Copy CHH Case Presentation

INTUSSUSCEPTION
A Pediatric Case
Presentation
(Abella, Bugash, Coja,
Montinola, Rosales, Tocaldo)
GENERAL OBJECTIVE
To discuss a case of N.T, a 7 month old

child who presented with fever and
vomiting.
SPECIFIC OBJECTIVES
● To be able to present a thorough history, physical

examination of the case
● To be able to discuss the differential diagnoses of a
patient presenting with fever and vomiting
● To be able to discuss the approach to fever and
vomiting.
● To be able to discuss incidence, pathophysiology,
clinical features, diagnosis, and management of
intussusception.
HISTORY
7-month old infant

Birthdate: 11/13/2018
PE
PE
Male
FORMULATION
FORMULATION
Filipino
Roman Catholic
From Cebu City
COURSE
COURSE
Problem: Fever and

PATIENT Persistent vomiting
DISCUSSION
DISCUSSION
PROFILE
HISTORY
HISTORY
● Born to a 32-year old G1P0 mother
● Regular Prenatal check-up starting at around 20
weeks of gestation by a physician
PE
PE
● Ultrasound at 6th month of pregnancy: live, single

fetus in cephalic presentation
FORMULATION
FORMULATION
● Elevation of BP on the 8th month of pregnancy

with intake of unrecalled antihypertensive (highest
COURSE
BP: 140/90)
DISCUSSION
PRENATAL HISTORY
HISTORY
HISTORY
● Other medications: multivitamins, Iron and Folic
Acid
● No other maternal illnesses noted throughout
PE
PE
pregnancy
● Immunizations: 2 doses of Tetanus Toxoid
FORMULATION
FORMULATION
● No food and drug allergies

● No history of hospitalizations
COURSE
● No vices
● No other complications during pregnancy
DISCUSSION
PRENATAL HISTORY
HISTORY
HISTORY
● Born via NSD assisted by an obstetrician

● Delivered around 4 hours after rupture of
PE
PE
membrane with passage of clear amniotic fluid

● Full term, cephalic with birth weight of 3.4 kg
FORMULATION
FORMULATION
● AS unrecalled but mother claimed patient had a

good cry and had vigorous activity
● Other anthropometric measures and BS
COURSE
unrecalled
DISCUSSION
NATAL HISTORY
HISTORY
HISTORY
● No meconium staining, cord coiling or other

complications noted upod delivery
PE
● Given 1 dose of BCG, Vitamin K and Hepatitis B

PE
Vaccine at birth, as well as eye prophylaxis

FORMULATION
FORMULATION
● Roomed in with mother immediately after birth

and was discharged the next day
COURSE
● Birth rank: 1/1

● Blood type: O+
DISCUSSION
NATAL HISTORY
HISTORY
HISTORY
● Well-adjusted to extrauterine life: no jaundice,

cyanosis or signs of respiratory distress
● No congenital defects noted
PE
PE
● Vaccinations: 3 doses of DPT, IPV, HiB,

FORMULATION
FORMULATION
Hepatitis B and Pneumococcal disease

● Exclusively breastfed from birth
● Started complementary feeding by 4 months
COURSE
of age.
DISCUSSION
POSTNATAL HISTORY
HISTORY
HISTORY
● Diet: Rice porridge with smashed vegetables

● Newborn screening: unremarkable
● Developmental milestones include:
PE
PE
○ Able to raise head and smile at 1 month

○ Turns head to sound at 4 months
FORMULATION
FORMULATION
○ Raises head and rolls over at 5 months

○ No head lag at 6 months
COURSE
○ Sits with support at 7 months

DISCUSSION
POSTNATAL HISTORY
HISTORY
HISTORY
● No previous hospitalizations
● Sleeps about 10-12 hours at night and naps
PE
PE
in the day
● Regular bowel movement at 1-2x per day
FORMULATION
FORMULATION
● Regular bladder habits

● Live with the mother's family, along with the
grandparents and the aunt
COURSE
● No known heredofamilial disease.

