Emergency Management of Suspected Intussusception
This 9-month-old infant requires immediate surgical consultation and urgent imaging with abdominal ultrasound, as the clinical presentation—episodic screaming with knee drawing, vomiting, diarrhea, and abdominal distention—is classic for intussusception, a life-threatening surgical emergency that can lead to bowel necrosis and death if not promptly treated.
Immediate Recognition and Action
The clinical triad described here is pathognomonic for intussusception:
- Episodic colicky pain manifesting as sudden screaming with drawing up of knees, followed by periods of lethargy or normal behavior between episodes 1
- Vomiting and diarrhea (which may progress to "currant jelly" stools containing blood and mucus) 1
- Abdominal distention and tenderness on examination 1
This is NOT simple gastroenteritis. While the provided guidelines address diarrhea and vomiting management 1, they specifically warn that bilious emesis or repeated forceful vomiting should be evaluated for underlying obstruction 1. The episodic nature with intervening periods where the infant "sleeps soundly" is a critical distinguishing feature of intussusception that differentiates it from gastroenteritis.
Critical Diagnostic Steps
Obtain abdominal radiographs immediately as the initial imaging study to assess for bowel obstruction patterns 1. However, do not delay surgical consultation while waiting for imaging.
Abdominal ultrasound is the definitive diagnostic test and should be performed urgently if intussusception is suspected, as it can identify the classic "target sign" or "donut sign" of telescoped bowel 1.
Management Algorithm
Step 1: Stabilization
- Establish IV access immediately and begin fluid resuscitation with boluses (20 mL/kg) of normal saline or Ringer's lactate 1
- The infant likely has moderate to severe dehydration after 28 hours of vomiting and diarrhea 1
- Make the infant NPO (nothing by mouth) - do not attempt oral rehydration in a child with suspected bowel obstruction 1
Step 2: Urgent Consultation
- Contact pediatric surgery immediately - intussusception requires urgent intervention to prevent bowel necrosis, perforation, and death 1
- Time is critical: delayed treatment significantly increases morbidity and mortality
Step 3: Definitive Treatment
- Air or contrast enema can be both diagnostic and therapeutic in many cases of intussusception, with success rates of 70-90% when performed early 1
- Surgical reduction is required if enema reduction fails or if there are signs of peritonitis, perforation, or hemodynamic instability 1
Critical Pitfalls to Avoid
Do NOT dismiss this as viral gastroenteritis simply because vomiting and diarrhea are present. The episodic screaming with knee drawing and intervening normal periods is the key distinguishing feature 1.
Do NOT attempt oral rehydration therapy as recommended for simple gastroenteritis 1. Patients with intestinal obstruction should not be given oral fluids until bowel sounds are audible and obstruction is ruled out 1.
Do NOT delay imaging or surgical consultation to "observe" the infant. Intussusception can rapidly progress to bowel ischemia, necrosis, and perforation, dramatically increasing mortality 1.
Do NOT give antimotility agents or antibiotics empirically - these are contraindicated in suspected bowel obstruction and will not address the underlying surgical emergency 1, 2, 3.
Why This Takes Priority Over Gastroenteritis Management
While the guidelines provided extensively discuss oral rehydration for acute diarrhea 1, 2, 3, they explicitly state that severe dehydration and suspected obstruction require different management 1. The ACR guidelines specifically emphasize that bilious or forceful vomiting in infants warrants evaluation for obstruction, with intussusception being a primary consideration in this age group 1.
The mortality and morbidity from missed or delayed diagnosis of intussusception far exceeds that of over-treating presumed gastroenteritis. When in doubt with this clinical presentation, always rule out surgical emergencies first.