1. 2-year-old with Abdominal Pain Case MRN 6628633
Sarah Kurian, MS4
Diagnostic Radiology
February 2014

2. 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

3. KUB

4. 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

5. KUB
Findings highly suggestive of ileocolic intussusception, best seen at the hepatic flexure.

7. Ultrasound Target or donut — on transverse view
Sonographically positive for ileocolic intussusception to the level of the proximal transverse colon. Small lower abdominal free fluid.

8. Lower GI with Fluoroscopy
Contrast administration via gravity. Successful reduction of ileocolic intussusception.

9. 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

10. 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
Symptoms followed hours to days later with bloody currant jelly stool.

11. 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)

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

13. 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

14. 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

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