DISCUSSION
PMH, PSH AND FAMILY HISTORY

HISTORY
5 DAYS PTA
● Onset of fever (Tmax=38.5 degrees
PE
Celsius)
● No associated signs and symptoms
FORMULATION
● No consult done
● Mother gave Paracetamol (Tempra) drops
COURSE
250mg/5mL 2mL by mouth every 4 hours

(AD = 10.4 mkd) with temporary relief.
DISCUSSION
HISTORY OF PRESENT ILLNESS

HISTORY
3 DAYS PTA
● Fever persisted
PE
● Vomiting of previously ingested food, non-

bilious, non-bloody about 10 episodes
FORMULATION
amounting to equal the intake

● Admission at Saint Anthony Mother and
COURSE
Child Hospital
DISCUSSION

HISTORY
3 DAYS PTA
● Passage of loose stools: dark brown in color,
PE
soft consistency, nonmucoid amounting to less

than ½ cup x 3-4 episodes
FORMULATION
● Vomiting previously ingested food, nonbilious,

nonbloody amounting to equal the intake x 3-4
episodes
COURSE
● Abdominal distention, loss of appetite and

weakness
DISCUSSION

HISTORY
3 DAYS PTA
● Labs taken:
○ CBC:
PE
■ RBC: 6.04
■ Hemoglobin: 10.68g/dL
FORMULATION
■ Hematocrit: 31.8%
■ Platelet: 261.1
■ Diff count: neutrophils=61.14%,
COURSE
Lymphocytes=30.9%, Monocytes=7.19%,
Basophils=0.58%, Eosinophils=0.19%
DISCUSSION

HISTORY
3 DAYS PTA
● Labs taken:
PE
○ Sodium: 134.8 mg/dL

○ Potassium: 3.68 mg/dL
FORMULATION
○ Urinalysis: yellow, cloudy with few bacteria

○ Stool exam: watery, brown, with 5-10
RBC/hpf and no ova and parasites
COURSE
visualized.
DISCUSSION

HISTORY
3 DAYS PTA
● Management:
PE
○ IV fluids
○ Unrecalled parenteral dose of GI medication
FORMULATION
○ Paracetamol (Tempra) drops 250mg/5mL 2mL

by mouth every 4 hours (AD = 10.4 mkd) for
fever.
COURSE
● No relief of abdominal distention and partial relief

of fever
DISCUSSION

HISTORY
DAY PTA
● Vomiting persisted: previously ingested food,
PE
nonbloody and non-bilious with amount still

equal to the intake
FORMULATION
● 3 episodes of jelly-like dark brown colored stool

in minimal quantities
● Persistence of fever and abdominal distention
COURSE
● Abdominal x-ray: Small bowel obstruction

DISCUSSION

HISTORY
HISTORY
Awake, drowsy T=36.6

Weight = 9.6 kg HR=135 bpm
(z-score: 0 to 2) RR= 39 cpm
PE
Length = 73 cm BP=80/50 mmHg

(z-score: 0 to 2) O2 sat = 99% at
FORMULATION
FORMULATION
WFA: 0 to 1 room air

BMI = 18.01
COURSE
COURSE
kg/m2 (z-score: 0 Good turgor and

to 1) mobility
DISCUSSION
DISCUSSION
HC = 43cm No rashes or
lesions
HISTORY
HISTORY
Supple Normocephalic,
In midline open and flat
No LAD anterior fontanel,
whitish sclerae,
PE
ECE pink palpebral

conjunctiva,
FORMULATION
FORMULATION
No retractions,
CBS eyes not sunken,
no naso-aural
Adynamic discharges, pink
COURSE
COURSE
precordium and moist oral

PMI: MCL 4th ICS mucosa, no
Distinct heart
DISCUSSION
DISCUSSION
growth of
sounds
deciduous teeth
No murmurs
Strong peripheral
HISTORY
HISTORY
pulses
Distended
CRT < 2 secs Hypoactive bowel
PE
Warm sounds
Abdominal girth of
FORMULATION
FORMULATION
56cm
No masses palpated
Grossly male, due to distention
COURSE
COURSE
Tanner stage I No guarding noted

