Eduovisual
Pediatrics (System-Integrated)
Intussusception: diagnosis and management
— Peak incidence 3 months to 3 years, with 6–18 months the classic window
— Boys > girls (~3:2)
— Leading cause of bowel obstruction in infants and a top cause of acute abdomen in toddlers
— Telescoping drags mesentery in with the bowel → venous congestion → edema → arterial compromise → ischemia → necrosis → perforation/peritonitis
— Currant-jelly stool reflects sloughed mucosa mixed with blood and mucus (a late finding)
— Idiopathic (~90%) in young children, often post-viral with hypertrophied Peyer patches (adenovirus, recent URI/gastroenteritis)
— Pathologic lead points more likely if age <3 months or >5 years: Meckel diverticulum (most common pathologic lead point), HSP (Henoch-Schönlein purpura) with intramural hematoma, polyps (Peutz-Jeghers), lymphoma (especially Burkitt in older kids), CF inspissated stool, duplication cysts
— Previously well infant/toddler with sudden, episodic, severe abdominal pain with screaming, drawing knees to chest, lasting minutes, then becoming limp/lethargic between spells
— Vomiting (initially non-bilious → bilious as obstruction progresses)
— Bloody/mucousy stool
— Lethargy as the only finding can be the presenting clue — intussusception is on the differential for the "altered toddler"
Board pearl: In a child 6–18 months with intermittent inconsolable crying and unexplained lethargy, put intussusception at the top of the list before waiting for currant-jelly stool — that finding is late and often absent.
— Paroxysmal, sudden-onset, crampy episodes every 15–20 minutes
— Child screams, flexes hips and knees, may appear pale/diaphoretic
— Between episodes: initially appears well → progressively lethargic, hypotonic, "shock-like"
— Pain-free lethargy is a notorious mimic of sepsis, meningitis, or postictal state
— Early: reflexive, non-bilious
— Later: bilious (mechanical obstruction)
— Feculent vomiting → late, advanced obstruction
— Early stools may be normal
— Currant-jelly stool (dark red, mucoid) in ~50% — late marker of mucosal ischemia
— Heme-positive stool on rectal exam much more sensitive than gross blood
— Recent viral illness, gastroenteritis, URI, or adenovirus infection
— Recent rotavirus vaccination (timing within ~1 week)
— Henoch-Schönlein purpura: palpable purpura on buttocks/legs in a school-age child with abdominal pain → suspect ileoileal intussusception from intramural hematoma
— Family history of polyposis syndromes (Peutz-Jeghers) or CF
— Prior episodes (recurrence ~10%)
— <3 months: consider duplication cyst, lymphoma rare
— >5 years: lymphoma (Burkitt) until proven otherwise; consider Meckel, polyp
Key distinction: Henoch-Schönlein purpura causes ileoileal (small-bowel) intussusception → not reliably reduced by air enema; needs ultrasound of the entire abdomen and often surgical management. Don't anchor on the typical ileocolic playbook.
Step 3 management: When parents describe "episodes of screaming with knees up, then he just goes limp," skip the temptation to diagnose colic or a viral syndrome — order abdominal ultrasound the same visit.
— Between paroxysms, infant may look deceptively well early on
— Progression: pallor, diaphoresis, lethargy, hypotonia → "neurologic" presentation that misleads to LP/CT head
— Late: signs of shock — tachycardia, delayed capillary refill, mottling, hypotension (a late and ominous sign in children)
— Sausage-shaped mass in the right upper quadrant or epigastrium (~60%) — palpable along the line of the transverse colon
— Dance sign: empty right lower quadrant from cecum being pulled cephalad
— Tenderness may be mild between episodes; peritoneal signs (rigidity, guarding, rebound) → suggest ischemia/perforation
— Distension worsens with prolonged obstruction
— Heme-positive stool is highly suggestive even without gross blood
— Rarely, intussusceptum may be palpable or prolapse through the anus (advanced)
— HR and capillary refill are the most sensitive early markers
— Hypotension is late — children compensate via tachycardia until ~30–40% volume loss
— Assess mental status, urine output (target >1 mL/kg/hr in infants), mucous membranes
— 2 large-bore IVs (or IO if access fails)
— Isotonic crystalloid bolus 20 mL/kg, repeat as needed
— NG tube to decompress if vomiting/obstruction
— NPO, correct electrolytes, type and screen
— Broad-spectrum antibiotics if peritonitis or perforation suspected (e.g., piperacillin-tazobactam)
CCS pearl: On the CCS interface, the correct opening sequence is IV access → isotonic bolus → NPO → NG decompression → surgical consult → abdominal ultrasound, not "send to radiology" first. Stabilize, then image, then reduce.
