Intermittent Abdominal Pain in a Toddler
20-month-old boy is brought after 14 hours of intermittent inconsolable crying with drawing up of the legs. He had three episodes of nonbilious vomiting and one bloody, mucoid stool. He is lethargic but arousable. Temperature 37.8°C, heart rate 150, blood pressure 90/55, respiratory rate 32. Abdomen is mildly distended and tender in the right upper quadrant, without rebound or guarding. Plain radiograph shows a nonspecific bowel gas pattern and no free air. Ultrasound demonstrates a 3.2-cm target sign in the right lower quadrant with preserved Doppler flow and no free fluid. He has no prior abdominal surgery. The surgical team is in the OR and asks whether to take him now, obtain CT, or attempt a fluoroscopic enema. The family is anxious and asks about radiation.
1. What is the diagnosis and preferred next management? Why is CT not the best choice?
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The diagnosis is ileocolic intussusception. In a stable child without peritonitis, perforation, or shock, the preferred next step is fluoroscopically guided air enema, which is both diagnostic and therapeutic. CT would confirm the diagnosis but adds radiation and delays reduction; ultrasound already shows a target sign. The child should be resuscitated and the enema performed with surgical backup. Contrast enema is an alternative if air is not available. Immediate surgery is reserved for perforation, peritonitis, shock, or failed reduction.
2. The enema reduces the mass to the ileocecal valve but does not completely reduce it. What now?
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If the intussusception reduces to the ileocecal valve but does not completely reduce, repeat the enema with careful technique and adequate pressure rather than proceeding immediately to CT. Many ileocolic intussusceptions reduce with a second attempt. If it still fails, or if the child deteriorates, stop and call surgery. Complete reduction should be confirmed by free reflux of air or contrast into the terminal ileum and resolution of the mass.
3. What findings would make you stop the enema and call surgery?
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Stop the enema for suspected perforation, development of tension pneumoperitoneum, worsening peritonitis, hemodynamic instability, or a lead point such as a polyp or mass. Failure after adequate attempts also leads to surgery. A recurrent intussusception after successful reduction can often be treated with a repeat enema if the child remains stable; recurrent episodes or age over 2 years raise concern for a pathologic lead point and may warrant surgical evaluation.