Pediatric case discussion R2 趙怡荏

Patient Information Name: 陳 X 柔 Name: 陳 X 柔 Girl Girl Chart No.: Chart No.: Birth Date: (1y 1m/o) Birth Date: (1y 1m/o) 就診日期 : 就診日期 :

General Data Vital sign: Vital sign: BT:36.1 ’ C HR:163 bpm RR:28 BP:139/65 mmHg E4V5M6 BW:10 kg Information: mother Information: mother

Chief Complain Irritable crying with vomiting for one day Irritable crying with vomiting for one day

Present Illness She was afebrile and had no diarrhea. She was afebrile and had no diarrhea. She was sent to other hospital on 9/10 due to abdominal pain and vomiting. She was sent to other hospital on 9/10 due to abdominal pain and vomiting. X-ray was arranged and stool impaction was impression at LMD X-ray was arranged and stool impaction was impression at LMD Blood tinged stool passed after glycerin edema and MBD later Blood tinged stool passed after glycerin edema and MBD later Due to recurrent vomiting, nausea and abdominal pain after discharge, she went to our OPD on 9/11.She went home with OPD medication (Metoclopramide 1ml tid ; Biogen 1# tid) Due to recurrent vomiting, nausea and abdominal pain after discharge, she went to our OPD on 9/11.She went home with OPD medication (Metoclopramide 1ml tid ; Biogen 1# tid)

She still suffered from vomiting after leave our OPD, and went to LMD ER again. She still suffered from vomiting after leave our OPD, and went to LMD ER again. Then transferred to our ER for further treatment. Then transferred to our ER for further treatment.

Past History Development ： normal Development ： normal Growth: within normal percentile Growth: within normal percentile Denied OP history Denied OP history Denied any other systemic disease Denied any other systemic disease Newborn screening ： negative Newborn screening ： negative Vaccination ： scheduled Vaccination ： scheduled

Physical Examination GENERAL APPEARANCE: Acute-ill, alert GENERAL APPEARANCE: Acute-ill, alert HEENT: HEENT: Grossly normal, Sclera (Icterus): -, Conjunctiva (pale): - Grossly normal, Sclera (Icterus): -, Conjunctiva (pale): - CHEST: CHEST: Shape: grossly normal, Breath pattern: smooth Shape: grossly normal, Breath pattern: smooth Breathing sound: bilateral clear Breathing sound: bilateral clear HEART: HEART: Regular heart beat, S3(-),S4(-), murmur (-) Regular heart beat, S3(-),S4(-), murmur (-) ABDOMEN: ABDOMEN: Tactile: soft and distended, Operation scar: - Tactile: soft and distended, Operation scar: - Tenderness: nil; pain, poorly descripted Tenderness: nil; pain, poorly descripted Bowel sound: normoactive Bowel sound: normoactive EXTREMITIES: EXTREMITIES: Pitting edema: -, Freely movable: +, Deformity: - Pitting edema: -, Freely movable: +, Deformity: -

Impression intestine obstruction,susp. intussusception intestine obstruction,susp. intussusception

Initial Order IVF with half-saline run 40ml/hr IVF with half-saline run 40ml/hr Lab & Exam: Lab & Exam: Abdomen Abdomen CBC/DC, CRP, Na, K CBC/DC, CRP, Na, K Ampicillin 250mg IVF stat Ampicillin 250mg IVF stat Gentamicin 20 mg IVF stat Gentamicin 20 mg IVF stat Metronidazole 100mg stat Metronidazole 100mg stat

Lab 9/11 血液生化 WBC6100CRP12.3 RBC4.93Na133 Hb12.9K4.3 Hct37.4 MCV75.9 MCH26.2 MCHC34.5 RDW13.6 Platelet Segment60.4 lymphocyte25.6 Monocyte13.5 Basophil0.5

9/11

9/11 9/11 CXR: CXR: increased small bowel gas with distension in the abdomen increased small bowel gas with distension in the abdomen R/O intestinal obstruction R/O intestinal obstruction Arrange air reduection Arrange air reduection Fluoroscopic Reduction of Intussusception Fluoroscopic Reduction of Intussusception

