resuming diet the next morning; he was discharged home within 24 hours.