DISCUSSION
DISCUSSION
HISTORY
HISTORY
Cerebral: awake
but drowsy
Cerebellar: well-
Lax sphincter tone
PE
coordinated
movements No mass in rectal
vault
FORMULATION
FORMULATION
Cranial nerves:
Intact (+) mucus in
Reflexes: 2+ examining finger
COURSE
Primitive
COURSE
Reflexes: Absent
DISCUSSION
DISCUSSION
HISTORY
HISTORY
No swallowing No persistent
problems itching or scratching
No cough or
PE
tachypneic No shortness of
episodes breath
FORMULATION
FORMULATION
Unremarkable
With bloated
abdomen with
COURSE
COURSE
No changes in vomiting of ingested

bladder habits food
DISCUSSION
DISCUSSION
REVIEW OF SYSTEMS
PRIMARY IMPRESSION
HISTORY
Intussusception
PE
RULE IN RULE OUT

FORMULATION
● 7 months old ● (-) Dance sign

● Intestinal obstruction:
vomiting, distended
abdomen with hypoactive
COURSE
bowel sounds
● Red currant jelly stool
● Abdominal x-ray showing
DISCUSSION
small bowel obstruction

DIFFERENTIAL DIAGNOSIS
HISTORY
Meckel Diverticulum
PE
RULE IN RULE OUT

FORMULATION
● 7 month old ● No associated vitelline duct

● GI bleeding anomalies
● Currant jelly colored stool
COURSE
● Vomiting
● Low hemoglobin
DISCUSSION
HISTORY
Shigellosis
PE
RULE IN RULE OUT

FORMULATION
● Fever ● Hypoactive bowel sounds

● Bloody, mucoid stools ● Leukocytes not increased
COURSE
DISCUSSION
HISTORY
Dengue Fever with Warning Signs

PE
RULE IN RULE OUT

FORMULATION
● Endemic ● No rashes, defervescence

● Consistent initial ● Low hematocrit
manifestations:
● Fever
COURSE
● Vomiting
● abdominal distension
● loss of appetite
DISCUSSION
● mucosal bleeding
DEFINITIVE DIAGNOSTICS
HISTORY
Abdominal Ultrasonography
PE
SUPPORTIVE DIAGNOSTICS
FORMULATION
● CBC ● Dengue NS1, IgM and

Blood IgG
Chemistry (Na, K) ● Blood Culture and
COURSE
● Blood Culture sensitivity

Abdominal X-ray ● Blood typing
● Stool exam and culture
DISCUSSION
DEFINITIVE MANAGEMENT
HISTORY
Surgical Reduction
PE
SUPPORTIVE MANAGEMENT
FORMULATION
Fluid Therapy
Surgical Prophylaxis
COURSE
NPO
Secure 1 unit PRBC
DISCUSSION
Insert NGT
Hospital day 1, 4th Day of Illness
S
HISTORY
(+) 3 episodes of vomiting, (+) 3 episodes of passage of

jelly-like stools
● HEENT: lymphadenopathy
O
PE
● Abdomen: distended, hypoactive bowel sounds,

abdominal girth of 56cm
FORMULATION
● DRE: lax sphincter tone, no mass in rectal vault, (+)

mucus in examining finger
A
COURSE
P
DISCUSSION
Problem: Fever and Persistent Vomiting 6/13/2019

S
HISTORY
Laboratories:
O
PE
UTZ(6/13/19): Consider intussusception with

enlarged lymph nodes.
FORMULATION
Xray(6/13/19)
● Chest: Dilated bowel loops in upper abdomen
region
A
COURSE
● Abdomen: Bowel gas pattern suggestive of distal

small bowel obstruction. P
DISCUSSION

S
HISTORY
O
PE
FORMULATION
Small Bowel Obstruction - T/C

Intussusception A
COURSE
P
DISCUSSION

1. For blood culture and sensitivity
S
HISTORY
2. Give oxygen
3. Monitor abdominal growth q shift
O
PE
4. PEWS monitoring
5. Start cefuroxime (Profurex)
FORMULATION
6. Give Metronidazole (flagyl)

7. Hgt every 8 hours A
8. For chest xray APL
COURSE
9. Secure 1 unit of PRBC

10. To proceed with explorative laparotomy P
DISCUSSION

Hospital day 2, 5th day of illness, Post op day: 1
S
HISTORY
(-) fever and vomiting

(-) loose bowel movements and recurrence of bilious vomiting
(-) episodes of desaturation.
O
PE
● Abdomen: soft non tender, with post op site on the

