GENERA

L
Baby Boy
DATA
6 month old
 CHIEF
COMPLAI
 Pallor
NT
 Abdominal pain
 HISTORY OF
PRESENT ILLNESS
  Intermittent abdominal pain
2 DAYS  Sleep disturbances
PTA  Pulling legs up toward chest
 Rigid abdomen
 Appetite not affected
  Reddish stool 2x
1 DAY
 Intermittent abdominal pain
PTA
 Normal behaviour in between
episodes
  Reddish stool 1x
MORNING  Occasional crying and pain
PTA followed by BM almost entirely of
blood including a large clot
 Pale and diaphoretic
 brought to the emergency hospital
 Vital Signs
 BP- 92/52 mmHg
 PR- 178 bpm
 CR- 24 cpm
 Temp- 36.5
 O2 sat- 100% in ambient air
PHYSICAL Weight- 9.1 kg
EXAMINATIO
N
 GIT
• Diffuse tenderness R > L
• (-) masses
• (-) external anal fissures

PHYSICAL
EXAMINATIO
N
 2 HRS
AFTER
ARRIVAL
TO THE
 Dark red stool resembling currant
OTHER jelly
HOSPITAL  Given PNSS IVF 5ml/kg
 Brought to Tertiary hospital
PAST MEDICAL
HISTORY
 Infantile colic and
Gastroesophageal reflex treated
with ranitidine
 Received low lactose cow milk base
formula
 Constipated developed after pureed
food and vegetables introduction of
diet
 Received cholecalciferol,
unspecified over the counter
teething gel and unspecified
homeopathic teething tablets

 Immunization: current through 4

months of age
 Oral human-bovine reassortment
pentavalent rotavirus vaccine
 No known allergies
 Lives with parents
 Attends Daycare
 No known sick contacts
 FAMILY
HISTORY
 (-) Bleeding disorders
 Vital Signs
 BP- 98/47 mmHg
 PR- 160 bpm
 RR - 32cpm
 Temp- 36.3
 O2 sat- 99% in ambient air

Appeared well
PHYSICAL (+) bowel sounds
EXAMINATIO (+) Melena with small amounts of
N stool
 35
MINUTES
INTO  Ultrasound was done
ADMISSIO (+) peristalsis
N
 Vital signs
 BP- 94/36 mmHg
 PR- 168 bpm
Pale
Soft abdomen
(-) distention
(-) tenderness
PHYSICAL (-) masses
EXAMINATIO (+) bowel sounds
N
LABORATORY
RESULTS
Electrolytes
Glucose Normal
AST
ALP
Total Bilirubin
Direct Bilirubin
Given packed RBC, Pantoprazole, and
Famotidine IVTT
Table 1. Laboratory Data

Reference Range, Age-

Variable Present laboratories
Adjusted*
Hematocrit (%) 33.0-3.0 17.5 ↓
Hemoglobin (g/dl) 10.5-13.5 5.7 ↓
Reticulocyte count (%) 0.5-2.5 7.6 ↑
White-cell count (per
6,000-17,500 22,200 ↑
mm3)
Differential count (%)
Neutrophil 17-49 38 N
Lymphocyte 67-77 59 ↓
Monocytes 4-11 3↓
Red-cell count (per mm3) 3,700,000-5,300,000 2,070,000 ↓
Table 1. Laboratory Data
Reference Range, Age-
Variable Present laboratories
Adjusted*
Prothrombin time (sec) 11.0-14.0 12.4 N
Prothrombin-time international
0.9-1.1 1.0 N
normalized ratio
Activated partial thromboplastin
22.1-37.0 19.4 ↓
time (sec)
Total protein (g/dl) 6.0-8.3 5.4 ↓

Albumin (g/dl) 3.3-5.0 4.1 N

Globulin (g/dl) 1.9-4.1 1.3 ↓

Iron (g/dl) 45-160 19 ↓

Iron-binding capacity (µg/dl) 230-404 351 N

LEARNING
ISSUES
1
2 Was there any weight loss?

