A 2-year-old boy is brought to the emergency department by his grandmother due to abdominal pain and lethargy. The grandmother reports that he was playing calmly last night when he suddenly began screaming and holding his abdomen. The pain resolved after several minutes, but the patient has had 5 additional episodes of sudden-onset, severe pain since then. Today, the grandmother notes that he has no interest in eating or drinking and has been "sleeping all day" but intermittently awakens in pain. The patient has also had several episodes of nonbloody, nonbilious emesis and "fewer wet diapers than usual." He has had no fever, diarrhea, or recent infections. He is an otherwise healthy child with no prior hospitalizations or chronic medical conditions. The patient takes no medications, and his immunizations are up to date. Temperature is 37 C (98.6 F), blood pressure is 90/56 mm Hg, pulse is 160/min, and respirations are 24/min. During the examination, the boy is sleeping and arouses briefly. The abdomen has hypoactive bowel sounds and diffuse mild tenderness to palpation. He is circumcised, with both testes descended and with intact cremasteric reflexes. Immediately after the examination, the child passes blood in his diaper, as shown in the image below.
X-ray of the abdomen reveals dilated loops of bowel and no free air. Which of the following is the best next step in management of this patient?

Question

A 2-year-old boy is brought to the emergency department by his grandmother due to abdominal pain and lethargy.  The grandmother reports that he was playing calmly last night when he suddenly began screaming and holding his abdomen.  The pain resolved after several minutes, but the patient has had 5 additional episodes of sudden-onset, severe pain since then.  Today, the grandmother notes that he has no interest in eating or drinking and has been "sleeping all day" but intermittently awakens in pain.  The patient has also had several episodes of nonbloody, nonbilious emesis and "fewer wet diapers than usual."  He has had no fever, diarrhea, or recent infections.  He is an otherwise healthy child with no prior hospitalizations or chronic medical conditions.  The patient takes no medications, and his immunizations are up to date.  Temperature is 37 C (98.6 F), blood pressure is 90/56 mm Hg, pulse is 160/min, and respirations are 24/min.  During the examination, the boy is sleeping and arouses briefly.  The abdomen has hypoactive bowel sounds and diffuse mild tenderness to palpation.  He is circumcised, with both testes descended and with intact cremasteric reflexes.  Immediately after the examination, the child passes blood in his diaper, as shown in the image below.  
X-ray of the abdomen reveals dilated loops of bowel and no free air.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf40_fb47_8f63_234f7ab55169_MD0005_00 This child's presentation is concerning for intussusception, which involves telescoping of a proximal portion of the intestine into a distal portion. This telescoping typically occurs due to lymphoid hyperplasia (Peyer patches) in the setting of viral infection or a pathologic lead point (eg, Meckel diverticulum). Most cases occur from age 6 months to 3 years. The most common presenting symptom is severe, intermittent, crampy abdominal pain accompanied by nonbilious emesis and drawing up of the legs to the abdomen. The classic clinical triad, seen in only 15% of patients, also includes a palpable sausage-shaped mass in the right abdomen (eg, telescoped bowel) and "currant jelly" stools (a late finding indicating bowel ischemia). When the presentation is unclear, ultrasonography is the imaging methodology of choice. The characteristic finding is a "target sign". Ultrasonography is not required in patients with a classic clinical presentation (as seen in this patient). However, radiographs of the abdomen should be considered to rule out intestinal perforation (eg, free air under the diaphragm). Radiographs may demonstrate findings of small bowel obstruction (dilated bowel loops with air-fluid levels). "target sign" After intestinal perforation has been ruled out, treatment of intussusception typically involves nonoperative reduction via air (pneumatic) or water-soluble (hydrostatic contrast) enema. These procedures allow for direct visualization of the intussuscepted bowel and are therefore both diagnostic and therapeutic. Surgical reduction is indicated if nonoperative reduction is unsuccessful. If a pathologic lead point is identified, elective surgery for removal of the lead point may be indicated. (Choice B) Barium contrast enemas were traditionally used for reduction of intussusception, but are no longer preferred given the risk of peritonitis if perforation occurs. (Choice C) Although CT scan of the abdomen can diagnose intussusception, ultrasonography is preferred given its high sensitivity and lack of associated radiation. (Choice D) A technetium-99m scan can highlight ectopic gastric mucosa within a Meckel diverticulum, which presents with painless rectal bleeding. Although Meckel diverticulum can sometimes be a lead point, hypertrophied Peyer patches are usually the nidus for intussusception. (Choice E) An upper gastrointestinal series is the radiologic test of choice to evaluate for intestinal malrotation and volvulus. Although malrotation can present with severe abdominal pain, vomiting is typically bilious. Educational objective: Intussusception occurs in children age 6 months to 3 years and presents with severe, episodic, crampy abdominal pain; emesis; and "currant jelly" stools. Air or water-soluble contrast enema is the gold standard for diagnosis and treatment of this condition. References: Intussusception in children: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/26559998) Intussusception. (http://www.ncbi.nlm.nih.gov/pubmed/19018227)

A 2-Year-Old Boy Is Brought to the Emergency Department by His