A 2-year-old girl presented to the ED with intermittent abdominal
pain that began 18 hours earlier.
The previous evening, she had an episode of abdominal pain accompanied
by a large bowel movement. During the night and following day, she
had several bouts of abdominal pain. Her oral intake was poor and
she vomited after eating. Late that afternoon, her mother brought
her to the ED.
The child had been in good health. At age 4 months, she was brought
to the ED for abdominal pain, which resolved over several hours.
A medical evaluation at that time was normal.
In the ED, her vital signs were: pulse 114 beats/min,
respiratory rate 24 breaths/min, and temperature 100.1°F
The child appeared well. Her abdomen was soft and nondistended.
There was minimal right lower quadrant tenderness with no rebound
tenderness or palpable mass. Stool was guiac negative. The child
would not eat or drink and was admitted to the hospital for observation.
An abdominal radiograph was interpreted as showing a nonspecific
bowel gas pattern (Figure 1).
During the night, the child had intermittent episodes of abdominal
pain during which she was doubled-over with her legs flexed. In
between these episodes, she was comfortable.
- Was an abdominal radiograph indicated in this
- How would you interpret the radiograph?
- Are further diagnostic tests needed?
In an adult patient with abdominal pain, the principal indication
for abdominal radiography is to detect mechanical bowel obstruction.
The role of radiography in children with abdominal pain is less
Intussusception is the most common
cause of intestinal obstruction in children between the ages of
6 months and 2 years. However, the radiographic findings of intussusception
are different from those of mechanical small bowel obstruction.
Diagnostic difficulty with intussusception is due to its variable clinical presentation. The classic
triad of intussusception consists of intermittent crampy abdominal
pain, vomiting, and bloody stools (“currant jelly”).
A soft tissue mass may be palpable in the right side of the abdomen,
especially during episodes of pain. However, the triad is present
in only a minority of cases, and bloody stool, a late sign, is seen
in only few cases. The child often appears well between episodes
of pain. In some cases, there is no abdominal pain, and the child
presents only with listlessness or irritability. Most cases occur
between the ages of 6 months and 2 years—60% occur
in children younger than 1 year of age and 80% in children
younger than 2 years.
Knowledge of the pathologic anatomy of
intussusception helps in understanding its radiographic features. Ileocolic intussusception occurs in
about 85% of cases (Figure 2A). The distal ileum invaginates