2-year-old with Abdominal Pain Case MRN 6628633

Sarah Kurian, MS4Diagnostic RadiologyFebruary 2014

History 2 year old female with no significant past medical history who

presents with abdominal pain and non-bloody, non-bilious vomiting x 3 days.

Afebrile, normal WBC count Decreased urine output, last BM 4 days ago Admitted from ED for management of dehydration

KUB

History, continued Abdominal US to assess appendix – normal Surgery consulted - concern for malrotation vs. obstruction Surgery recommended further imaging Upper GI series with small bowel follow-through

KUB

Ultrasound

Target or donut — on transverse view

Lower GI with Fluoroscopy

Intussusception Ileocolic (90%) Mostly idiopathic

Thought to be 2/2 hypertrophied lymphoid tissue in the terminal ileum, induced by a preceding viral illness

Only 2–12% caused by an identifiable lead point Common lead points are Meckel's diverticulum, polyp, or

lymphoma ages 6 months to 2 years

Intussusception Classic triad of symptoms

Pain, vomiting, palpable abdominal mass Plain radiographs are diagnostic in 29–50% of cases Get at least 2 views including supine and prone or left

lateral decubitus views Force air into the cecum

Radiographic findings lack of air-filling of the

cecum on the supine film

Other findings:

Air crescent sign—gas around part of the intussusceptum (although rare, this is highly specific for the diagnosis)

Rim or Target sign—soft-tissue mass containing a faintly visible circle of fat density (the mesenteric fat)

Target or Rim Sign

Ultrasound 98.5–100% sensitive

and 88–100% specific

Able to identify anatomic lead points

Target or donut Crescent or donut—

the entrapped mesentery (often containing nodes) within the intussusception

Treatment Air or barium enema reduction under continuous

observation with fluoroscopy Contraindications = peritonitis, perforation Complication = bowel perforation

Surgery (if enema fails)

Recurrence – in 10% and is highest within the first 2 days following reduction

Back to our patient Returned with fevers 4 days after discharge Admitted + for Rhino-/Entero- virus Likely caused the intussusception in the first place!