Clinical Scenario:
A 9-month-old male infant is brought to the emergency department with intermittent episodes of severe colicky abdominal pain for the last 8 hours. During painful episodes, he draws his legs toward his abdomen and cries intensely. Between episodes, he appears lethargic. The parents noticed one episode of vomiting and passage of a small amount of blood-stained mucus per rectum.
On examination:
- Pulse: 120/min
- Abdomen: Mild distension with a palpable sausage-shaped mass in the right upper quadrant
- Rectal examination reveals blood-stained mucus
Ultrasound abdomen shows a target sign with concentric rings.
What is the most appropriate next step in management?
A. Appendectomy
B. Barium enema reduction
C. Immediate laparotomy without imaging
D. Intravenous antibiotics and observation
E. Surgical resection as first-line therapy
Correct answer & Explanation:
Correct Answer: B. Barium enema reduction
Explanation:
The clinical picture is classic for intussusception, most commonly ileocolic intussusception in infants.
Key diagnostic clues:
- Age 6–36 months → peak incidence of intussusception.
- Intermittent colicky abdominal pain → due to telescoping of bowel segments.
- Vomiting and lethargy → common associated features.
- Blood-stained mucus stool (“red currant jelly stool”) → occurs due to mucosal ischemia.
- Sausage-shaped abdominal mass → classic palpable finding.
- Target sign on ultrasound → diagnostic.
Management:
In a hemodynamically stable child without signs of bowel perforation or peritonitis, the treatment of choice is non-operative reduction by air enema or contrast enema (often called pneumatic or hydrostatic reduction).
Why other options are incorrect:
A. Appendectomy
- Appendicitis may cause abdominal pain and vomiting but does not cause intermittent colic, target sign, or sausage-shaped mass.
C. Immediate laparotomy without imaging
- Surgery is indicated if there is perforation, peritonitis, failed enema reduction, or unstable condition. It is not first-line in a stable child.
D. Intravenous antibiotics and observation
- Antibiotics alone do not treat the mechanical obstruction caused by bowel telescoping.
E. Surgical resection as first-line therapy
- Surgical intervention is reserved for complicated cases. Most uncomplicated cases are successfully reduced by enema.
Nelson Textbook of Pediatrics Key Point:
Ultrasound is the preferred diagnostic modality, and pneumatic (air) enema reduction is the preferred initial treatment for uncomplicated ileocolic intussusception.
