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. The appropriate procedure is performed and the intussusception is reduced successfully. After about an hour of rest, the patient experiences acute onset of severe abdominal pain. Which of the following is the best next step in immediate 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.  The appropriate procedure is performed and the intussusception is reduced successfully.  After about an hour of rest, the patient experiences acute onset of severe abdominal pain.  Which of the following is the best next step in immediate management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf41_be99_8f63_c3b0f38d7962_MD0005_00 The resulting venous and lymphatic congestion in intussusception can cause significant intestinal edema and may result in bowel ischemia and perforation. Intestinal perforation is also the primary risk of nonoperative reduction of intussusception with therapeutic enema, although it is rare overall (<1% incidence). Children who have had symptoms for several days, those with evidence of small bowel obstruction, and those age <6 months are at greatest risk of this complication. An air (pneumatic) enema is generally preferred for initial reduction as it tends to be fast, thereby minimizing radiation exposure. In addition, perforations from air enemas tend to be smaller than from those occurring with water-soluble (hydrostatic) or barium enemas. Air, unlike other contrast mediums, is not harmful to the contents of the peritoneal cavity. Intestinal perforation results in severe abdominal pain and possible signs of peritonitis (eg, rebound, guarding). Diagnosis can be confirmed by radiographs of the abdomen in the upright or lateral decubitus positions that demonstrate the presence of free air. Treatment of intestinal perforation involves immediate surgical repair. (Choice A) Intussusception recurs in approximately 10% of patients who undergo nonoperative reduction. If recurrent intussusception is confirmed by ultrasound, repeat air enema may be indicated, but reduction should be performed only after excluding intestinal perforation. (Choice B) CT scan of the abdomen can also demonstrate the presence of free air from perforation, but plain radiographs can often be obtained more quickly and involve less radiation. (Choice C) Intravenous antibiotics are indicated in cases of intestinal perforation to cover gastrointestinal flora. However, unless the patient appears septic, antibiotics are given after the diagnosis is confirmed by imaging. (Choice E) Although ultrasound of the abdomen can demonstrate free air, radiographs are preferred and are less operator dependent than ultrasound. If no free air is demonstrated on radiography, ultrasound may be considered to evaluate for recurrent intussusception. Educational objective: Intestinal perforation is a potential complication of enema reduction of intussusception. Patients with acute pain after reduction should undergo radiographs of the abdomen to rule out intestinal perforation. References: Meta-analysis of air versus liquid enema for intussusception reduction in children. (http://www.ncbi.nlm.nih.gov/pubmed/26496576)

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