Fuloroscopic reduction of intussusception with air edema then low GI Fuloroscopic reduction of intussusception with air edema then low GI series with water-soluble contrast medium: series with water-soluble contrast medium: 1. Plain film shows dilatated and increased small bowel loops, r/o 1. Plain film shows dilatated and increased small bowel loops, r/o small bowel obstruction. small bowel obstruction. 2. Air enema via pressure-monitored device was performed. 2. Air enema via pressure-monitored device was performed. 3. Free reflux of air into the cecum, but a soft tissue density is 3. Free reflux of air into the cecum, but a soft tissue density is still noted at ileocecal valve region, DDx: residual ileo-ileo-colic still noted at ileocecal valve region, DDx: residual ileo-ileo-colic type intussusception, edematous change of ileocecal valve. type intussusception, edematous change of ileocecal valve. 4. Then water-soluble contrast medium was injected into the colon via 4. Then water-soluble contrast medium was injected into the colon via the foley catheter. Opacification of the cecum and appendix is noted, the foley catheter. Opacification of the cecum and appendix is noted, but only poor opacification of the distal ileum with a suspicious but only poor opacification of the distal ileum with a suspicious filling defect at the terminal ileum. filling defect at the terminal ileum. 5. No extraluminal free air isnoted during and after the procedure. 5. No extraluminal free air isnoted during and after the procedure. IMP: IMP: Intussusception, could not r/o ileo-ileo-colic type. After air-enema, Intussusception, could not r/o ileo-ileo-colic type. After air-enema, there is residual soft tissue density near the ileocecal valve, DDx: there is residual soft tissue density near the ileocecal valve, DDx: residual ileo-ileo-colic type intussusception, edematous change of residual ileo-ileo-colic type intussusception, edematous change of ileocecal valve. Suggest clinical correlation and follow up plain ileocecal valve. Suggest clinical correlation and follow up plain abdomen radiography, and further study with CT, or small bowel series, abdomen radiography, and further study with CT, or small bowel series, or repeat LGI series study if clinical indicated. or repeat LGI series study if clinical indicated.

CT of abdomen without and with enhancement: CT of abdomen without and with enhancement: Retained contrast medium in the colon due to previous LGI study. Retained contrast medium in the colon due to previous LGI study. There is "target" appearance at the distal ileum with mesenteric fat There is "target" appearance at the distal ileum with mesenteric fat in the distal ileal lumen, suggestive of ileo-ileal intussusception. in the distal ileal lumen, suggestive of ileo-ileal intussusception. Dilatation of the proximal bowel loops indicating small bowel Dilatation of the proximal bowel loops indicating small bowel obstruction. obstruction. Unremarkable liver, pancreas, spleen, and kidneys. Unremarkable liver, pancreas, spleen, and kidneys. No enlarged paraaortic nor pelvic lymph node. No enlarged paraaortic nor pelvic lymph node. Clear bilateral basal lung fields. Clear bilateral basal lung fields. IMP: IMP: suggestive of ileo-ileal intussusception with small bowel obstruction. suggestive of ileo-ileal intussusception with small bowel obstruction.

OP: OP: milking reduction of intussusception with appendectomy milking reduction of intussusception with appendectomy OPERATIVE INDICATION: OPERATIVE INDICATION: Failure of air reduction of the ileo-ileal part Failure of air reduction of the ileo-ileal part OPERATIVE FINDINGS: OPERATIVE FINDINGS: There was about 50cc clear ascites. An ileo-ileal intussusception was found. The intussusceptum was about 6cm in length. No leading point was found. The intussusception was viable without vascular compromise. There was about 50cc clear ascites. An ileo-ileal intussusception was found. The intussusceptum was about 6cm in length. No leading point was found. The intussusception was viable without vascular compromise. OPERATIVE METHODS: OPERATIVE METHODS: Milking reduction of intussusception Milking reduction of intussusception Incidiental appendectomy Incidiental appendectomy

remove NG remove NG sip water then on diet gradually sip water then on diet gradually discharge discharge