Board pearl: A lethargic, pale infant with a palpable RUQ sausage and heme-positive stool is intussusception until proven otherwise — proceed to ultrasound without delay.
— CBC: leukocytosis common; left shift or marked elevation suggests ischemia/perforation
— BMP: assess for dehydration, hypokalemia, metabolic acidosis (lactic acidosis → bowel ischemia)
— Lactate: elevated in advanced ischemia
— Type and screen (preparing for possible OR)
— Coags if surgery anticipated
— Blood culture if febrile/toxic
— Abdominal ultrasound is the imaging modality of choice — sensitivity and specificity >97% in experienced hands
— Findings:
— "Target" or "donut" sign on transverse view (concentric rings of bowel-within-bowel)
— "Pseudokidney" sign on longitudinal view
— Trapped mesenteric fat and lymph nodes within the intussusceptum
— Free fluid, absent blood flow on Doppler → suggests ischemia (relative contraindication to enema reduction)
— Not required but often obtained — useful primarily to exclude free air (perforation) before enema
— Findings (insensitive): paucity of gas in RLQ, soft tissue mass, "crescent sign" (intussusceptum outlined by gas), target sign in RUQ
— Normal radiograph does NOT exclude intussusception
— Both diagnostic and therapeutic — see chunk 8
— No longer the first diagnostic test in modern practice because ultrasound is faster, radiation-free, and operator-accessible
— CT is not first-line in children due to radiation; reserve for older children with suspected lymphoma lead point or diagnostic uncertainty
— Don't delay imaging awaiting lab results in a clinically obvious case
Step 3 management: Order ultrasound first. If the question shows a plain film with a "target sign" or "crescent sign," recognize it — but on the wards/CCS, US is the right next step, not CT.
Key distinction: Doppler showing absent flow + free fluid → bowel may be ischemic/perforated → go to OR, not enema.
— Age <3 months or >5 years
— Recurrent intussusception (after 2–3 episodes)
— Ileoileal (small-bowel) intussusception on US — frequently associated with HSP, lymphoma, Meckel
— Failed enema reduction with persistent symptoms
— Atypical location, mass, or imaging features
— CT with contrast: older children/adolescents with suspected lymphoma (Burkitt) — assess for mesenteric mass, lymphadenopathy; also useful when diagnosis is unclear or for adult-type presentations
— MRI enterography: young patients needing lead-point characterization without radiation, particularly for chronic/recurrent disease
— Meckel scan (99mTc-pertechnetate): if Meckel diverticulum suspected, especially in a child with painless GI bleed history
— Capsule endoscopy or push enteroscopy: rarely needed; for polyposis syndromes
— Colonoscopy: consider in older children with recurrence or if polyp suspected as lead point (Peutz-Jeghers)
— Often transient and self-limited if small (<2 cm) and short segment with normal Doppler — observe with serial US
— Persistent or longer segments → surgical evaluation, as enema cannot reach small bowel
— Suspect in school-age child with palpable purpura + crampy abdominal pain
— Almost always ileoileal → ultrasound the entire abdomen, including beyond the ileocecal valve
— Surgery often required
— ~90% have a pathologic lead point, often malignant (vs ~10% pathologic in kids)
— Workup: CT abdomen/pelvis with contrast, almost always followed by surgical resection without attempted reduction
Board pearl: A 5-year-old African child with intussusception → think Burkitt lymphoma as the lead point; obtain CT and oncology consult after surgical reduction with pathology of the lead point.
Key distinction: Pediatric ileocolic = idiopathic, reduce with enema. Adult or older-child ileoileal = lead point until proven otherwise, operate.
