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Atypical Case of Intussusception Recognized with Point of Care Ultrasound.

Disclosure of Interest: All authors report no financial interests or potential conflicts of interest.

Approval from the West Virginia University Institutional Review Board was not required for this study, as data is de-identified in the NEDS and not considered human subjects research.

Introduction

Abdominal pain in children and adolescents is a common complaint in the emergency department. Intussusception should be considered in children with abdominal pain and vomiting. The pathogenesis of intussusception in children is most often idiopathic, but a pathologic lead point may be present as well. Ultrasound is recommended as the initial imaging test to diagnose or exclude intussusception. Additionally, bedside ultrasound is a rapid, accurate, non-invasive modality to evaluate these patients, and typical sonographic findings are relatively easy to identify. If capable of recognizing these findings, emergency physicians can come to a more rapid diagnosis, decrease use of radiology resources and expedite management.

Case Report

A 17-year-old- male presented to the emergency department (ED) from a pediatrician's office with a complaint of abdominal pain. For two weeks, He had been experiencing cramping and lower abdominal pain that was intermittently stabbing in character. He had a decreased appetite but was still able to tolerate food and liquids. The patient denied having nausea, vomiting, stool changes, including no bloody bowel movements, along with no recent illnesses or fevers. There were no penile, scrotal, or urinary complaints and no trauma to the abdomen. He had an umbilical hernia repair at age 4, but otherwise no prior abdominal surgeries. Past medical history was significant for neuroretinitis as a young child. The patient's immunizations were up to date.

On examination, the patient was noted to have mild right lower quadrant and right pelvic tenderness to palpation with no rebound, guarding, or masses noted; negative heel strike and Rovsings signs. Testicular exam showed no pain on palpation, no hernias, or overlying skin changes. Lab work revealed mild leukocytosis of 11.1. A bedside ultrasound was performed which revealed a target-shaped lesion in transverse plane and bowel-in-bowel configuration in longitudinal plane representing the multilayered lesion of an intussusception (Figures 1-4).

Since the presentation was very atypical, a CT scan was performed to confirm the findings and evaluate for more extensive intra-abdominal pathology. No additional findings were appreciated on the CT scan. We anticipate that as more physicians gain experience with bedside ultrasound, additional imaging with CT will be needed and desired less frequently.

Due to the inability of gastrografin enema to reduce the intussusception and probable mass or polyp as lead point in this age group, he was taken for exploratory laparotomy where a small polyp was discovered as the likely etiology of intussusception. He underwent resection of the portion of small bowel including the polyp in the ileum that served as a lead point. Biopsy of the polyp later revealed stage III Burkitt's lymphoma.

Discussion

Intussusception is the most common abdominal surgical emergency in children less than 2 years old. Its peak incidence is between 3 months and 3 years of age, but can also occur in older children. (1) Intussusception is commonly described as one portion of an intestine telescoping into itself. The proximal segment of bowel with associated mesentery telescopes into the distal segment, leading to venous and lymphatic congestion, edema, and eventually development of obstruction, ischemia, and perforation. A lead point is a focal area of intestine that is brought into and trapped in the distal segment of intestine. A Meckel's diverticulum, polyp, tumor, hematoma, or vascular malformation can act as a lead point for intussusception. The pathogenesis of intussusceptions in children is most often idiopathic. Increasing evidence sites possible viral triggers are leading to lymphatic hypertrophy in the intestine that acts as a lead point for intussusception. (2) In approximately 25 percent of cases, a pathologic lead point is present with a higher proportion of children less than 3 months or greater than 5 years of age. (4) Intussusception in older children and adults tends to occur and resolve spontaneously, rarely requiring specific intervention.

Intussusception most commonly presents as intermittent, colicky abdominal pain. Episodes may be associated with inconsolable crying or drawing up legs to the chest in younger patients. Vomiting may follow episodes of abdominal pain. The child may appear and feel relatively normal in between episodes of abdominal pain leading to potential early missed diagnosis. Eventually, as the disease and potential ischemic bowel process progress, children may develop lethargy and mimic sepsis or nervous system infection. A sausage-shaped mass may be palpated on the right side of the abdomen. Up to 70 percent of cases develop blood in stool that can mix with mucus to give the appearance of "currant jelly" stools. The classic triad of palpable mass, vomiting, and currant jelly stools is present in less than 15 percent of patients. (4)