Diagnosis intussusception, ileo-ileo-colic intussusception, ileo-ileo-colic

Intussusception Intussusception occurs when one segment of bowel invaginates into a more distal segment. Intussusception occurs when one segment of bowel invaginates into a more distal segment. the leading cause of acute intestinal obstruction in infants the leading cause of acute intestinal obstruction in infants occurs most commonly between 3 and 12 months of age. occurs most commonly between 3 and 12 months of age. The most common intussusception is ileocolic The most common intussusception is ileocolic Often, it will be ileoileal at a location close to the cecum. Often, it will be ileoileal at a location close to the cecum. In infants, the lead point for the intussusception may be hypertrophied Peyer's patches. In infants, the lead point for the intussusception may be hypertrophied Peyer's patches. In children older than 2 years of age, a specific lead point such as a polyp, a Meckel's diverticulum, a duplication, or a tumor is much more likely. In children older than 2 years of age, a specific lead point such as a polyp, a Meckel's diverticulum, a duplication, or a tumor is much more likely. A diarrheal illness, viral syndrome, or Henoch-Schonlein purpura may be a preceding illness several days to a week before the onset of abdominal pain and obstruction. A diarrheal illness, viral syndrome, or Henoch-Schonlein purpura may be a preceding illness several days to a week before the onset of abdominal pain and obstruction.

Ileocolic intussusception. A: Beginning of an intussusception in which terminal ileum prolapses through ileocecal valve. B: Ileocolic intussusceptum continuing through the colon. This can often be palpated as a mass in the right upper quadrant. Ileocolic intussusception. Barium enema shows the intussusception as the filing defect within the hepatic flexure surrounded by spiral mucosal folds. Significant distended small bowel represents distal small bowel obstruction.

Clinical Manifestations The primary manifestation of intussusception is colicky abdominal pain. The primary manifestation of intussusception is colicky abdominal pain. This symptom may have been preceded by the symptoms and signs of a viral gastroenteritis or even an upper respiratory infection. This symptom may have been preceded by the symptoms and signs of a viral gastroenteritis or even an upper respiratory infection. becomes more irritable and anorectic, and may vomit. becomes more irritable and anorectic, and may vomit. the diagnosis is suggested strongly if a history of episodic pain is obtained. The child may appear to be comfortable and well between episodes. the diagnosis is suggested strongly if a history of episodic pain is obtained. The child may appear to be comfortable and well between episodes. The localized portion of the intussusception leads to partial or complete obstruction and generalized abdominal distension. The localized portion of the intussusception leads to partial or complete obstruction and generalized abdominal distension.

In some cases, the intussuscepted mass can be palpated as an ill-defined, sausage-shaped structure if the abdomen is not too distended. This mass is most often palpable in the right upper quadrant. In some cases, the intussuscepted mass can be palpated as an ill-defined, sausage-shaped structure if the abdomen is not too distended. This mass is most often palpable in the right upper quadrant. the absence of bloody stools should not preclude making the diagnosis of a possible intussusception. the absence of bloody stools should not preclude making the diagnosis of a possible intussusception. Infants and young children with colicky abdominal pain and emesis should be evaluated for intussusception. Infants and young children with colicky abdominal pain and emesis should be evaluated for intussusception. Only 20% of infants with intussusception have the triad of colicky abdominal pain, vomiting, and bloody stools. Only 20% of infants with intussusception have the triad of colicky abdominal pain, vomiting, and bloody stools. As the bowel becomes more tightly intussuscepted, the mesenteric veins become compressed, whereas the mesenteric arterial supply remains intact. This leads to the production of the characteristic currant jelly stool, which may be passed spontaneously or found on the rectal examination As the bowel becomes more tightly intussuscepted, the mesenteric veins become compressed, whereas the mesenteric arterial supply remains intact. This leads to the production of the characteristic currant jelly stool, which may be passed spontaneously or found on the rectal examination