— Step 1: Is the patient stable?
— Unstable (peritonitis, shock, free air, septic): surgical emergency → OR for operative reduction ± resection
— Stable: proceed to non-operative reduction
— Step 2: Resuscitate and prepare
— IV fluids, NPO, NG decompression, labs, type and screen
— Surgical consultation BEFORE attempting enema (must be available for failure or perforation)
— Step 3: Non-operative reduction
— Air (pneumatic) enema under fluoroscopic guidance is preferred in the US — lower perforation risk, less mess if perforation occurs
— Hydrostatic enema (saline or water-soluble contrast) under fluoroscopy or ultrasound — comparable success
— Success rate: 80–90% for uncomplicated ileocolic intussusception
— Step 4: Post-reduction observation
— Admit for observation 12–24 hours (some centers shorter for clear-cut cases)
— Watch for recurrence (~10%), perforation, missed lead point
— Advance diet as tolerated
— Peritonitis
— Free intraperitoneal air (perforation)
— Hemodynamic instability despite resuscitation
— Significantly long duration of symptoms with bowel necrosis suspected
— Ileoileal intussusception (enema can't reach)
— Symptoms >48 hours
— Significant dehydration, lethargy
— Small-bowel obstruction on imaging
— Free fluid in abdomen
— Age <3 months or >5 years (pathologic lead point likely)
Step 3 management: Always call surgery before the radiology suite — never send an unstable or peritonitic child for enema "to try first." Pneumatic reduction is a procedure, not a triage step.
CCS pearl: Order set = "NPO, IV NS bolus 20 mL/kg, NG tube to LIS, CBC/BMP/type-and-screen, surgery consult, fluoroscopic air enema reduction."
— Isotonic crystalloid (normal saline or lactated Ringer's) 20 mL/kg IV bolus
— Repeat boluses up to 60 mL/kg, then reassess
— Add maintenance fluids with D5 ½NS + 20 mEq/L KCl once urinating
— Correct hypokalemia, metabolic acidosis
— IV opioid (morphine 0.05–0.1 mg/kg or fentanyl 1–2 mcg/kg) for pain
— Sedation for enema is generally not needed, as the procedure is brief; some centers use light sedation (midazolam) — avoid deep sedation that could mask perforation signs
— Avoid NSAIDs (bleeding risk, renal)
— Ondansetron 0.15 mg/kg IV for vomiting
— Not routine for uncomplicated reduction
— Indicated if:
— Peritonitis or perforation suspected
— Going to OR
— Sepsis/systemic toxicity
— Regimens: piperacillin-tazobactam, OR ceftriaxone + metronidazole, OR ampicillin-sulbactam
— Cover gram-negatives and anaerobes (enteric flora)
— Continue IV fluids until tolerating PO
— Advance diet to clears → regular as tolerated
— Pain control transitioned to PO acetaminophen
Board pearl: The "drug regimen" tested for intussusception is really fluids + antiemetic + opioid analgesia ± antibiotics for complications. If the stem mentions fever, rigidity, free air, or septic appearance, antibiotics become the right answer.
Step 3 management: Don't pick "trial of bowel rest and NG decompression" as definitive therapy — it's a bridge to reduction, not the cure.
— Pneumatic (air) enema under fluoroscopy — most common in US
— Insufflation pressure: ≤120 mmHg in infants (some use up to 80 mmHg starting, max ~120)
— Three attempts of ~3 minutes each is typical ("rule of 3s")
— Success = free reflux of air into terminal ileum — radiographic endpoint
— Hydrostatic enema — saline (under US) or water-soluble contrast (under fluoroscopy)
— Column height ≤1 meter above patient
— Success rates 80–90%; higher with shorter symptom duration
— Perforation (~1%) — typically at the cecum or transverse colon
— Air enema → tension pneumoperitoneum risk → have a large-bore needle ready for decompression
— Surgical team must be in-house
— Incomplete reduction
— Recurrence (~10%, mostly within 72 hours; ~50% of those within 48 hours)
— Failed enema reduction
— Peritonitis, free air, or hemodynamic instability
— Suspected or identified pathologic lead point (especially older children)
— Recurrent intussusception (≥2–3 episodes) → look for and resect lead point
— Ileoileal intussusception that doesn't self-resolve
— Laparoscopic or open manual reduction (milk the intussusceptum out distally — do not pull)
— Bowel resection with primary anastomosis if:
— Bowel non-viable/ischemic/necrotic
— Cannot be reduced
— Pathologic lead point identified (Meckel, polyp, lymphoma mass)
— Send specimens to pathology
— NPO with NG decompression until bowel function returns
— IV fluids, IV antibiotics if resection done
— Advance diet as tolerated; typical LOS 3–5 days
CCS pearl: If the air enema "fails" (intussusceptum doesn't reduce past the ileocecal valve), the next step is operative reduction, not a repeat enema attempt indefinitely.