FORMULATION
abdomen with gross blood.
Surgical post op findings of:

A
COURSE
● (+)dilated bowel loops

● (+)congestion of appendix
● (+)ileocolic intussusception P
DISCUSSION

S
HISTORY
O
PE
FORMULATION
Partial Intestinal obstruction 2 to intussusception S/P

exploratory laparotomy, manual reduction of
intussusception, appendectomy. Patient clinically stable.
A
COURSE
P
DISCUSSION

1. Continue medications
S
HISTORY
2.Place on NPO, while on NGT and FBC.

3.Start IVF D5LR 500 ml at 60 ml/hr
5.Get Serum NA, K, blood culture results, chest and
O
PE
cord
6.Cefuroxime (Profurex) (AD:117 mkDay)
FORMULATION
7.Metronidazole (Flagyl) (AD: 39 mkDay)

500mg/100ml. A
COURSE
8.Ranitidine (Ulcin) 50mg/amp,

9.May decrease hgt monitoring to every 12 hours
10. Correct serum K with 3 bottles of D5IMB P
DISCUSSION

Hospital day 3, 6th day of illness, Post Op day: 2
S
HISTORY
(+)1 episode of bilious vomit any to 20 ml non bloody non mucoid

(+)good suck and latching
(-) recurrence of fever.
(+)dark yellow BM.
O
PE
● C/L: harsh breath sounds

● Abdomen: soft, non tender. Has clean dressing on
FORMULATION
post op site.
A
COURSE
P
DISCUSSION

S
HISTORY
O
PE
FORMULATION

exploratory laparotomy, manual reduction of
intussusception, appendectomy. Patient clinically stable.
A
COURSE
P
DISCUSSION

1.Decrease IVF rate
S
HISTORY
2.Repeat serum NA and K

3.Remove FBC and NGT
O
PE
4.Resume breastfeeding
5. Discontinue HGT monitoring
FORMULATION
6. Abdominal girth daily

A
COURSE
P
DISCUSSION

4th Hospital day, 7th Illness day, 3rd Post-op day
S
HISTORY
5-8 episodes of bilious vomiting amounting to 10-50mL/episodes

2 episodes of bowel movements of 200mL, light green in color.
● Awake, alert, not in respiratory distress with the following

O
PE
vital signs: T: 36.5 PR: 111 RR: 26 02 Say: 100%

● C/L: clear breath sounds, (-) Retractions, (+) Productive
FORMULATION
cough noted
● ABD: Globular, soft, clean dressing on post-op site, A
hyperactive, soft
COURSE
● EXT: CRT <2secs, Strong peripheral pulses

● NGT drainage was 17mL. P
DISCUSSION

S
HISTORY
CBC Laboratory Result:

O
PE
● Increased RBC: 4.56 (Reference Range: 3.7-4.5)

● Increased Platelet: 720 (Reference range: 150-350)
FORMULATION
● Decreased Hemoglobin: 10.2 (Reference Range: 10.5-

12)
● Decreased Hematocrit: 31.7 (Reference Range: 33-36)
A
COURSE
● Decreased MCV: 60 (Reference Range: 70-78)

● Decreased MCH: 22.4 (Reference Range: 23-27)
P
DISCUSSION

S
HISTORY
O
PE
FORMULATION

exploratory laparotomy, manual reduction of intussusception,
appendectomy. Patient clinically stable.
A
COURSE
P
DISCUSSION

1. Increase IVF fluid rate to 40cc/hr.
S
HISTORY
2. Replace all GI losses with PLR volume per volume

replacement. Give 50mL over 1 hour.
3. Monitor HGT every 8 hours.
O
PE
4. Please reinsert NGT French 10, open to drain. Please

FORMULATION
chart all loses and replace every 4 hour

5. Give Salbutamol (Ventolin) 2.5mg/2.5mL neb, 1 neb
(AD: 0.26 mkd) every 8 hours via face mask.
A
COURSE
6. For repeat CBC.

7. Watch out for episodes of billous vomiting. Refer if
there’s any.
P
DISCUSSION

8. Hold NGT insertion for now.
S
HISTORY
9. Keep on NPO.
10. Encourage parents to carry the patient.
O
PE
11. Measure abdominal girth every 4 hours and record.

