It’s mid-morning in the Pediatric ED, and business has been steady. The phone keeps ringing – referrals, follow-ups, pharmacies. It feels as though you are spending more time with patients who are not in the ED than with patients who are. Your resident fidgets as he waits for you to get off the phone, ready to present the next case. Finally he has your attention, then, you guessed it, another phone call. This time, it’s your Pediatric Radiology attending. He has been reviewing the films read by the upper level resident last night and he wants to alert you that the final read of one of the studies has been changed. You sigh and get ready to take down the information. The study was an abdominal US to evaluate abdominal pain. The initial reading was your basic “negative study, no appendicitis.” The reason for the re-read is a small bowel intussusception that the overnight radiology resident had missed. It is in the left lower quadrant and measures 1.3 cm. So what do you do with that? Is it time for you to gear up?
You know what to do with your typical ileo-colonic intussusception. If the child has peritonitis or is severely ill, they go to the OR. The vast majority will go to radiology with a surgery resident standing by. They will get a contrast or air enema to attempt reduction, which usually works. Then they get admitted for observation in case of recurrence. If the reduction doesn’t work, they go to the OR. That’s the drill, you’ve done this dozens of times.
But this is a small bowel intussusception. An enema probably isn’t going to work. Does it need to? Does the kid need to go to the OR then? What is the significance of a small bowel intussusception in a child?
In the past, patients in whom you suspected an intussusception were packed off to radiology to get an enema, which was diagnostic as well as therapeutic. That’s increasingly not the case anymore. At many institutions, ultrasound is now the modality of choice for the diagnosis of intussusception. And with the increased use of ultrasound, more small bowel intussusceptions are being found. Some of them are assymptomatic and transient, truly incidental findings of limited significance. Those patients can be managed expectantly. Some are symptomatic, in which case the length of the intussusception helps guide the management.
If the small bowel intussusception is short, less than 3.5 cm in length, it may resolve spontaneously. Plan for IV fluids, pain management and serial examinations. If the patient remains symptomatic, nonoperative reduction by radiology is not likely to work and the patient will need operative treatment. If the small bowel intussusception is longer than 3.5 cm it is not likely to resolve spontaneously and will need operative management. In either case, it makes sense to get the surgeons involved early.
You pull the chart from last night and review it. The patient is a 5-year-old girl who had one day of waxing and waning abdominal pain and vomiting when she presented to the ED last night. Her exam and work-up were felt to be unremarkable at the time (Hey, they didn’t know about the re-read of the US) and she tolerated a po challenge in the ED and felt better, so she was sent home. So far, so good. Patients with small bowel intussusception are typically older than patients with ileo-colonic intussusception, 80 percent of whom are younger than two. Patients with small bowel intussusception are most likely to present with just abdominal pain and vomiting. They are unlikely to have blood in their stools and somewhat less likely to have a sausage-shaped abdominal mass than their ileo-colonic counterparts.
This child was symptomatic last night, so this cannot be considered an incidental finding. You phone the family to see how she is doing today. They report that she is still experiencing abdominal pain and vomiting. You advise the family to bring her back to the ED where you make plans to repeat the ultrasound. You give the surgery resident the “heads up” so she is expecting a consult from you. With increased use of ultrasound, small bowel intussusception is becoming more frequently recognized. It is more likely to resolve spontaneously than intussusception involving the colon. It occurs in older kids than your typical colonic intussusception. It can be assymptomatic. The most important predictor of whether it will need to go the OR is length greater than 3.5 cm. Make sure you have a surgeon involved early if the child has symptoms.
Amy Levine, MD, is an associate professor of pediatric emergency medicine at UNC Chapel Hill