Board pearl: Sudden abdominal distension and respiratory compromise during air enema = tension pneumoperitoneum → immediate needle decompression and OR.
— High pretest probability for a pathologic lead point (~25–60%)
— Lymphoma (Burkitt) is the leading concern, particularly in school-age and adolescent males
— Meckel diverticulum common across pediatric ages
— Polyps (Peutz-Jeghers, juvenile polyposis) — examine for mucocutaneous pigmentation, family history
— Workup should include CT before or after reduction, and surgical exploration with biopsy is often warranted even if reduction succeeds
— Outcome heavily depends on identifying and treating the underlying lesion
— Higher intussusception rate, often from inspissated stool acting as a lead point in the terminal ileum
— May present atypically or with distal intestinal obstruction syndrome (DIOS) mimicking intussusception
— Optimize CF management: pancreatic enzymes, hydration, osmotic laxatives (polyethylene glycol), N-acetylcysteine or Gastrografin enemas for DIOS
— Causes submucosal hematomas as lead points
— Ileoileal location → often missed on standard US technique unless full abdomen scanned
— Often requires surgical management if persistent
— Adjust opioid dosing in renal impairment (avoid morphine accumulation → use fentanyl)
— Monitor contrast load if water-soluble contrast enema in renal disease
— Hepatic dysfunction: caution with acetaminophen dosing, opioid metabolism
— Lower threshold for empiric antibiotics
— Consider post-transplant lymphoproliferative disease (PTLD) as a lead point in transplant recipients
Key distinction: In CF, "intussusception" mimickers like DIOS are managed with Gastrografin/PEG, not enema reduction — get the right diagnosis on US.
Board pearl: Older child + intussusception → find the lead point. Pathology drives prognosis, not the reduction itself.
— Intussusception is uncommon in this age — when it occurs, pathologic lead point is highly likely (duplication cyst, ectopic pancreas, lymphoma rare)
— Presentation often atypical: feeding intolerance, abdominal distension, bilious emesis — overlaps with NEC, malrotation/volvulus, Hirschsprung
— Surgical evaluation is the default; enema reduction less successful
— Classic idiopathic ileocolic disease
— Excellent response to enema reduction
— High recurrence rate after first episode (~10%) — counsel families specifically
— Slightly increased risk of intussusception, 1–7 days after the first dose (and to a lesser extent the second)
— Excess risk: ~1–5 cases per 100,000 vaccinated infants
— Benefits substantially outweigh risks — continue routine vaccination
— Contraindications to rotavirus vaccine:
— History of intussusception (absolute contraindication)
— SCID (severe combined immunodeficiency)
— Uncorrected congenital GI malformation predisposing to intussusception
— Step 3 may test: 4-month-old with recent rotavirus vaccine → still get US, manage same way; do not withhold reduction
— Behavior shifts toward adult disease pattern — lead point in most cases, often surgical from the start
— Consider lymphoma, Peutz-Jeghers, IBD-related, post-surgical adhesions
— Post-op intussusception is rare but reported after retroperitoneal surgery (e.g., Wilms resection); typically small-bowel and may require surgical reduction
Step 3 management: A parent asks about giving rotavirus vaccine after their infant had an episode of intussusception — answer is do not vaccinate; history of intussusception is an absolute contraindication.
Board pearl: Neonates and adolescents play by adult rules: assume a lead point, image with CT/MRI as needed, and plan for surgery.
