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Within Normal Limits

Ultrasound, Not X-Rays, Holds the Answer

Tong, Angela MD; Patel, Himanshu MD; Patel, Shivani MD

doi: 10.1097/01.EEM.0000481781.96483.59
Within Normal Limits

Dr. Tongis a fourth-year radiology resident at Westchester Medical Center in Valhalla, NY, whereDr. Himanshu Patelis the director of musculoskeletal radiology. He is also an assistant professor of radiology at New York Medical College. Dr. Shivani Patelis an emergency physician at Stamford (CT) Hospital.

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A 3-year-old girl presented to the emergency department with two days of worsening abdominal pain occurring every 60 to 90 minutes that is now increasing to every 20 minutes. She has had no vomiting or diarrhea, and her father reported no fever.

Initial imaging should include a left lateral decubitus radiograph of the abdomen to evaluate for more worrisome etiologies of acute abdomen such as obstruction or free air. Ileocolic intussusception appears as a soft tissue mass in the right upper or lower quadrants. Left lateral decubitus views excludes free intraperitoneal air, which is a contraindication to air enema.

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A dedicated ultrasound of the abdomen to evaluate for intussusception should be performed next. It appears as a targetoid soft tissue mass with increased blood flow, which is evaluated by color Doppler. Air enema should be performed to reduce the ileocolic intussusception if it's positive on ultrasound. Several attempts should be made to reduce the intussusception. The likelihood of successful reduction, however, decreases with increasing length of symptoms. The mean duration of symptoms for successful reduction was 1.6 days versus 2.8 days in unsuccessful reductions in one study. Surgical reduction of the intussusception is necessary if air enema is unsuccessful.

Ileocolic intussusception is a common cause of acute abdomen in infancy and early childhood. It occurs when the terminal ileum telescopes into the adjacent cecum and proximal colon. This can cause obstruction and eventually ischemia of the bowel. Ileocolic intussusception usually occurs in children from 6 months to 2 years. The common clinical presentation includes the triad of intermittent abdominal pain with currant-jelly stool and a palpable abdominal mass. Lead points of an ileocolic intussusception are most commonly lymph nodes, which can occur in post-viral syndrome or, less commonly, Meckel's diverticulum.

The patient may be discharged after:

  • Excluding an acute abdomen before ultrasound imaging.
  • Using ultrasound of the abdomen to confirm the diagnosis without any radiation exposure.
  • Treating with an air or contrast enema, the first line for an ileocolic intussusception.
  • Opting for surgical reduction of the ileocolic intussusception if an air or contrast enema is unsuccessful.

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