Rosen & Barkin's 5-Minute Emergency Medicine Consult (398 page)

• Fever
  
• Abdomen distended and swollen:
  
  • A “sausage” mass may be palpated in the right upper quadrant.
    
  • May have absent cecum in right iliac fossa.
    
  • Peristaltic wave may be present.
    
  • Rectal exam may reveal bloody stool and palpable mass.
    
• Dependent on the time from onset to diagnosis; perforation with peritonitis and sepsis may be present.
  

• The diagnosis is suggested by the history and is proven radiographically.
  
• A heme-positive stool may aid in the diagnosis, particularly in the presence of lethargy or listlessness.
  

• CBC
  
• Serum electrolytes, BUN
  
• Type and cross-match
  

• Abdominal radiograph:
  
  • Abnormal in 35–40% of patients
    
  • Decreased bowel gas and fecal material in the right colon
    
  • Abdominal mass
    
  • Apex of intussusceptum outlined by gas
    
  • Small bowel distention and air–fluid levels secondary to mechanical obstruction
    
  • May aid in excluding intestinal perforation.
    
• Enema:
  
  • Often both diagnostic and therapeutic. Reoccurrences do happen.
    
    • 74% successful if intussusception present ≤24 hr
      
    • 32% effective when present >24 hr
      
    • The more distal the intussusception, the lower is the ability to reduce it radiographically.
      
    • Recurrent disease (up to 10%) has similar success to initial episode.
      
  • Complications include bowel perforation, reduction of necrotic bowel, incomplete reduction with delay in surgery, and overlooking pathologic lead point.
    
  • Hypovolemic shock reported following reduction secondary to endotoxins and cytokines.
    
  • Barium:
    
    • Traditional standard for diagnosis and treatment
      
    • Characteristic coiled-spring appearance
      
  • Air:
    
    • Fluoroscopic guidance
      
    • Avoids peritoneal contamination if perforation
      
    • Increasingly used for diagnosis and treatment
      
  • Contraindications:
    
    • Peritonitis
      
    • Perforation
      
    • Unstable patients secondary to sepsis or shock
      
• US is highly accurate and may be useful as a screening technique; operator dependent:
  
  • Typical appearance is a “donut” or “bull’s eye” structure, with hyperechoic core surrounded by hypoechoic rim of homogeneous thickness.
    

If enema is unsuccessful in reducing, surgery is required on an emergent basis.

• Infection
  
• Acute gastroenteritis
  
• Appendicitis
  
• Inflammatory bowel disease
  
• Infectious mononucleosis
  
• Pneumonia
  
• Pharyngitis/group A streptococcal
  
• Pyelonephritis
  
• Colic
  
• Intestinal obstruction/peritonitis
  
• Strangulated hernia
  
• Malrotation/volvulus
  
• Hirschsprung disease
  
• Trauma
  
• Intestinal vascular/hemorrhagic disorder
  
• Anal fissure/hemorrhoids
  
• Ulcer disease
  
• Vascular malformations
  
• Henoch–Schönlein purpura
  
• Polyp
  
• Protein-sensitive enterocolitis
  
• Diabetes mellitus
  
• Coagulopathy
  

TREATMENT

• IV access
  
• IV bolus of 20 mL/kg of 0.9% NS or lactated Ringer (LR) if evidence of hypovolemia, abdominal distention, peritonitis, sepsis
  
• Diagnosis rarely confirmed in pre-hospital setting
  

• IV access and initiation of 0.9% NS or LR at 20 mL/kg bolus
  
• Nasogastric tube
  

• Stabilize patient hemodynamically.
  
• Surgical consultation
  
• Abdominal radiograph film series
  
• Interventional radiography for reduction if no contraindications:
  
  • Enemas are 75–80% successful at reduction, reflecting duration of condition.
    
  • Recurrences may also be reduced radiographically.
    
• Antibiotics:
  
  • Initiate if evidence of peritonitis, perforation, or sepsis.
    