— Result of prolonged venous and arterial compromise
— Risk rises sharply after 48 hours of symptoms
— Necrosis mandates resection at surgery; do not attempt to reduce non-viable bowel into the peritoneum
— Spontaneous or iatrogenic (during enema reduction, ~1%)
— Air enema → tension pneumoperitoneum → cardiopulmonary compromise → needle decompression in the radiology suite
— Hydrostatic enema → peritoneal contamination with contrast/saline
— Requires emergent laparotomy, peritoneal lavage, and bowel repair/resection
— Bowel ischemia translocates flora → polymicrobial sepsis
— Broad-spectrum antibiotics (pip-tazo or ceftriaxone + metronidazole) + aggressive resuscitation + surgical source control
— ~10% overall after successful non-operative reduction
— Higher after hydrostatic vs pneumatic in some series
— Most recurrences within 72 hours (50%+ within 48 hours)
— Recurrent episodes can again be managed with enema if otherwise uncomplicated; consider lead-point workup after 2–3 episodes
— Long-term complication if extensive resection performed
— Manifests as malabsorption, diarrhea, failure to thrive, TPN dependence
— Standard post-laparotomy risks in operative cases
— Recurrence or persistent symptoms → reassess for lymphoma, polyp, Meckel
— <1% in developed countries with prompt diagnosis
— Substantially higher in late-presenting or under-resourced settings (delayed presentation is the dominant risk factor for death)
Step 3 management: A child becomes hypotensive with abdominal distention during air enema → immediately stop the procedure, decompress the abdomen with a large-bore angiocatheter in the midline, and take to the OR.
Board pearl: Delay is the deadliest complication. The single greatest predictor of bowel resection and morbidity is time from symptom onset to reduction.
— Confirmed or strongly suspected intussusception on US
— Plain film with free air, peritonitis on exam
— Hemodynamic instability
— Failed enema reduction
— Septic shock unresponsive to initial fluid resuscitation
— Need for vasopressors (epinephrine first-line in pediatric septic shock)
— Respiratory failure / need for intubation
— Post-op course with hemodynamic concern, large resection, or significant fluid shifts
— Peritonitis with multiorgan dysfunction
— Community ED without pediatric surgery or interventional radiology: stabilize, resuscitate, give antibiotics if peritonitis, and transfer to a pediatric tertiary center
— Avoid attempting enema reduction at a center without immediate surgical backup
— Use a pediatric transport team with airway, vascular access, and PALS capability
— Successful enema reduction → 23-hour observation is standard
— Monitor vitals every 4 hours, abdominal exams, advance diet, watch for recurrence
— Pediatric surgery — always
— Pediatric radiology / interventional — for reduction
— Pediatric oncology — if lymphoma identified as lead point (especially Burkitt — high-grade, oncologic emergency for tumor lysis syndrome)
— Pediatric gastroenterology — for recurrent disease, polyposis workup
— Pediatric infectious disease — for atypical or refractory sepsis
CCS pearl: Standard advance-clock orders post-reduction: "Admit pediatric ward, NPO advance to clears in 6 hours, IV maintenance fluids, vital signs q4h, abdominal exam q4h, surgery to follow." If symptoms recur → repeat US, re-consult surgery.
Step 3 management: Burkitt lymphoma found on resection → admit to PICU/oncology, start tumor lysis prophylaxis (IV hydration + allopurinol or rasburicase), check uric acid, K, Ca, Phos, and initiate chemotherapy promptly.
