3-year-old-fever

This condition can be associated with adenovirus infection, upper respiratory tract infection, and gastroenteritis; as a result, the Peyer patches become swollen and induce strong peristalsis. The most common age group is between 3 month and 2 years old. In some patients, intussusception can be precipitated by leading points in the GI tract, including Meckel diverticulum, intestinal polyps, appendiceal stump, and Henoch-Schonlein purpura. Ilecocecal intussuception is the most common site.

Prepared by...................Nuthapong Ukarapol, M.D.
CC : A 3-month-old boy has presented with bleeding per rectum for 3 hours.
PI : The mother reported that his son appeared fussy and more irritable 8 hours before admission. He has later on developed bloody stools and non-billous vomiting. The patient has had intermittent cry and mild fever as well. He was finally brought to the hospital.
Past History: His birth weight was 2,700 grams. He had a history of congenital hypothyroidism and has been treated with L-thyroxine 12 mg/kg/day.
Significant PE
VS: Tempt 36 C, PR 130/min, RR 40/min, BP 90/54 mmHg GA: A male infant, afebrile, not pale, irritable Abdomen: no distention, decreased bowel sound, soft, ill-defined mass sized 3.5 cm in diameter was noted at RUQ, liver 1 cm below right costal margin, no splenomegaly The patient passed stool at the ER. It looked similar to currant jelly.
Problem list 1. Lower gastrointestinal hemorrhage 2. Abdominal mass on physical examination 3. Congenital hypothyroidism (Lingual thyroid)
Investigation: CBC: Hb 11.0 g% Hct 30.6% WBC12,500 /mm3 N56.6% L 35.7% B1% plt. 435,000 /mm3 Blood chemistry: BUN 6 mg% Cr.0.5 mg% Na+ 136 mEq/L K+ 5.0 mEq/L Cl- 103 mEq/L HCO3- 19 mEq/L Urinalysis: pH 5.0 sp.gr. 1.021 Alb 1+ sugar neg microscopic no RBC no WBC

Figure 1. An abdominal ultrasound shows pseudokidney and target sign in long and cross-sectional view, respectively.
Provisional diagnosis: Intussusception
This patient was treated using pneumatic reduction and discharged home on the next day.
Intussusception
This condition can be associated with adenovirus infection, upper respiratory tract infection, and gastroenteritis; as a result, the Peyer patches become swollen and induce strong peristalsis. The most common age group is between 3 month and 2 years old. In some patients, intussusception can be precipitated by leading points in the GI tract, including Meckel diverticulum, intestinal polyps, appendiceal stump, and Henoch-Schonlein purpura. Ilecocecal intussuception is the most common site.
Diagnosis: 1. Plain abdomen: Soft tissue density in an area of intussusception and a pattern of bowel obstruction are expected. Plain film is also helpful in diagnosing pneumoperitoneum before performing barium or pneumatic redution. 2. Ultrasonography is a sensitive diagnostic tool as shown in figure 1. 3. Barium enema: A filling defect and coiled-spring sign can be noted during performing BE. Apart from diagnostic aid, it is one of therapeutic options.
Treatment: 1. Barium or pneumatic reduction 2. Surgical manual reduction or bowel resection with re-anastomosis
Review of pneumatic reduction of intussusception
China is a country reported more than 14,000 cases of pneumatic reduction with a 94% sucess rate.
How to perform the pneumatic reduction 1. Give sedation 2. Place a Foley catheter with balloon in the rectum 3. Inflate balloon under fluoroscopy 4. Insufflation of the colon can be performed with an apparatus in an "electric" (automatic) or manual mode. 5. Manometer directly measures intracolonic pressure. 6. The exhaust valve will operate when an intracolonic pressure is above a preset valve (usually set at 110-120 mmHg) 7. If initial reduction fails, repeat reduction might be tried after 2-3 hrs. 8. Second reduction can achieve in 50%.
Conditions associated with failure of pneumatic reduction 1. Ileoileocolic intussusception 2. Duration of symptoms > 2 days 3. Rectal bleeding 4. Prior failure reduction with barium
Contraindication for pneumatic reduction
1. Peritonitis 2. Free air 3. Clinical unstable
Relative contraindication for pneumatic reduction
1. Duration > 24 hrs 2. Small bowel obstruction 3. Severe abdominal distention 4. Newborn , age < 3 mo , >2 yr 5. Bloody stool 6. Large or firm mass
Suggested readings: 1. Zheng JY, Frush DP, Guo JZ. Review of pneumatic reduction of intussusception: evolution not revolution. J Pediatr Surg 1994; 29:93-7. 2. Stein M, Alton DJ, Daneman A. Pnematic reduction of intussusception: 5 year experience. Radiology 1992; 183:681-4. 3. Rosenfeld K, McHugh K. Survey of intussusception reduction in England, Scottland, and Wales: how and why we could do better. Clin Radiol 1999; 54:452-8. 4. Guo JZ, Ma XY, Zhou OH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986; 21:1201-3.