  • Ampicillin, clindamycin, and gentamicin
    
  • Ampicillin/sulbactam
    
• Laparotomy:
  
  • Indications:
    
    • Enema is unsuccessful.
      
    • Enema is contraindicated.
      
    • Pathologic lead point
      
    • Multiple recurrences
      
  • Procedure:
    
    • Gentle milking of the intussusceptum
      
    • Resection of any nonviable bowel as well as any lead points that are identified
      

• Ampicillin: 100–200 mg/kg/d q4h IV
  
• Clindamycin: 30–40 mg/kg/d q6h IV
  
• Gentamicin: 5–7.5 mg/kg/d q8h IV
  
• Ampicillin/sulbactam 100–200 mg/kg/d q6h IV
  

FOLLOW-UP

• Patients undergoing successful enema reduction should be observed for complications or recurrence.
  
• Patients undergoing surgery
  

• May be considered after a
  very prolonged
  period of observation following successful enema reduction:
  
  • Stable patient with normal mental status
    
  • Symptomatic relief of abdominal pain during the postreduction period
    
  • Parents have appropriate understanding to watch for potential reoccurrence, even after prolonged period observation
    

Surgeon should be aware of patients with potential diagnosis of intussusception.

Infants with intermittent abdominal pain, impaired mental status, and blood in stools should generally have intussusception considered.

• Bajaj L, Roback MG. Postreduction management of intussusception in a children’s hospital emergency department.
  Pediatrics
  . 2003;112:1302–1307.
  
• Hryhorczuk AL, Strouse PJ. Validatiion of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception.
  Pediatr Radiol.
  2009;39:1075–1079.
  
• Kleizen KJ, Hunck A, Wijnen MH, et al. Neurological symptoms in children with intussusception.
  Acta Paediatr.
  2009;98:1822–1824.
  
• Saverino BP, Lava C, Lowe LH, et al. Radiographic findings in the diagnosis of pediatric ileocolic intussusception: Comparison to a control population.
  Pediatr Emerg Care.
  2010;26:281–284.
  
• Willetts IE, Kite P, Barclay GR, et al. Endotoxin, cytokines and lipid peroxides in children with intussusception.
  Br J Surg
  . 2001;88:878–883.
  

CODES

560.0 Intussusception

BASICS

• Inflammation of anterior uveal tract
  
• Iritis and anterior uveitis are synonymous.
  
• Uveitis secondary to trauma is also called traumatic iritis.
  

• Most cases are idiopathic, but may be traumatic or associated with numerous infectious and noninfectious systemic diseases.
  
• May be acute or chronic.
  
• Noninfectious systemic diseases include the following:
  
  • Ankylosing spondylitis
    
  • Reiter syndrome
    
  • Sarcoidosis
    
  • Behcçet disease
    
  • Inflammatory bowel disease
    
  • Juvenile rheumatoid arthritis
    
  • Kawasaki syndrome
    
  • Interstitial nephritis
    
  • IgA nephropathy
    
  • Drug reactions
    
  • Sjögren syndrome
    
  • Psoriatic arthritis
    
• Infectious conditions include the following:
  
  • Viral:
    
    • Rubella
      
    • Measles
      
    • Adenovirus
      
    • Herpes simplex virus
      
    • Herpes zoster virus
      
    • HIV
      
    • Mumps
      
    • Varicella
      
    • Cytomegalovirus
      
    • West Nile virus
      
  • Bacterial:
    
    • Tuberculosis
      
    • Syphilis
      
    • Pertussis
      
    • Brucellosis
      
    • Lyme disease
      
    • Chlamydia
      
    • Rickettsia
      
    • Gonorrhea
      
    • Leprosy
      
  • Fungal:
    
• Malignancies include the following:
  
  • Leukemia
    
  • Lymphoma
    
  • Multiple sclerosis
    
  • Malignant melanoma
    
• Other causes include the following:
  
  • Cocaine use
    
  • Exposure to pesticides
    
  • Corneal foreign body
    
  • Blunt trauma