248 Chapter 9: Gastrointestinal emergencies

Follow-up
! Hepatomegaly without jaundice or ill appearance: primary care follow-up in one week

Indications for admission

! Signs and symptoms of hepatic failure
! Severe vomiting that prevents adequate oral intake
! Suspicion of serious disease (leukemia, heart failure, cirrhosis, etc.) for evaluation and
management

Bibliography Mishra A, Pant N, Chadha R, Choudhury SR:

Clayton PT: Diagnosis of inherited disorders of liver
metabolism. J Inherit Metab Dis 2003;26:
135–46.
Choledochal cysts in infancy and childhood.
Indian J Pediatr 2007;74:937–43.
Wolf AD, Lavine JE: Hepatomegaly in neonates and
children. Pediatr Rev 2000;21:303–10.

Intussusception
Intussusception is the most frequent cause of intestinal obstruction in infants over 3 months
of age. It can occur at any age, although 60% of patients are <1 year and 80% are <2 years of
age. Anatomically, there is an invagination of one part of the bowel into the lumen of the
distal adjoining part. Although the most common type is an ileocolic, intussusception may
occur at any level of the GI tract.
In the majority of cases, no etiology for the intussusception can be identified. However,
a lead point such as a polyp, lymphoma, Meckel’s diverticulum, or bowel hematoma (as in
Henoch-Schönlein purpura) is present in 5–10% of cases, especially in those >6 years of
age. Mesenteric venous engorgement due to compression between the layers of the intus-
suscepted bowel causes mucous secretion and blood seepage, leading to the typical currant
jelly stools. If the compression is not relieved, necrosis of the bowel with subsequent
perforation and peritonitis can occur.

Clinical presentation
Intussusception usually presents with the acute onset of intermittent abdominal pain and
vomiting in a previously well infant. The classic triad of colicky abdominal pain, vomiting,
and bloody stool is present in only about 25% of cases. The pain lasts from 1 to 5 minutes,
recurring every 5–20 minutes. During these paroxysms the baby may cry out, draw up
his/her legs, and appear extremely uncomfortable. In between episodes the patient may
initially appear well, but eventually becomes lethargic and apathetic. Vomiting follows
the pain and, in the case of an ileoileal intussusception, may contain bile and suggest an
intestinal obstruction. Classic currant jelly stools are present early in only 10%. In some
cases, a currant jelly stool is found only with a rectal examination. Constipation, nonspecific
diarrhea, and fever may also occur. With recurrent intussusception and spontaneous
reduction, symptoms may be subacute or chronic over a period of a few days to weeks.
Initially the abdomen is soft between episodes of pain, but later it becomes distended and
tender. In 85% of cases a sausage-like mass can be palpated in the right lower quadrant or
upper abdomen. When the intussusception has progressed into the transverse colon, there
may be absence of palpable viscera in the right lower quadrant (Dance’s sign). An abdominal
 Chapter 9: Gastrointestinal emergencies 249

mass may be appreciated on rectal examination and stool for occult blood is positive in 75%
of cases. Bowel sounds are initially hyperactive and then become hypoactive or absent.
Occasionally lethargy will be the most prominent presenting sign. A history of crampy
abdominal pain and vomiting demands a careful physical examination for an abdominal
mass and rectal bleeding. Consider the possibility of intussusception in any child with
altered mental status.

Diagnosis
If the clinical suspicion of intussusception is high, prompt confirmation is necessary, as persist-
ence of the intestinal obstruction may increase the child’s risk for surgical intervention. Prone
and supine plain abdominal radiographs are a useful screening tool. Normally, the transverse
colon and rectosigmoid are filled with air when a patient is supine; the ascending and descending
colons are air-filled when prone. The inability to fill the ascending colon is highly suggestive of
intussusception, while the leading edge of the intussusceptum may be seen as a curvilinear
density in the transverse colon. The diagnosis can be confirmed with an ultrasound, looking for
the target sign on transverse view and the pseudokidney sign on longitudinal view. In addition,
color Doppler can be used to assess blood flow to the involved segment of bowel.
Ultimately, a contrast enema, preferably with air, is both the diagnostic and therapeutic
procedure of choice. In up to 90% of cases, the enema will reduce the intussusception.

ED management
If intussusception is suspected, immediately notify a pediatric surgeon and radiologist.
Insert an IV and give a bolus of 10–20 mL/kg of NS, followed by maintenance fluids. Timely
diagnosis and intervention are paramount. If the patient is stable, obtain an air contrast
enema as soon as possible. However, if intussusception is confirmed and there are signs of
perforation or peritonitis, start IV piperacillin–tozobactam (<6 months of age: 200 mg/kg
per day div q 6 h; >6 months of age: 350 mg/kg per day div q 6 h, 3 g/dose maximum) and
prepare for emergency laparotomy. Surgery is also indicated if the radiologist is unsuccess-
ful in reducing the intussusception.
Admit all patients with suspected or confirmed intussusception, as the immediate
recurrence risk is about 10%. The majority of recurrent cases occur in the first 24 hours
following reduction.

Indication for admission

! Suspected intussusception

Bibliography McCollough M, Sharieff GQ: Abdominal pain

in children. Pediatr Clin North Am 2006;
Cera SM: Intestinal intussusception. Clin Colon 53:107–37.
Rectal Surg 2008;21:106–13.

Jaundice
The goals of the ED evaluation of the icteric child include rapid diagnosis of the acutely
treatable causes of jaundice (sepsis, obstruction, metabolic disease), identification of patients
in acute or impending liver failure, prophylaxis of susceptible contacts when icterus is caused
by viral hepatitis, and reassurance when jaundice is physiologic or related to breast feeding.