In a 5-year-old boy with sudden severe diffuse abdominal pain, inability to ambulate, afebrile, and approximately four bowel movements yesterday, what is the most likely diagnosis and appropriate management plan?

Likely Diagnosis: Intussusception

In a 5-year-old boy presenting with sudden severe diffuse abdominal pain, inability to walk due to pain intensity, and absence of fever, intussusception is the most likely diagnosis and requires immediate ultrasound evaluation followed by urgent reduction if confirmed. 1, 2, 3

Why Intussusception is Most Likely

• Age and presentation match perfectly: Intussusception most commonly affects children between 3 months to 5 years of age, with this patient falling within the classic age range 3, 4

• Severe intermittent pain preventing ambulation: The hallmark of intussusception is intermittent colicky abdominal pain that can be so severe the child cannot walk or engage in normal activities 2, 3, 5

• Absence of fever does not exclude intussusception: While fever can occur, many children with intussusception are afebrile, particularly in early presentation 3, 4

• Multiple bowel movements yesterday: This is consistent with early intussusception before complete obstruction develops; bloody stools (currant jelly) typically appear later in the disease course 3, 4

Critical Red Flags Present

• Severe progressive pain with inability to ambulate indicates a surgical emergency requiring immediate evaluation 1, 6

• Diffuse abdominal tenderness in a 5-year-old with severe pain warrants urgent imaging 1, 2

• The absence of the complete "classic triad" (intermittent pain, currant jelly stool, sausage-shaped mass) does NOT exclude intussusception—most patients do not present with all three features 3, 4

Immediate Management Algorithm

Step 1: Initial Stabilization and Pain Control

• Provide immediate pain relief without delay—administer oral NSAIDs (ibuprofen) for moderate pain or intravenous opioids for severe pain, as withholding analgesia is an outdated practice that impairs examination quality 1, 6

• Establish intravenous access and begin fluid resuscitation before diagnostic procedures 4

• Notify pediatric surgery immediately while diagnostic workup proceeds 4

Step 2: Urgent Diagnostic Evaluation

• Obtain ultrasound of the abdomen immediately—this is the diagnostic modality of choice for intussusception, providing excellent sensitivity and specificity without radiation exposure 1, 2, 3, 4

• Look specifically for the "target sign" or "pseudokidney sign" on ultrasound, which confirms intussusception 4

• Plain abdominal radiography may be obtained to evaluate for bowel obstruction or perforation but lacks sensitivity to exclude intussusception 1, 4

• Obtain urinalysis to exclude urinary tract infection as a mimic, though the clinical picture strongly suggests intussusception 1, 2

Step 3: Definitive Treatment Based on Findings

If intussusception is confirmed and the patient is stable without peritonitis:

• Proceed immediately to pneumatic or hydrostatic enema reduction as first-line treatment 3, 4

• Ensure pediatric surgery is present or immediately available during the reduction attempt 4

• Success rates for non-operative reduction are lower in older children and when symptoms have been present longer 3, 7

If the patient shows signs of perforation, peritonitis, or hemodynamic instability:

• Proceed directly to operative intervention without attempting enema reduction 3

• Signs requiring immediate surgery include generalized peritonitis, hemodynamic instability, or evidence of perforation on imaging 2, 3

Step 4: Post-Reduction Management

• After successful non-operative reduction, observe the patient and ensure they can tolerate clear fluids and remain asymptomatic before discharge 3

• Provide explicit return precautions: immediate return for recurrence of severe abdominal pain, vomiting, bloody stools, or inability to tolerate oral intake 1, 3

• Recurrence occurs in approximately 10% of cases after successful reduction 3

Alternative Diagnoses to Consider (Less Likely but Important)

Appendicitis

• Less likely because: children under 5 with appendicitis typically present with fever and localized right lower quadrant pain, though atypical presentations occur 2
• This patient's diffuse pain, absence of fever, and inability to walk favor intussusception over appendicitis 2
• If ultrasound is negative for intussusception and clinical suspicion for appendicitis remains, proceed with right lower quadrant ultrasound 1, 2

Constipation

• Can cause severe abdominal pain in young children but typically does not prevent ambulation or cause this degree of acute distress 2
• Plain radiography would show stool burden if this were the primary diagnosis 1

Critical Pitfalls to Avoid

• Do not dismiss intussusception because the "classic triad" is absent—most children do not present with all three features (pain, bloody stool, palpable mass) 3, 4

• Do not delay imaging while waiting for bloody stools to appear—currant jelly stools are a late finding indicating bowel ischemia 3, 4

• Do not withhold pain medication pending diagnosis—this outdated practice causes unnecessary suffering and does not improve diagnostic accuracy 1, 6

• Do not routinely prescribe antibiotics unless there is confirmed complicated intra-abdominal infection or perforation 1, 6

• Consider pathologic lead points in this age group: while most intussusception in infants is idiopathic, 10-25% of cases have an underlying mass or lead point, and this risk increases with age beyond 3 years 3, 7, 8

Special Consideration for This 5-Year-Old

• At age 5, this patient is at the upper end of the typical intussusception age range, which increases the likelihood of a pathologic lead point (lymphoma, Meckel's diverticulum, polyp) 3, 7, 8

• If enema reduction fails or if imaging reveals a focal mass, operative intervention will be necessary both for treatment and to identify any underlying pathology 3, 7

• Small bowel-small bowel intussusception in a child over age 3 should raise suspicion for celiac disease or lymphoma as underlying causes 7, 8