The Fussy Vomiter

A healthy 9 month old presented to the ED 2 hours after being discharged with persistent vomiting (now spinach green in color). He was reported to be somewhat fussy at times and at other times sleepy.
 
You obtain the following images…
What do you see? (click arrow to reveal answer)
Answer:
This patient was found to have ileocolic intussusception on point-of-care ultrasound. Surgery was notified, and the patient underwent a department of radiology ultrasound  confirming the POCUS findings. The patient then underwent successful air enema and was admitted overnight and discharged the following day.

Intussusception and Ultrasound

Intussusception is the most common cause of intestinal obstruction in young children. It is seen most commonly between 3 months and 6 years, peaking in the first year of life.

Formal ultrasound has been shown to be 98-100% sensitive and 88-100% sensitive. A prospective POCUS study by Riera et al. showed a sensitivity of 85% and specificity of 97%, NPV 97% and PPV 95%.

Technique and Diagnosis

Use a linear, high-frequency transducer, place the probe in the right lower quadrant and trace the length of the colon along it’s traverse axis. Ensure the depth is set to at least 6cm. Intussusception is identified by the finding of a “target” or “doughnut” which represents the layering of bowel wall caused from the telescoping of of a proximal area of bowel into a distal segment of bowel.

Ileocolic intussusception is measured from outer – to – outer wall of bowel.

Ileocolic intussusception ≥2.5cm 

Small bowel-small bowel intussusception <2.5cm

Want to Read more? Check out these sources

Doniger SJ, Salmon M, Lewiss RE. Point-of-Care Ultrasonography for the Rapid Diagnosis of Intussusception: A case series. Pediatr Emergency Care. Feb 2016. Epub ahead of print.

 Justice FA, de Campo M, Liem NT et al. Accuracy of ultrasonography for the diagnosis of intussusception in infants in Vietnam. Pediatr Radiol. 2007;37(2): 195-9.

 Kim JH, Lee JY, Kwon JH et al. Point-of-care ultrasound could streamline the emergency department workflow of clinically nonspecific intussusception. Pediatric Emergency Care. September 2017. Epub ahead of print.

 Riera A, Hsiao AL, Langhan ML et al. Diagnosis of intussusception by physician novice sonogrpahers in the emergency department. Ann Emerg Med. 2012;60(3):264-8.

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Laurie Malia

Laurie Malia

Assistant Professor of Emergency Medicine and Pediatrics,Pediatric Emergency Medicine Ultrasound Fellow at Morgan Stanley Children's Hospital /Columbia University Medical Center Department of Emergency Medicine
PEM doc; POCUS; Pediatrics; Healthcare equality
Laurie Malia

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Laurie Malia

Laurie Malia

PEM doc; POCUS; Pediatrics; Healthcare equality