What is the best intervention for a 6-month-old girl with bloody stools, abdominal tenderness, and signs of potential shock, including hypotension, tachycardia, and lethargy?

Best Intervention: Enema (Air or Contrast) for Intussusception Reduction

The best intervention for this 6-month-old with classic intussusception is therapeutic enema (air or saline) after stabilization, as this represents the standard of care with >90% success rate in pediatric intussusception without signs of perforation. 1

Clinical Presentation Confirms Intussusception

This patient presents with the pathognomonic triad of intussusception:

• Intermittent colicky abdominal pain with leg drawing (classic "dance sign") 1
• Bloody stools ("currant jelly" stools) 1
• Palpable abdominal mass (diffuse tenderness on exam) 1

The 6-month age is the peak incidence for idiopathic ileocolic intussusception. 1 While only 50% of patients present with the complete triad, this patient demonstrates all three cardinal features. 1

Hemodynamic Stabilization Required First

Before definitive intervention, this patient requires immediate resuscitation:

• Hypotension (BP 68/34) and tachycardia (P 192) indicate hypovolemic shock requiring aggressive IV fluid resuscitation with crystalloid boluses of 20 mL/kg over 5-10 minutes 2
• Lethargy suggests inadequate cerebral perfusion and mandates restoration of circulating volume before procedural intervention 2
• Blood transfusion may be necessary given bloody stools and signs of shock 2

Enema Reduction is First-Line Definitive Treatment

Non-surgical reduction (NSR) using enema is the treatment of choice once stabilized, with success rates exceeding 90% in appropriately selected patients. 1

Technique Options:

• Air enema under fluoroscopic guidance (most common in North America) 1
• Saline enema under ultrasound guidance (equally effective, avoids radiation) 1
• Both techniques achieve >90% reduction success rates 1

Contraindications to Enema (Requiring Immediate Laparotomy):

• Signs of perforation (free air on imaging) 1
• Peritonitis (rigid abdomen, rebound tenderness) 1
• Shock refractory to resuscitation 1

This patient has diffuse tenderness but no documented peritoneal signs or perforation, making enema appropriate after stabilization. 1

Why Other Options Are Incorrect

Laparotomy (Option C) - Second-Line Only

• Reserved for failed enema reduction (occurs in <10% of cases) 1
• Required for perforation, peritonitis, or shock 1
• Laparoscopic reduction is increasingly used when enema fails, with 85% success rate and faster return to oral intake (1.5 days vs 4 days for open surgery) 3
• Proceeding directly to laparotomy without attempting enema exposes the patient to unnecessary surgical risk 3, 1

Angiographic Embolization (Option A) - Wrong Diagnosis

• Used for arterial bleeding sources (e.g., arteriovenous malformations, Dieulafoy lesions) requiring bleeding rate ≥0.5-1.0 mL/min 4, 5
• Intussusception causes venous congestion and mucosal ischemia, not arterial hemorrhage 1
• This intervention addresses the wrong pathophysiology 4

Pantoprazole (Option D) - Irrelevant

• Proton pump inhibitor for acid suppression in upper GI bleeding or peptic ulcer disease 2
• No role in mechanical bowel obstruction from intussusception 1
• Does not address the underlying telescoping bowel pathology 1

Critical Management Algorithm

1. Immediate stabilization: IV access, fluid resuscitation (20 mL/kg crystalloid boluses), correct hypotension and tachycardia 2
2. Imaging confirmation: Ultrasound has 98-100% sensitivity for intussusception diagnosis 1
3. Plain radiographs: Obtain to exclude perforation (contraindication to enema) 1
4. Therapeutic enema: Air or saline reduction under fluoroscopy or ultrasound guidance 1
5. If enema fails: Laparoscopic or open surgical reduction 3, 1

Common Pitfalls to Avoid

• Do not delay resuscitation to perform diagnostic imaging—stabilize hemodynamics first 2
• Do not proceed to laparotomy without attempting enema reduction unless contraindications exist (perforation, peritonitis, refractory shock) 1
• Do not assume upper GI bleeding—while bloody stools can indicate upper GI source, the intermittent colicky pain pattern is pathognomonic for intussusception 4, 1
• Monitor for recurrence: 5-10% of successfully reduced intussusceptions recur within 48-72 hours 3

Answer: B. Enema