Within Normal Limits

Abstract

Figure: Radiographs are not reliable to evaluate for ileocolic intussusception, but can be a helpful preliminary study to exclude worrisome findings such as free air. Ileocolic intussusception appears as a soft tissue mass on abdominal radiographs, sometimes with a targetoid appearance. The left lateral decubitus view is also important because it evaluates for free intraperitoneal air, which is a contraindication for an air enema.FigureFigureFigureA 3-year-old girl presented to the emergency department with two days of worsening abdominal pain occurring every 60 to 90 minutes that is now increasing to every 20 minutes. She has had no vomiting or diarrhea, and her father reported no fever. Initial imaging should include a left lateral decubitus radiograph of the abdomen to evaluate for more worrisome etiologies of acute abdomen such as obstruction or free air. Ileocolic intussusception appears as a soft tissue mass in the right upper or lower quadrants. Left lateral decubitus views excludes free intraperitoneal air, which is a contraindication to air enema.Figure: Ultrasound of the abdomen shows a targetoid lesion in the right upper quadrant, shown here in transverse view, which is compatible with an ileocolic intussusception. The color Doppler image shows that the soft tissue mass is hyperemic, suggesting the bowel is still viable.Figure: This fluoroscopic image was taken during an air enema. There is a soft tissue mass, the ileocolic intussusception, in the right upper quadrant. This is displaced proximally with air during the procedure. Post-procedural radiograph showed no soft tissue mass in the right upper or lower quadrants. Gas was also seen in the region of the terminal ileum, confirming reduction of the intussusception.A dedicated ultrasound of the abdomen to evaluate for intussusception should be performed next. It appears as a targetoid soft tissue mass with increased blood flow, which is evaluated by color Doppler. Air enema should be performed to reduce the ileocolic intussusception if it's positive on ultrasound. Several attempts should be made to reduce the intussusception. The likelihood of successful reduction, however, decreases with increasing length of symptoms. The mean duration of symptoms for successful reduction was 1.6 days versus 2.8 days in unsuccessful reductions in one study. Surgical reduction of the intussusception is necessary if air enema is unsuccessful. Ileocolic intussusception is a common cause of acute abdomen in infancy and early childhood. It occurs when the terminal ileum telescopes into the adjacent cecum and proximal colon. This can cause obstruction and eventually ischemia of the bowel. Ileocolic intussusception usually occurs in children from 6 months to 2 years. The common clinical presentation includes the triad of intermittent abdominal pain with currant-jelly stool and a palpable abdominal mass. Lead points of an ileocolic intussusception are most commonly lymph nodes, which can occur in post-viral syndrome or, less commonly, Meckel's diverticulum. The patient may be discharged after: Excluding an acute abdomen before ultrasound imaging. Using ultrasound of the abdomen to confirm the diagnosis without any radiation exposure. Treating with an air or contrast enema, the first line for an ileocolic intussusception. Opting for surgical reduction of the ileocolic intussusception if an air or contrast enema is unsuccessful. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].