This child presented with abdominal pain, and blood stained mucus PR.

■ What do the abdominal film and the ultrasound (US) (Figs 2.20 and 2.21) show?

■ What would you request next?

■ What precautions are necessary?

Fig. 2.20 Quiz case.

Fig. 2.21 Quiz case.

Fig. 2.21 Quiz case.

Answer Intussusception

The abdominal film demonstrates a soft tissue mass in the left upper quadrant in the region of the transverse colon. This is clearly outlined on one side by gas in the colon distal to it. This is the lead point of

Ban intussusception - the clinical history is extremely suggestive in a child of this age. The ultrasound (US) confirms a mass which is characteristic of an intussusception.

Air enema/pneumatic reduction is the preferred initial method of treatment. This requires fluid resuscitation and IV antibiotics prior to the procedure. This should only be carried out in a centre with paediatric surgical cover. The procedure fails in a proportion of cases and open surgical reduction may be necessary. Pneumoperitoneum, peritonitis and hypovolaemic shock are contraindications to the technique. A large bore Foley catheter is inserted into the rectum and the buttocks are taped together. Air is insufflated using a pump with a pressure gauge that has a valve mechanism to prevent excessive pressures. The lead point of the intussusception can be followed fluoroscopically and usually reduces fairly easily (success rate is up to 90%) but there may be some hold up at the ileo-caecal valve level. When the intussusception reduces, the small bowel can be seen to suddenly fill with a puff of gas. Bowel perforation is a potential complication and this may splint the diaphragm compromising respiration. A large bore needle should be kept to hand and used to decompress a pneumoperitoneum. Incomplete reduction and recurrence in up to 10% are further complications.

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