Early diagnosis of intussusception can decrease the need for surgical intervention. Contrast enema was classically recommended as confirmatory imaging, but US is now recommended as the initial imaging test to diagnose or exclude intussusception. The superior performance, cost-effectiveness, safety, and patient comfort of ultrasound in the diagnosis of intussusception has led contrast enemas to be reserved for therapeutic purposes. Ultrasound sensitivity and specificity in the diagnosis of ileocolic intussusception may approach 100% in the hands of experienced operators. (5) The classic ultrasound finding is of a target sign and emergency physicians with limited training can accurately diagnose ileocolic intussusception in children by using bedside ultrasonography. (6) Abdominal x-rays are less sensitive and specific than ultrasound. Radiographic findings may include signs of bowel obstruction or a target sign consisting of two concentric radiolucent circles. More than 20 percent of intussusceptions can present with negative radiographs. (6) Therefore, with high clinical suspicion of this process, radiographs are not recommended to exclude diagnosis. CT scanning is typically reserved for those children where the diagnosis is inconclusive after other imaging modalities or to characterize the pathologic lead point. (7)

Stable patients with a high clinical suspicion for intussusception or those who have a confirmed diagnosis typically undergo non-operative reduction by hydrostatic or pressure enema. The success of this procedure is approximately 80 to 95 percent with ileocolic intussusception and is highest in populations with idiopathic intussusception with no identifiable lead point. (8) Prior to reduction, intravenous fluid resuscitation should be initiated and surgical consultation obtained, as there are risks associated with the reduction, such as perforation. Due to the risk of recurrent intussusception, these children should be observed in the hospital after procedure. Children displaying systemic toxicity or peritonitis may need to go directly to surgery.

Conclusion

Intussusception is an important diagnosis for the emergency physician to consider in at-risk patients. The sonographic findings are easily obtained and interpreted by emergency physicians even with limited training in bedside ultrasound. Earlier diagnosis of this disease process should lead to more focused patient evaluations, consultation and management, and improve outcomes.

Acknowledgements

Shelley Layman, MPH, and Anna Cantoni, WVU Department of Emergency Medicine

References

(1.) Ramachandran P. Chapter 49: Intussusception. In: Puri P, Hollwarth M. Pediatric Surgery Diagnosis and Management. New York: Springer; 2009:485-490.

(2.) Bhisitkul DM, Todd KM, Listernick R. Adenovirus infection and childhood intussusception. Am J Dis Child. 1992 Nov;146(11):1331.

(3.) Yamamoto LG, Morita SY, Boychuk RB, et al. Stool appearance in intussusception: assessing the value of the term "currant jelly." Am J Emerg Med 1997 May;15(3):293.

(4.) A.L. Hryhorczuk, P.J. Strouse. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radioi. 2009 Oct;39(10):1075-1079.

(5.) Riera A, Hsiao AL, Langhan ML, Goodman TR, Chen L. Diagnosis of intussusception by physician novice sonographers in the emergency department. Ann Emerg Med. 2012 Sep;60(3):264-8.

(6.) Weihmiller SN, Buonomo C, Bachur R. Risk stratification of children being evaluated for intussusception. Pediatrics. 2011 Feb;127(2):e296.

(7.) Navarro O, Daneman A. Intussusception. Part 3: Diagnosis and management of those with an identifiable or predisposing cause and those that reduce spontaneously. Pediatr Radioi. 2004 Apr; 34(4):305-312.

Justine Pagenhardt, MD

Department of Emergency Medicine, West Virginia University

Erica Shaver, MD

Department of Emergency Medicine, West Virginia University

Joseph Minardi, MD

Department of Emergency Medicine, West Virginia University

Nicole Dorinzi, MD

Department of Emergency Medicine, West Virginia University

Greta Hanks Massey, MD

Department of Emergency Medicine, Louisiana State University

Corresponding Author: Justine Pagenhardt, Department of Emergency Medicine, West Virginia University, 1 Medical Center Dr., Morgantown, WV 26506. Email: jpagenhard@hsc.wvu.edu.
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Title Annotation:Case Report
Author:Pagenhardt, Justine; Shaver, Erica; Minardi, Joseph; Dorinzi, Nicole; Massey, Greta Hanks
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1U5WV
Date:Nov 1, 2017
Words:1409
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