— <1 year, often <1 month
— Sudden bilious emesis in a previously well infant is volvulus until proven otherwise
— Upper GI series: "corkscrew" duodenum, ligament of Treitz on right side, duodenojejunal junction abnormal
— Emergent Ladd procedure — bowel viability hinges on minutes-to-hours timing
— Premature neonates, typically in first weeks of life
— Feeding intolerance, abdominal distension, bloody stools, pneumatosis intestinalis on abdominal X-ray
— Bowel rest, IV antibiotics, surgical consult; perforation → laparotomy or peritoneal drain
— 2–8 weeks, non-bilious projectile vomiting, palpable "olive", hypochloremic hypokalemic metabolic alkalosis
— US: pyloric muscle >3 mm thick, channel >15 mm long
— Fluid/electrolyte correction, then pyloromyotomy
— Delayed meconium passage history, megacolon on imaging
— Rectal biopsy diagnostic (absent ganglion cells)
— Older children typically; periumbilical → RLQ pain, anorexia, vomiting after pain
— US/CT, surgical management
— Tender groin/scrotal bulge, vomiting, irritability
— Manual reduction (most cases) → elective repair; if non-reducible or strangulated → emergent surgery
— Post-viral, enlarged mesenteric lymph nodes, mimics appendicitis, self-limited
— Common mimic; KUB or rectal exam can clarify; not usually with shock signs
Key distinction: Bilious vomiting in a young infant = malrotation/volvulus as the leading concern, not intussusception. Both are emergencies, but the upper GI is the time-critical test for volvulus.
Board pearl: The age window is your best discriminator: pyloric stenosis ~2–8 weeks, NEC in preemies, volvulus <1 year (often <1 month), intussusception 6–18 months, appendicitis older.
— Meningitis/encephalitis: fever, meningismus, altered mental status — LP if concerned, but examine the abdomen in every lethargic infant
— Seizure/postictal state: witnessed seizure activity, no GI symptoms; remember intussusception can mimic postictal lethargy
— Non-accidental head trauma: retinal hemorrhages, fontanel fullness — keep on differential, but abdominal exam stays mandatory
— Sepsis from any source — fluid resuscitate while seeking source
— DKA in a toddler — Kussmaul respirations, dehydration, abdominal pain
— Ingestion — clonidine (lethargy, bradycardia), opioid (miosis), iron (hematemesis)
— Bacterial gastroenteritis (Salmonella, Shigella, Campylobacter, EHEC): bloody diarrhea, fever, but typically more diffuse symptoms; EHEC → watch for HUS (thrombocytopenia, AKI, MAHA)
— C. difficile (if recent antibiotics)
— Testicular torsion in boys — examine the scrotum
— UTI/pyelonephritis — pyuria, fever, costovertebral tenderness
— Bowel obstruction from adhesions (post-op patients)
— Internal hernia, mesenteric ischemia (rare in children)
— HSP — bridges differential and cause (can both mimic and cause intussusception)
— Sickle cell vaso-occlusive crisis with splenic sequestration — splenomegaly, anemia
— Infant colic — diagnosis of exclusion; never colic if there's bilious vomiting, blood in stool, lethargy, or abnormal exam
Step 3 management: In a lethargic infant with vague history, palpate the abdomen and do a rectal exam before chasing a CNS workup. Many missed intussusceptions are diagnosed in retrospect after a "negative" LP.
Key distinction: EHEC bloody diarrhea + abdominal pain in a toddler — don't anchor on intussusception, but a confused picture warrants US to rule out — the two can be confused, and treatment is utterly different (no antibiotics for EHEC).
— Observation period: typically 12–24 hours inpatient (some centers offer same-day discharge for highly selected, brief observation cases)
— Tolerating PO, ambulating, normal vital signs, normal abdominal exam, stooling
— No further imaging required if asymptomatic
— Diet advancement when bowel function returns (flatus, BM)
— Pain control transitioned to PO acetaminophen ± oxycodone short course
— Wound care instructions
— Activity restrictions: no heavy lifting/contact sports for 4–6 weeks after laparotomy; sooner after laparoscopy
— Recurrence ~10% (most within 72 hours, can be up to months later) — counsel explicitly
— Return precautions: intermittent severe crying, drawing legs up, vomiting (especially bilious), bloody stools, lethargy, abdominal distention → return to ED immediately
— Do not wait to see if "it passes"
— History of intussusception = absolute contraindication to future rotavirus vaccine doses
— Document clearly in chart; communicate to PCP
— Excellent if treated promptly; full recovery typical
— Short bowel syndrome if extensive resection — multidisciplinary GI/nutrition follow-up, possible home TPN
— Lead-point pathology drives long-term course (e.g., Burkitt requires full oncology treatment)
Step 3 management: Discharge packet must include: return precautions sheet, PCP follow-up in 1–2 weeks, surgery follow-up in 2–4 weeks (if operative), updated vaccination plan with rotavirus contraindication documented.
