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Difficulty: HardPediatric Gastrointestinal Disorders

A 1010-month-old female infant is brought to the emergency department by her parents due to severe, episodic abdominal pain and lethargy. The parents report she has been pulling her legs up to her chest and crying inconsolably for the past 2424 hours. In the last 44 hours, she has become increasingly difficult to arouse. She recently passed a stool described by the parents as looking like "currant jelly."

Physical examination reveals:
Temperature: 38.7∘C38.7^\circ\text{C} (101.7∘F101.7^\circ\text{F})
Heart rate: 185/min185/\text{min}
Respiratory rate: 55/min55/\text{min}
Blood pressure: 65/40 mmHg65/40\text{ mmHg}

The infant appears toxic, mottled, and lethargic. The abdomen is grossly distended, rigid, and exquisitely tender to light palpation. Bowel sounds are absent.

Laboratory results:
pH: 7.247.24
PaCO 2_2: 30 mmHg30\text{ mmHg}
HCO 3−_3^-: 12 mEq/L12\text{ mEq/L}
Lactate: 5.8 mmol/L5.8\text{ mmol/L} (Normal: 0.5−1.50.5-1.5)

After initiating airway management and aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

  1. Emergent surgical explorationAnswer
  2. B
    Diagnostic and therapeutic pneumatic enema
  3. C
    Transport to radiology for a stat abdominal computed tomography scan
  4. D
    Intravenous sodium bicarbonate administration based on calculated respiratory compensation
  5. E
    Initiation of broad-spectrum intravenous antibiotics as definitive therapy

Answer

Emergent surgical exploration
The correct answer is emergent surgical exploration. This patient's classic history of episodic pain, drawing up the legs, and "currant jelly" stool strongly suggests intussusception. However, the physical examination reveals a rigid, distended abdomen with absent bowel sounds, tachycardia, hypotension, and lactic acidosis. These findings indicate that the intussusception has progressed to bowel ischemia, necrosis, and peritonitis. In a hemodynamically unstable pediatric patient with an acute surgical abdomen, the definitive and life-saving management is emergent laparotomy to resect the necrotic bowel and restore continuity.

Step-by-Step Solution

1
Identify the primary clinical diagnosis.
The combination of severe episodic abdominal pain, pulling legs up, lethargy, and "currant jelly" stool in a 1010-month-old infant is a classic presentation of intussusception.
Recognizing the underlying pathology is the required first step in determining the management algorithm.
2
Assess for complications such as bowel ischemia, perforation, or peritonitis.
The physical examination reveals a rigid, exquisitely tender abdomen with absent bowel sounds, indicative of peritonitis. Additionally, the patient is in shock with a severe lactic acidosis.
Complications drastically alter the management pathway from medical/radiologic to emergent surgical intervention.
3
Select the appropriate intervention based on the presence of complications.
Because peritonitis and shock are absolute contraindications to the standard pneumatic enema, emergent surgical exploration is required to resect the necrotic bowel.
Non-operative reduction maneuvers risk further perforation and delay definitive source control in an unstable patient.

Key Concept

In pediatric patients with intussusception, the presence of peritonitis, perforation, or hemodynamic instability is an absolute contraindication to non-operative reduction (pneumatic or hydrostatic enema) and requires emergent surgical exploration.
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Topics

Pediatric Gastrointestinal Disorders

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