Intussusception
USMLE Step 2 CKDifficulty: easyLast updated:
A 10-month-old boy is brought to the emergency department because of episodes of sudden, inconsolable crying with drawing up of his legs every 15 to 20 minutes over the past 12 hours, with vomiting. Between episodes he is quiet and lethargic. He just passed a stool that contains blood and mucus. Temperature is 37.4°C (99.3°F), and he is well perfused after a fluid bolus. A sausage-shaped mass is palpable in the right upper quadrant; there is no guarding or rigidity. Abdominal ultrasound shows a target sign consistent with ileocolic intussusception, and there is no free air.
Which of the following is the most appropriate next step in management?
Answer and explanation
Correct answer: A. Air enema reduction
Intermittent colicky pain with drawing up of the legs, lethargy between episodes, vomiting, a currant-jelly-type stool, and a sausage-shaped mass in an infant are typical of intussusception. Ultrasound is the diagnostic test of choice. The source states that once ileocolic intussusception is confirmed, an air enema is used for reduction, which lessens the likelihood and consequences of perforation. Surgery is reserved for failed enema reduction or perforation. Ill children with peritonitis need fluid resuscitation, broad-spectrum antibiotics, nasogastric suction, and surgery. The source stresses urgency because survival and the likelihood of nonoperative reduction decrease significantly with time. This child is stable and has no peritoneal signs or free air, so enema reduction is appropriate.
Each option explained
- A. Air enema reductionCorrect. In a stable child with confirmed ileocolic intussusception and no perforation, air enema is the treatment of choice.
- B. Emergency laparotomyIncorrect. Laparotomy is reserved for failed enema reduction, perforation, or peritonitis.
- C. Upper gastrointestinal contrast seriesIncorrect. An upper GI series evaluates malrotation and has no therapeutic role in ileocolic intussusception.
- D. Nasogastric decompression and observation for spontaneous reductionIncorrect. Waiting reduces the success of nonoperative reduction and risks ischemia and perforation.
- E. Intravenous antibiotics alone and reassessment in 24 hoursIncorrect. Antibiotics alone do not reduce the intussusception; delay increases the risk of bowel ischemia.
Key point
Stable ileocolic intussusception confirmed by ultrasound is treated with air enema reduction; surgery is for failure or perforation.
From the source
“If ileocolic intussusception is confirmed, an air enema is used for reduction, which lessens the likelihood and consequences of perforation”