Management inserting an IV line and a nasogastric tube. inserting an IV line and a nasogastric tube. Once blood has been sent to the laboratory for CBC, BUN, serum electrolytes, and a cross-match, the patient should be taken to the radiology department. Once blood has been sent to the laboratory for CBC, BUN, serum electrolytes, and a cross-match, the patient should be taken to the radiology department. Plain radiograph findings of intussusception are variable and depend primarily on the duration of the symptoms and the presence or absence of complications. Plain radiograph findings of intussusception are variable and depend primarily on the duration of the symptoms and the presence or absence of complications. In early cases, a normal gas pattern is seen. In early cases, a normal gas pattern is seen. In the patient with symptoms longer than 6 to 12 hours, flat and upright films often show signs of intestinal obstruction, including distended bowel with air – fluid levels (Fig ). In the patient with symptoms longer than 6 to 12 hours, flat and upright films often show signs of intestinal obstruction, including distended bowel with air – fluid levels (Fig ). US can be used diagnostically with reported sensitivity of 98% to 100%. US can be used diagnostically with reported sensitivity of 98% to 100%.

A: Small bowel obstruction. Numerous dilated small bowel loops occupy the midabdomen and have a stepladder configuration. Minimal air is seen in the rectum. B: Same patient as in A. The upright abdominal roentgenogram shows numerous dilated loops in the small bowel

barium enema or air insufflation enema has been a successful therapy in up to 70% to 95% of cases with higher success rates reported with air reduction. barium enema or air insufflation enema has been a successful therapy in up to 70% to 95% of cases with higher success rates reported with air reduction. Strict reduction guidelines must be adhered to so perforation is avoided. Strict reduction guidelines must be adhered to so perforation is avoided. The full reduction of the intussusception is confirmed only when there has been adequate reflux of barium or air into the ileum. The full reduction of the intussusception is confirmed only when there has been adequate reflux of barium or air into the ileum. Patients with peritonitis or free air on plain radiograph should not have an enema study or reduction attempt. Patients with peritonitis or free air on plain radiograph should not have an enema study or reduction attempt.

Perforation rates with enema reduction have been reported in up to 3%. Perforation rates with enema reduction have been reported in up to 3%. Criteria that are linked to a lower reduction rate and a higher perforation rate, especially if more than one is present, are patient age younger than 3 months or older than 5 years; long duration of symptoms, especially if greater than 48 hours; passage of blood via the rectum (hematochezia); significant dehydration; and evidence of small bowel obstruction on plain radiograph. Criteria that are linked to a lower reduction rate and a higher perforation rate, especially if more than one is present, are patient age younger than 3 months or older than 5 years; long duration of symptoms, especially if greater than 48 hours; passage of blood via the rectum (hematochezia); significant dehydration; and evidence of small bowel obstruction on plain radiograph.

require emergency surgery, especially if the intussusception has been of long duration or the child shows evidence of gangrenous bowel, including high fever, leukocytosis, significant distension, and general toxicity. require emergency surgery, especially if the intussusception has been of long duration or the child shows evidence of gangrenous bowel, including high fever, leukocytosis, significant distension, and general toxicity. the operating room should be placed on standby and the operating team should be ready to commence immediate surgery if complications develop during the procedure or if unsuccessful. the operating room should be placed on standby and the operating team should be ready to commence immediate surgery if complications develop during the procedure or if unsuccessful. Barium enemas can lead to peritoneal contamination with barium, and air enemas can lead to massive pneumoperitoneum and sudden death unless the abdomen is decompressed (by needle decompression). Barium enemas can lead to peritoneal contamination with barium, and air enemas can lead to massive pneumoperitoneum and sudden death unless the abdomen is decompressed (by needle decompression). Delay in reduction can lead to gangrenous bowel. Delay in reduction can lead to gangrenous bowel.

The recurrence rate after enema reduction ranges from 1% to 3%. The recurrence rate after enema reduction ranges from 1% to 3%. When there is a recurrence, a second attempt at reduction may be done by enema. When there is a recurrence, a second attempt at reduction may be done by enema. Recurrences are more common in older children and may be caused by a lead point such as a Meckel's diverticulum, an intestinal polyp, or an intraluminal tumor such as lymphoma. Therefore, it may be wise in an older child to operate with the first recurrence. Recurrences are more common in older children and may be caused by a lead point such as a Meckel's diverticulum, an intestinal polyp, or an intraluminal tumor such as lymphoma. Therefore, it may be wise in an older child to operate with the first recurrence.

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