Board pearl: Recurrence rates do not increase after multiple successful non-operative reductions in the absence of a lead point — but after 2–3 recurrences, look for one with CT or surgical exploration.
— 1–2 weeks post-discharge — confirm symptom resolution, normal growth/feeding, no recurrence signs
— Review return precautions again with family
— Reinforce vaccination plan (rotavirus contraindicated; all other routine immunizations on schedule)
— Operative patients: 2–4 weeks for wound check, abdominal exam
— Confirm pathology results if specimen taken; discuss any lead-point findings
— Resume normal activity by 4–6 weeks (open) or sooner (laparoscopic)
— Urgent linkage to pediatric hematology/oncology
— Staging workup: bone marrow biopsy, LP for CSF cytology, imaging (CT chest/abdomen/pelvis, PET)
— Initiate tumor lysis syndrome prophylaxis before chemotherapy
— Peutz-Jeghers: lifelong surveillance — colonoscopy, EGD, small bowel imaging; genetic counseling (STK11/LKB1)
— Juvenile polyposis (SMAD4, BMPR1A): surveillance and genetic counseling
— Meckel diverticulum post-resection: no special long-term surveillance
— Weight and growth at each visit
— Bowel habits, abdominal pain episodes
— Hemoglobin if chronic blood loss suspected (lead-point bleeding)
— Reassurance: most idiopathic intussusception cases do not recur and have no long-term sequelae
— Vigilance: episodic abdominal pain in the future warrants prompt evaluation
— Vaccine guidance: clear, written instructions about rotavirus contraindication; siblings can still be vaccinated
— Sibling risk: not significantly elevated for idiopathic cases; elevated only for inherited polyposis syndromes
Step 3 management: Document closed-loop communication to the PCP about the rotavirus vaccine contraindication — this is a common transition-of-care safety gap.
Board pearl: Recurrence after 2–3 reductions flips management toward surgical exploration for lead point, even if imaging is unrevealing.
— Obtain consent from parents/legal guardians for non-operative and operative procedures
— Discuss: success rate (~80–90% for enema), perforation risk (~1%), recurrence (~10%), and need for surgery if reduction fails
— Document discussion clearly
— For older children (typically ≥7 years), seek assent in addition to parental consent — explain the procedure in age-appropriate language
— Assent does not override parental authority but respects developing autonomy
— In a life-threatening scenario (peritonitis, tension pneumoperitoneum, shock) where parents are unreachable, proceed under the emergency doctrine — document the clinical justification and attempts to contact family
— Rare but possible (e.g., religious objection to blood transfusion if needed)
— Life-threatening pediatric emergencies override parental refusal — seek emergency court order or invoke child protection laws when necessary
— Engage hospital ethics committee and risk management early
— Not directly required for intussusception itself, but if the delay in seeking care raises concerns for medical neglect, file a report with child protective services
— Consider non-accidental trauma if injuries inconsistent with history
— Transition-of-care risk: the rotavirus vaccine contraindication after an episode of intussusception is a common documentation failure — must be transmitted to PCP, immunization registry, and family in writing
— Diagnostic anchoring on viral gastroenteritis or colic in a lethargic infant — formal cognitive debiasing strategies and structured handoffs reduce missed diagnoses
— Radiation stewardship: use ultrasound first in children, reserve CT for specific indications
— Closed-loop communication during enema reduction between radiology and surgery
— Same-day discharge protocols after uncomplicated reduction reduce cost and nosocomial exposure but require clear safety-net criteria and family teach-back
— Time of symptom onset, time of diagnosis, time of reduction → quality metric for pediatric surgical care
Step 3 management: A parent refuses surgery for their child with peritonitis from failed reduction — do not delay: contact hospital legal/ethics, document the imminent threat, obtain emergency court order, and proceed with life-saving care.
Board pearl: Forgetting to document the rotavirus vaccine contraindication at discharge is a classic, exam-testable transition-of-care patient safety failure.
