Usually, kids with abdominal pain and vomiting do not have worrisome medical problems. Most of the time, they have eaten something that didn’t agree with them or have a stomach virus. But, there are some serious conditions that give kids abdominal pain and make them vomit. An emergency physician has to think of the bad things every time, in order to make certain that nothing life-threatening is missed.
An example of such a serious condition is intussusception. This happens when a part of the intestine folds into an adjacent part. This “telescoping” causes strain on the walls of the intestine and its blood supply. The damage to intestinal tissues can cause blood and excess mucous in the stool. The classic stool of patients with intussusception is described as “currant jelly,” meaning dark purple and slimy with mucous. If intussusception is not diagnosed quickly, the bowel can become severely obstructed and the involved section of the intestine can die, leading to the need for emergency surgery or even death. Intussusception is something that, though rare, should not be missed by an emergency physician.
Often the diagnosis and treatment of intussusception are accomplished with a barium enema. Barium is a liquid preparation that shows up on x-rays. When intussusception is suspected, the child is sent to the radiology department and the radiologist gently squirts barium through the anus into the intestine, while taking x-rays. If an intussusception is present, it shows up on the x-rays and the diagnosis is made. Often, the pressure of the barium being injected into the colon causes the intussusception to be “reduced,” meaning the intestine is pushed back into normal position. In such cases, the diagnosis and treatment take place at the same time. When a kid comes in with abdominal pain and vomiting, the emergency physician has to decide if the chances are high enough for intussusception to call in the radiologist from home to do the barium enema.
I have only made the diagnosis of intussusception twice in my long career.
Ryan was a previously healthy, 16-month-old boy who had been having abdominal pain and vomiting for three days. He had been seen twice in that time by pediatricians who treated him for dehydration and sent him home. On arrival in our emergency department, he had a large, black stool covered in slime. Given that history, it was clear to me he needed a barium enema. I called the radiologist, who came in from home and confirmed my diagnosis. Unfortunately for Ryan, the intussusception was not able to be fully reduced. I had to admit him to the hospital to be cared for by a surgeon.
Such a case makes me feel really good. I identified a sick kid. I thought of the right disease. I ordered the correct test. This led to timely and appropriate care. It is just the kind of case that makes emergency medicine so fulfilling and rewarding.
The very next night, I saw another little boy, about the same age, also with vomiting and abdominal pain. He had a distended abdomen and had passed a stool that was dark and covered in mucous. You can imagine how this played with my decision making. In all my years as an emergency physician, I had only diagnosed intussusception one time and it had been the night before. Could this even be possible? Yet, all the signs were there and I called for the barium enema.
The radiologist was pleasant but skeptical. Intussusception is unusual enough that, earlier in the day, the radiologists had all sat around together and looked at the x-rays from my case. So, this radiologist knew I had made that diagnosis the night before. Essentially, he was questioning my need for another barium enema, suspecting my diagnosis the night before had me over-call the need for another one tonight.
I acknowledged his justifiable skepticism but said something like, “Last night, we got lucky. Tonight, this kid read the book.” By this, I meant that he had all the things a textbook would say to watch out for in intussusception. He agreed to come in and, just like the night before, made the diagnosis of intussusception. Again, he was unable to reduce it with the barium enema, so I admitted the patient to a surgeon for further care.
As far as I know, I have only seen two patients in my career with intussusception. And they came in on consecutive nights. What are the chances of that?