12. IVF of 100mL of PLR in 1 hour.
FORMULATION
13. For abdominal xray flat plate and lateral.

14. IVFTF: d5IMB 500mL at 20mL/hour. A
COURSE
15. Give Ranitidine (Ulcin) 25mg/mL, 10mg/0.4mL via

IVTT every 8hours. (AD: 3.13 mkD)
P
DISCUSSION

S
HISTORY
5th Hospital day, 8th Illness Day, 4th Post-op day
(+) 7 vomiting episodes with bilious material. Bowel movement of 4
episodes with greenish.

O
PE
vital signs: T: 36.8 HR: 119 RR: 35 O2 sat: 100%

● SKIN: warm, good turgor and mobility
FORMULATION
● C/L: clear breath sounds, (-) Retractions

● ABD: Globular, Clean dressing per post-op site, A
COURSE
hyperactive bowel sounds, soft.

P
DISCUSSION

S
HISTORY
● NGT drainage of ~ 200mL greenish (bilious)

O
PE
drain.
● Blood culture (-) for 4 days.
FORMULATION
● ABDOMINAL XRAY RESULT: Interval resolution

of small bowel obstruction. Interval resolution of
A
COURSE
feeding tube in place.

P
DISCUSSION

S
HISTORY
O
PE
FORMULATION

A
COURSE
P
DISCUSSION

1. Run 100cc PLR for 1 hour.
S
HISTORY
2. Replace all loses with PLR vol per vol replacement.

3. IVFTF: d5IMB 500mL @ 40cc/hour.
4. Please chart and record at chart the NGT Drainage
O
PE
every shift.
FORMULATION
5. Start d10 IMB prepared as follows:

D50Water – 18mL, D5IMB – 100mL, Amino Acid 6% - 27mL
Total: 145mL refill every 4 hours to run at 35cc/hour using
A
COURSE
infusion pump.
6. Please refer HGT >140mg/dl.
7. Change NGT.
P
DISCUSSION

S
HISTORY
6th Hospital day, 9th Illness day, 5th Post-op day
(-) vomiting after NGT was removed and changed, defecation yellow in
color, still in NPO

O
PE

FORMULATION
● HEENT: Anicteric sclerae, (-) LAD

● C/L: clear breath sounds, (-) Retractions A
● ABD: Globular, soft, normoactive bowel sounds
COURSE

● NGT Drainage of 104mL. P
DISCUSSION

S
HISTORY
O
PE
FORMULATION

A
COURSE
P
DISCUSSION

1. Watch out for any recurrence of vomiting.
S
HISTORY
Refer if there’s any.

2. Run 100mL of PLR in 1 hour for the GI LOSS.
O
PE
3. Remove NGT.
FORMULATION
A
COURSE
P
DISCUSSION

7th Hospital day, 10th Illness day, 6th Post-op day
S
HISTORY
No recurrence of vomiting after NGT was removed.

O
PE

FORMULATION
● HEENT: Anicteric sclerae, (-) LAD

● C/L: clear breath sounds, (-) Retractions A
● ABD: Globular, soft, normoactive bowel sounds
COURSE

● NGT drain of 50mL before NGT was removed. P
DISCUSSION

S
HISTORY
O
PE
FORMULATION

A
COURSE
P
DISCUSSION

1. Remove NGT.
S
HISTORY
2. Run 50ml PLR for 1 hour.

3. Measure abdominal girth.
O
PE
4. Discontinue HGT monitoring.

5. Continue IVF d5IMB 500 mL @20mL/hr.
FORMULATION
6. May start direct breastfeeding. 10min per

feeding/breast.
A
COURSE
7. Decrease Salbutamol (Ventolin) 2.5mg/2.5mL neb,

1 neb (AD: 0.26 mkd) every 12 hrs via face mask. P
DISCUSSION

INTUSSUSCEPTION
HISTORY
HISTORY
Epidemiology
PE
PE
● most common cause of

intestinal obstruction between
FORMULATION
FORMULATION
5 months and 3 yr of age

● most common abdominal
Etiology
COURSE
emergency in children
Approximately 90% of younger than 2 yr.
cases of intussusception
DISCUSSION
● Occurs more frequently in

in children are idiopathic. males
DISCUSSION COURSE FORMULATION PE HISTORY
Pathogenesis
HISTORY
Risk Factors
● Presence of pathological lead point
PE
● Abdominal surgery or trauma