3
4 Was the baby taking any iron supplementation?

5
6
 7 Was he breast fed exclusively since birth?

8 Was there any episode of diarrhea?

9
10 What were other results of the ultrasound?

11
12 Was a stool exam done?
13 Urine culture or analysis

14 Were the stools ribbon like?

15 Was the baby born prematurely?

16 ?

17 ?

18 ?
 SALIENT
FEATURES
 Intermittent episodes of abdominal pain

Reddish stools

Dark red stool that was resembling currant jelly

HISTORY
History of infantile colic and GERD

Normal behavior in between episodes

 Upon palpation of the abdomen, diffuse tenderness
greater on the right side than the left; no masses

No external anal fissures

Bowel peristalsis present

PHYSICAL
EXAMINATIO
Pale and diaphoretic
N

Afebrile

?
 WORKING
IMPRESSION
Intussusception
DIFFERENTIAL
DIAGNOSIS
Acute Abdominal Pain Chronic Abdominal Pain
Gastroenteritis Nephrolithiasis
Appendicitis Neoplastic
Peptic ulcer disease Celiac Disease
Meckel's diverticulum Pancreatic
IBS Hepatobiliary
Intussusception
INTUSSUSCEPTION
RULE IN RULE OUT
•
Male Cannot fully rule out
•
6 months old
•
Intermittent Abdominal pain
•
Abdominal tenderness more
in the right than left
•
Abdominal rigidity
•
Currant jelly stool
•
(+) peristalsis
MECKEL’S DIVERTICULUM
RULE IN RULE OUT
•
Brick red stool Cannot completely rule out
•
Abdominal pain
•
6 months old
•
Anemia
ACUTE APPENDICITIS
RULE IN RULE OUT
•
Abdominal pain more in the (-) vomiting
right than left (-) fever
•
Abdominal rigidity (-) anorexia
•
Leukocytosis (22,200)
INFLAMMATORY BOWEL
SYNDROME
Rule in Rule out
Abdominal pain (-)Fever
Anemia (-)Weight loss
(-)Diarrhea
(-)Growth failure
PEPTIC ULCER DISEASE
RULE IN RULE OUT
•
Melena (-) vomiting
•
Abdominal Pain (-) Feeding difficulties
•
Crying episodes
•
Bright red blood
 CASE
DISCUSSION
Intussusception
•
a portion of the alimentary tract
is telescoped into an adjacent
segment.
•
most common cause of
Intestinal obstruction 5 mos - 3
y.o
•
most common abdominal
emergency < 2 yrs. old

•
90% of cases of Intussusception
is idiopathic.
•
upper portion of bowel, the intussusceptum, invaginates

•
into the lower, the intussuscipiens, pulling its mesentery along with it into the

•
enveloping loop. Constriction of the mesentery obstructs venous return;

•
engorgement of the intussusceptum follows, with edema, and bleeding from the

•
mucosa leads to a bloody stool, sometimes containing mucus
 RISK
Risk
FACTORS
• Male > FemaleFactors
3:1
• <1 year old by 60 % incidence
• History of respiratory adenovirus (type C)
infection
• <1years old receiving a tetravalent rhesus-
human reassortant rotavirus vaccine within 2
wk of immunization.
• Lymphoid nodular hyperplasia
Clinical Manifestations
•
sudden onset of paroxysmal colicky pain
•
currant jelly stool
•
palpable sausage-shaped abdominal mass
 Leading Point

Telescopic Gut
Dx: Ultrasound,
Barium Enema

Increase Peristalsis

Constriction of Blood
Vessels
Ischemia
Abdominal
Pain
Sloughing Of:
Infarction • Intestinal Mucosa
• Blood
• Mucosa
Dark red stool
Perforation resembling currant jelly
Tachycardia
Low diastolic BP
Low hematorit

Shock
FINAL DIAGNOSIS
Intussusception
secondary to
Meckel’s
diverticulum
THANK
YOU