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Case 389

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A 10-month-old boy, previously healthy, was admitted with sudden irritation and crying. Beginning 6 hours ago, these symptoms were accompanied by intermittent colicky abdominal pain and vomiting. He looked pale and his legs were flexed against his abdomen. On physical examination, a right upper quadrant mass was found. Abdominal ultrasonography was requested.

Considering the clinical history and the presented images, what is the most likely diagnosis?

a) Intussusception

25%

b) Gastroenteritis

25%

c) Intestinal volvulus

25%

d) Meckel diverticulum

25%
   

Image Analysis

Image 1: Abdominal ultrasonography, transversal view above palpable mass in the right upper quadrant. A bowel loop (intussusceptum - in red) is seen inside the lumen of another bowel loop (intussuscipiens - in blue), characterizing the "target sign" and suggesting intussusception. There is a small amount of crescent anechoic liquid surrounding the affected bowel.

Highlights

-       Intussusception is defined as the invagination of a bowel segment into itself. It mostly occurs in children, typically between ages of 6 and 36 months;

-       Most of the cases in children are idiopathic, but anatomical causes must be considered;

-       Diagnosis is clinical and includes evidence of intestinal obstruction with intermittent, sudden and progressive episodes of colicky abdominal pain and right upper quadrant mass;

-       Ultrasonography is the first-line imaging exam for diagnostic confirmation in children, with high sensibility and specificity;

-       Treatment depends on duration of symptoms, patient's stability and presence of hemorrhage; being pneumatic reduction and surgery options with good prognosis.

References

-       Vo NJ, Sato TT. Intussusception in children [internet]. 2019. [Access on: Dec. 1st, 2019]. Available in: https://www.uptodate.com/contents/intussusception-in-children?search=intussuception%20in%20children&source=search_result&selectedTitle=1~111&usage_type=default&display_rank=1;

-       Patel N, Kay M. Lower gastrintestinal bleeding in children: Causes and diagnostic approach [internet]. 2019. [Access on: Dec. 1st, 2019]. Available in: https://www.uptodate.com/contents/lower-gastrointestinal-bleeding-in-children-causes-and-diagnostic-approach?search=intussuception%20in%20children&source=search_result&selectedTitle=2~111&usage_type=default&display_rank=2;

-       Di Lorenzo C. Approach to the infant or child with nausea and vomiting [internet]. 2019. [Access on: Dec. 1st, 2019]. Available in: https://www.uptodate.com/contents/approach-to-the-infant-or-child-with-nausea-and-vomiting?search=intussuception%20in%20children&source=search_result&selectedTitle=3~111&usage_type=default&display_rank=3;

-       Coppola CP, Kennedy Jr AP, Scorpio RJ. Pediatric Surgery. 1st Ed. E-book: Springer; 2014;

-       Mattei P. Fundamentals of pediatric surgery. 2nd Ed. E-book: Springer; 2017;

-       D'Iippolito G, Caldana RP. Gastrointestinal. Rio de Janeiro: Elsevier; 2011.

Author

Larissa Gonçalves Rezende, 4th year medical student at UFMG.

E-mail: larissarezendeg[at]gmail.com

Supervisors

Professor Clécio Piçarro, adjunct professor of the Department of Surgery at UFMG and pediatric surgeon at Hospital das Clínicas da UFMG.

E-mail: cleciop[at]hotmail.com

 

Professor Júlio Guerra Domingues, radiologist and professor of the Department of Anatomy and Image at UFMG.

E-mail: jgdjulio[at]gmail.com

Reviewers

Letícia de Melo Elias, Ana Luísa Melgaço, Victória Costa, Fernando Amorim and Aristeu Fonseca.

Test question

[Hospital Evangélico Cachoeira de Itapemerim (2018)] A 2-month-old boy was admitted in the emergency department with sudden and intense crying, accompanied by difficulty in evacuation and legs drawn up to the abdomen. Past medical history showed no constipation, only a runny nose and sneezing 2 days ago, with no fever or compromising the general state of health. Stool appeared normal at home, but during the pediatrician's evaluation he evacuated dark red and mucoid stools. There was also a painful palpable abdominal mass in the right upper quadrant. What is the most likely diagnosis and the initial management?

a) Viral gastroenteritis. Discharge with oral rehydration therapy.

25%

b) Bacterial gastroenteritis. Hospitalization, intravenous hydration and intravenous antibiotic.

25%

c) Suspected sexual abuse. Call guardianship council.

25%

d) Intestinal invagination. Hospitalization, fasting, intravenous hydration, evaluation of electrolyte replacement and surgical evaluation.

25%

e)

25%
   

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