● Rotavirus vaccine- associated with 1 in
FORMULATION
34,000 risk of intussusception in first week

following vaccination
COURSE
● Bacterial and parasitic infections

● Antibiotic use
DISCUSSION
HISTORY
Clinical Manifestations
● Sudden intermittent abdominal pain
● Palpable abdominal mass (RUQ)
PE
● Bilious vomiting
● Rectal passage of mucus and blood (“currant
FORMULATION
jelly” stools)
● Altered mental status
COURSE
DISCUSSION
HISTORY
Types
● Antegrade
● Retrograde
PE
● Jejunogastric
FORMULATION
Diagnostics
● Abdominal Ultrasound
COURSE
● Abdominal Xray
● Contrast Enemas
(coiled-spring sign)
DISCUSSION
HISTORY
Management
● Correct Hemodynamic Instability
PE
● Proceed to Non Operative

Reduction
FORMULATION
● If Non Operative Reduction fails,

resection of the intussusception
is necessary, with end-to-end
COURSE
anastomosis
DISCUSSION
FINAL DIAGNOSIS
Partial Intestinal obstruction secondary

to intussusception
S/P exploratory laparotomy, manual
reduction of intussusception,
appendectomy

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INTUSSUSCEPTION

To discuss a case of N.T, a 7 month old

● To be able to present a thorough history, physical

7-month old infant

Problem: Fever and

● Ultrasound at 6th month of pregnancy: live, single

● Elevation of BP on the 8th month of pregnancy

● No food and drug allergies

● Born via NSD assisted by an obstetrician

membrane with passage of clear amniotic fluid

● AS unrecalled but mother claimed patient had a

● No meconium staining, cord coiling or other

● Given 1 dose of BCG, Vitamin K and Hepatitis B

Vaccine at birth, as well as eye prophylaxis

● Roomed in with mother immediately after birth

● Birth rank: 1/1

● Well-adjusted to extrauterine life: no jaundice,

● Vaccinations: 3 doses of DPT, IPV, HiB,

Hepatitis B and Pneumococcal disease

● Diet: Rice porridge with smashed vegetables

○ Able to raise head and smile at 1 month

○ Raises head and rolls over at 5 months

○ Sits with support at 7 months

● Regular bladder habits

● No known heredofamilial disease.

PMH, PSH AND FAMILY HISTORY

250mg/5mL 2mL by mouth every 4 hours

HISTORY OF PRESENT ILLNESS

● Vomiting of previously ingested food, non-

amounting to equal the intake

HISTORY OF PRESENT ILLNESS

soft consistency, nonmucoid amounting to less

● Vomiting previously ingested food, nonbilious,

● Abdominal distention, loss of appetite and

HISTORY OF PRESENT ILLNESS

HISTORY OF PRESENT ILLNESS

○ Sodium: 134.8 mg/dL

○ Urinalysis: yellow, cloudy with few bacteria

HISTORY OF PRESENT ILLNESS

○ Paracetamol (Tempra) drops 250mg/5mL 2mL

● No relief of abdominal distention and partial relief

HISTORY OF PRESENT ILLNESS

nonbloody and non-bilious with amount still

● 3 episodes of jelly-like dark brown colored stool

● Abdominal x-ray: Small bowel obstruction

HISTORY OF PRESENT ILLNESS

Awake, drowsy T=36.6

Length = 73 cm BP=80/50 mmHg

WFA: 0 to 1 room air

kg/m2 (z-score: 0 Good turgor and

ECE pink palpebral

precordium and moist oral

Tanner stage I No guarding noted

No changes in vomiting of ingested

RULE IN RULE OUT

● 7 months old ● (-) Dance sign

small bowel obstruction

RULE IN RULE OUT

● 7 month old ● No associated vitelline duct

RULE IN RULE OUT

● Fever ● Hypoactive bowel sounds

Dengue Fever with Warning Signs

RULE IN RULE OUT