Vomiting, abdominal pain and blood in stools are the classic triad that should alert nurses to the possibility of intussusception in a child
Intussusception is defined as: “invagination or telescoping of proximal loop of intestine (intussusceptum) into a distal segment (intussuscipiens) and leads to bowel obstruction” (Rogers and Robb, 2010). This leads to impaired venous return, incarceration and finally necrosis of the trapped segment (Nylund et al, 2010).
It is the most common surgical emergency in infants and young children. Patients may present with the classic triad of symptoms - abdominal pain, vomiting and blood in stools - although 75% of children present with only two symptoms (Paul et al, 2010).
Intussusception has a male preponderance (four males to every one female) and is most common in children under two years of age, with a peak incidence between four to nine months (Paul et al, 2010).
Aetiology remains idiopathic in younger children and may be preceded by a viral upper respiratory tract infection or gastroenteritis-like illness (Rogers and Robb, 2010). Bacterial enteritis has been identified as a significant risk factor for developing intussusception (Nylund et al, 2010).
Intussusception most often occurs in the ileocolic region (80% of cases) but can appear in any part of the intestine (Rogers and Robb, 2010). Ultrasound is usually used to diagnose the condition, and treatment by radiological reduction (air or contrast enema) is successful in most cases (Paul et al, 2010).
An eight-month old baby, previously healthy, presented with a 36-hour history of non-bilious vomiting after every feed and one episode of blood tinge per rectum. This was diagnosed as gastroenteritis in primary care and oral rehydration therapy was advised. He was reported to be passing urine but less than usual.
The initial observations in the emergency department revealed a temperature of 36.8°C, pulse rate of 130/min, respiratory rate of 36/min, saturations 98% in air and central capillary refill time of two seconds. A clinical examination revealed that he was well hydrated. Findings were normal except that he was uncomfortable on abdominal palpation.
It is important to consider intussusception in a young child who presents with an intermittent abdominal pain followed by periods of normal behaviour, vomiting and blood in their stools. They should be closely monitored and investigated (Simpson and Ivey, 2004).
A provisional diagnosis of gastroenteritis was made, but a suspicion of intussusception was mentioned in the clinical notes. As the baby continued to vomit, he was admitted to the ward, blood investigations were done and he was started on intravenous fluids in order to rest the gut. Blood investigations showed a C-reactive protein level of 48mg/L, but were otherwise within normal limits.
Development and management
About six hours after admission, he had an episode of bilious vomiting and passed blood with mucous per rectum. Abdominal examination at this point revealed a suspicious mass and an abdominal X-ray showed evidence of bowel obstruction. It should be noted that a normal abdominal X-ray does not rule out intussusception.
The baby was transferred to the regional paediatric surgical unit where an abdominal ultrasound scan confirmed the diagnosis of intussusception. Ultrasound-guided air enema reduced the obstruction.
The baby was discharged after 48 hours and his parents were advised to seek medical advice if symptoms recurred. It is important to note that 10% of children who have reduction by the non-invasive enema method can develop intussusception again and will need surgical correction (Paul et al, 2010).
This case illustrates the importance of being aware of this common surgical presentation in early childhood and of being suspicious of intussusception if vomiting with abnormal abdominal examination or blood per rectum is present.
Dr Siba Prosad Paul is a specialist trainee year 4, paediatrics, Great Western Hospital, Swindon.
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Nylund CM et al (2010) Bacterial enteritis as a risk factor for childhood intussusception: a retrospective cohort study. Journal of Pediatrics; 156: 761-765.
Paul SP et al (2010) A case series on intussusceptions in infants presenting with listlessness. Infant; 6: 5, 174-177.
Rogers TN, Robb A (2010) Intussusception in infants and young children. Surgery; 28: 8, 402-405.
Simpson T, Ivey J (2004) Paediatric management problems. Pediatric Nursing; 30: 4, 326.