Toddler's sudden, intense pain leads to emergency surgery
Morning-time was full of toddler activity, but the energetic 2-year-old finally ran out of steam and settled down for a pre-lunch nap. An hour later, the little boy woke screaming and appeared to his mother to be experiencing an unusually intense type of pain. Just as the boy seemed to find a comfortable position and relax, he cried out again. As this pattern of pain and relief repeated itself, the concerned mother hurried to the phone to call the pediatric office.
The toddler was carried into the office exhibiting a level of discomfort that was both obvious and alarming. My partner examined the child, and suspecting an emergency gastrointestinal condition known as intussusception, or telescoping bowel, sent the child on to the emergency room for further evaluation and treatment. While notifying the surgeon of the child's arrival, the ER physician also ordered an air contrast enema that confirmed the original diagnosis, but did not correct the problem.
The surgeon, noting the boy's now unremitting and inconsolable abdominal pain, did not need the radiologist's report to know the enema had not completely straightened, or reduced, the intussusception. The little patient was then brought to the operating room for emergency surgery, and he recovered relatively quickly, experiencing a smooth, uncomplicated post-op course.
In a 2010 Pediatrics in Review article on causes of acute abdominal pain in children, Drs. Albert Ross and Neal LeLeiko explain that an intussusception is created when one part of the intestine is pulled into an adjoining section, essentially trapping bowel within bowel. An affected child can have abdominal pain, weakness, vomiting and a pale appearance, as well as a distended belly and production of a bloody bowel movement as the condition progresses.
The World Health Organization (WHO) reports that intussusception is the most common cause of sudden-onset intestinal obstruction in infants and young children. In developed countries, this condition occurs in up to four out of every 1,000 live births. WHO notes that while intussusception deaths are uncommon in developed countries, this surgical emergency can result in a mortality rate as high as 50 percent in developing countries, likely from delays in diagnosis, radiologic evaluation and surgical correction because of a lack of access to adequate medical care.
WHO researchers find that intussusception occurs more often in males, with infants between 4 months and 8 months most commonly affected. Infants who develop intussusception before their first birthday typically have a rapid onset of symptoms with no definitive cause for this telescoping gut, though mesenteric adenitis, an enlargement of gastrointestinal lymph nodes, and viral infection may play a role. Older children and adults tend to follow a more smoldering course, with the pathological "lead point" of the intussusception often found to be a mass, such as a gastrointestinal tumor, vascular malformation or polyp.
Experts at the American Pediatric Surgical Association note that one lower right abdominal incision or several very small laparoscopic incisions are used in the surgical correction of intussusception. After reaching the gut, the surgeon literally attempts to squeeze the trapped portion of intestine out of the enclosing outer section of intestine.
If this approach is successful, the involved portions of bowel are returned to their proper place, the appendix is removed, and the child's surgical incisions are sutured closed. When the involved sections of bowel appear to be damaged beyond repair, or if the surgeon cannot free the trapped bowel by the "squeeze technique," portions of the intestine are resected, or surgically removed, resulting in a longer hospital stay and recovery period.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.