A previously healthy 10‑month‑old boy is brought to the emergency department by his parents due to intermittent episodes of crying and drawing up his legs. His mother reports that the episodes last for a few minutes followed by periods where he appears tired. He had one episode of non‑bilious vomiting earlier today. He has not had any fever. Vital signs reveal mild tachycardia but are otherwise within normal limits. On physical examination, he looks fatigued between episodes of crying. Abdominal examination reveals mild distension. Stool in the diaper appears mixed with mucus and blood. An abdominal ultrasound is ordered.
Which of the following is the most appropriate best step in managing this patient?
The correct answer is:
A) Air contrast enema
This infant’s presentation with paroxysmal abdominal pain with periods of lethargy and currant jelly stools is classic for intussusception. Ultrasound is the preferred initial imaging and typically shows a target sign or donut sign. Definitive initial therapy for stable patients without signs of perforation or peritonitis is an air contrast enema, which is both diagnostic and therapeutic. Contrast enemas with air or contrast can reduce the intussusception, but air enema is preferred due to lower risk of barium peritonitis if perforation occurs and has similar success rates.
Surgery is reserved for failed enema or complications such as perforation.
Answer choice B: CT abdomen, is incorrect. CT is not first‑line in typical pediatric cases due to radiation and because ultrasound plus therapeutic enema is standard. CT is reserved for atypical presentations or older patients.
Answer choice C: Intravenous corticosteroids, is incorrect. Steroids have no role in the acute management of intussusception.
Answer choice D: Laparotomy, is incorrect. Laparotomy is indicated if the enema fails or if there is perforation/peritonitis. It is not the next step for a stable child with typical findings of intussusception.
Answer choice E: Upper gastrointestinal series with barium, is incorrect. A barium upper GI series uses fluoroscopy and a barium-based contrast liquid to examine the esophagus, stomach, and small intestine. It is not used to image the colon.
Key Learning Point
In a stable infant with suspected intussusception, ultrasound for diagnosis followed by air contrast enema for reduction is the next best step. Surgery is reserved for perforation, peritonitis, or failed enema.
