13. Resident-attending in the ED: Intussusception
Resident: Doctor Rogers, I’d like to discuss a patient with you. Oliver is a healthy 8-month-old baby brought into the ED because of inconsolable crying. His mother says he has been crying the whole afternoon and he has vomited 5 times. He doesn’t have fever or diarrhea and hasn’t lost his appetite. He has never had regurgitations after feedings. There’s nobody else sick at home and he doesn’t attend the nursery school.
Attending: Has he been crying non-stop? Do you think he is in pain? Has he had any other similar episodes before?
Resident: He has had intermittent crying episodes. He manages to be comforted and stays calm for about 20 minutes, but then he suddenly starts with intense crying again. His mother is worried because this is the first time he cries so much and during the episodes he becomes pale and sweaty. I think he might have abdominal pain because he draws up his legs towards the abdomen. However, now he is relaxed and the physical examination is normal.
Attending: Are the vomits bilious? When was the last time he had bowel-movements? Has he had bloody stools?
Resident: The vomits are non-bilious and he has had normal stools this morning.
Attending: So after all you’ve told me, what is your differential diagnosis?
Resident: It is still too soon to make an accurate diagnosis. According to the gastrointestinal symptoms he might be starting with a gastroenteritis, but vomiting and irritability are very unspecific symptoms in babies, and might sometimes be the only presentation of urinary infection. This is why I carried out a urine dipstick test which is normal. If he was younger, the crying could be simply due to infant colics. Nevertheless, the poor general condition makes me think of some organic pathology.
Attending: Good. There are many causes for vomiting and crying in babies. However, the paleness, sweating and bad general appearance during the intermittent sudden crying episodes and the drawing up of the legs are important signs that should make you consider and rule out an intussusception. This means that part of the intestine has telescoped into itself. It is one of the most common abdominal emergencies in children below two years of age and it has a high rate of morbidity if not treated promptly.
Resident: OK so we should order an ultrasonography then, right? What is the cause? And how is it treated?
Attending: Yes, ultrasonography would be the method of choice to detect intussusceptions. They are mostly idiopathic, but some episodes might be triggered by viral infections. Once the diagnosis is confirmed, stable patients with no evidence of intestinal perforation can be treated with non-operative reduction using a pneumatic or hydrostatic enema under sonographic guidance. This is generally safe and effective, although the surgical team should be notified because there is a small risk of perforation during the procedure. Acutely ill or children with intestinal perforation need a surgical reduction.
Resident: So what do we do now?
Attending: We should explain all of this to his mother. Make sure that the child discontinues oral intake from now on to ensure preoperative fasting and start him on IV fluids to maintain hydration. Order the ultrasonography and if the diagnosis is confirmed, inform the surgeons and the anaesthetist for sedation during the intervention.
Resident: Thank you for your help Dr. Rogers.
ED (Emergency Department): servicio de Urgencias.
Intussusception: invaginación intestinal.
Non-stop: sin parar.
Be comforted: ser consolado.
Draws up his legs: encoge las piernas.
Bloody stools: deposiciones sanguinolentas.
Differential diagnosis: diagnóstico diferencial.
Urine dipstick test: tira reactiva de orina.
Infant or baby colics: cólicos del lactante.
Bad general appearance/ poor general condition: mal estado general.
Organic pathology: patología orgánica.
Rule out: descartar.
Telescope: plegarse como un telescopio introduciendo un segmento dentro de otro.
Method of choice: método de elección.
Intestinal perforation: perforación intestinal.
Non-operative reduction: reducción no quirúrgica.
Under sonographic guidance: guiado por ecografía.
Oral intake: ingesta oral.
Preoperative fasting: ayuno prequirúrgico.
IV (intravenous) fluids: fluidoterapia intravenosa.