Examkin

Question

Difficulty: MediumPediatric Gastrointestinal Disorders

An 8-month-old female infant is brought to the pediatric emergency department due to sudden episodes of severe, inconsolable crying. During these episodes, she draws her knees to her chest. The episodes began 24 hours ago and have progressively worsened in frequency. Earlier today, she began having non-bilious vomiting, which recently transitioned to bilious emesis. Her last bowel movement contained dark red blood and thick mucus.

On physical examination, her temperature is 38.8°C (101.8°F), heart rate is 175/min, respiratory rate is 45/min, and blood pressure is 68/40 mmHg. She appears lethargic and pale. Abdominal examination reveals a rigid, distended abdomen with severe, diffuse tenderness and involuntary guarding. Bowel sounds are absent. Arterial blood gas analysis demonstrates a pHpH of 7.24, pCO2pCO_2 of 28 mmHg, and HCO3−HCO_3^- of 12 mEq/L.

Which of the following is the most appropriate next step in management?

  1. Prompt operative interventionAnswer
  2. B
    Fluoroscopy-guided pneumatic reduction
  3. C
    Cross-sectional abdominal imaging
  4. D
    Infusion of sodium bicarbonate solution
  5. E
    Empiric antimicrobial therapy and serial reassessment

Answer

Prompt operative intervention
This infant presents with classic signs of intussusception, including severe colicky pain, drawing the legs to the chest, and 'currant jelly' stool. Importantly, her physical examination reveals peritonitis (a rigid, guarded abdomen with absent bowel sounds) and hemodynamic instability (hypotension, tachycardia, and a severe metabolic acidosis indicating poor perfusion). While uncomplicated intussusception is typically managed with an image-guided air or contrast enema, the presence of peritonitis, perforation, or profound shock is an absolute contraindication to enema reduction. These findings suggest bowel ischemia or necrosis, making urgent operative intervention the only appropriate next step.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation.
The combination of colicky abdominal pain (drawing knees up), bilious emesis, and 'currant jelly' stools (blood and mucus) is highly characteristic of intussusception.
Recognizing the underlying condition is required before determining the appropriate treatment pathway.
2
Assess the patient's clinical stability and look for complications.
The patient is hemodynamically unstable (hypotensive, tachycardic) and has signs of peritonitis (rigid abdomen, involuntary guarding, absent bowel sounds).
The presence of peritonitis or shock drastically alters the management of pediatric gastrointestinal emergencies.
3
Select the most appropriate intervention for a complicated gastrointestinal obstruction.
Because the patient has peritonitis and shock, conservative or radiologic reduction is contraindicated. Immediate surgery is required.
Peritonitis indicates probable bowel necrosis or perforation, necessitating urgent surgical exploration and source control.

Key Concept

Management of complicated pediatric intussusception
Rate this question

Topics

Pediatric Gastrointestinal Disorders

More questions from this topic