— Small increased risk in the 1–7 days after first dose
— History of intussusception = absolute contraindication to future doses
— SCID is another absolute contraindication
Board pearl: Match the buzzword: "target sign" → US intussusception; "double bubble" → duodenal atresia; "corkscrew" → midgut volvulus; "string sign" → pyloric stenosis (US) or Crohn's (terminal ileum on contrast).
Key distinction: Kids = idiopathic, reduce. Adults = lead point, resect.
— "A 9-month-old previously healthy boy presents with intermittent inconsolable crying with drawing of the knees to the chest for 6 hours, two episodes of non-bilious vomiting, and one episode of dark red mucoid stool. He is currently lethargic. Exam: palpable sausage-shaped mass in the RUQ. Next best step?"
— Answer: Abdominal ultrasound
— "Ultrasound shows a target sign in the right upper quadrant. The child is hemodynamically stable. Next step?"
— Answer: IV fluids, NG decompression, surgical consult, then air-contrast enema reduction
— "During air enema, the child becomes hypotensive with marked abdominal distention. Next step?"
— Answer: Stop procedure, needle decompression of pneumoperitoneum, emergent laparotomy
— "A 6-year-old boy with abdominal pain, weight loss, palpable abdominal mass. US: intussusception. Most likely lead point?"
— Answer: Lymphoma (Burkitt) — workup with CT, oncology consult
— "A 7-year-old with palpable purpura on the buttocks and lower extremities, joint pain, and severe colicky abdominal pain. US shows ileoileal intussusception. Best management?"
— Answer: Steroids and surgical evaluation (enema typically ineffective for ileoileal)
— "An infant had air-enema reduction of intussusception at age 4 months. Now 6 months old, due for rotavirus vaccine. Recommendation?"
— Answer: Do not administer rotavirus vaccine — history of intussusception is an absolute contraindication
— "Two-week-old with sudden onset of bilious vomiting, ill-appearing. Best next test?"
— Answer: Upper GI series for malrotation/volvulus, NOT US for intussusception
— "Six hours after successful air enema, child has return of crampy pain and vomiting. Next step?"
— Answer: Repeat ultrasound; if recurrence, repeat enema (acceptable for first recurrence in absence of complications)
— "55-year-old with intermittent abdominal pain, weight loss, and CT showing target sign in colon. Best management?"
— Answer: Surgical resection — assume pathologic lead point (likely malignancy)
Board pearl: When the age, vaccine timing, or recent illness is named in the stem, that's the discriminator — answer accordingly.
Intussusception — most often ileocolic, idiopathic, and 6–18 months old — presents with paroxysmal crying, vomiting, and (late) currant-jelly stool, is diagnosed by abdominal ultrasound ("target sign"), and is managed with resuscitation plus pneumatic enema reduction (or surgery if unstable, failed, perforated, or lead-point driven).
— Age 6–18 months + episodic crying + lethargy → US first, don't wait for currant-jelly stool
— "Target/donut" on transverse, "pseudokidney" on longitudinal, Doppler for viability
— Resuscitate (IV fluids 20 mL/kg, NPO, NG), consult surgery, then reduce
— Pneumatic (air) enema under fluoroscopy is first-line — 80–90% success, ~1% perforation risk
— Operate for: failed reduction, peritonitis, perforation, instability, ileoileal disease, or pathologic lead point
— <3 months or >5 years, recurrent, or ileoileal location → suspect Meckel, lymphoma (Burkitt in older kids), HSP, polyp (Peutz-Jeghers), CF
— Adults: nearly always a lead point — resect, don't reduce
— Observe 12–24 hrs post-reduction (10% recurrence, most within 72 hrs)
— Rotavirus vaccine: absolute contraindication going forward — document and transmit to PCP
— Return precautions: recurrent screaming, bilious vomiting, blood in stool, lethargy
— PCP follow-up 1–2 weeks; surgery 2–4 weeks; oncology if Burkitt; GI/genetics if polyposis
Board pearl: Time-to-reduction is the single biggest determinant of outcome — every step of the workup is built around getting bowel decompressed fast and safely, then making sure you haven't missed a lead point hiding behind the textbook story.