Commentary

Charlie has an intussusception. It is one of a range of fairly uncommon causes in children of an acute abdomen. The distinctive features are the ‘redcurrant jelly stool’ and the spasmodic nature of the pain and clinical features. Intussusception is caused by a section of bowel being pulled inside another, by peristalsis. Eventually the bowel becomes ischaemic and obstructs. The condition is most common at the ileo-colic valve, and so the presentation is that of small bowel obstruction. The redcurrant jelly stool occurs after infarction.

Key to management of these children is first identification of the acute abdomen and a sensible investigation. Ultrasound is preferable in all causes of acute abdomen for its diagnostic ability and speed. It would be expected that students and trainees are able to identify the acute abdomen and arrange an appropriate test. Other causes of acute abdomens are managed similarly to this stage.

Once identified, an (early) intussusception can be managed with an air enema – physically pushing the bowel back into its correct position. More advanced cases will not be reduced in this way, and an open operation will need. Sometimes a section of dead bowel will need to be removed.

The other key in management is resuscitation. Children with an acute abdomen are often dehydrated and shocked. They may have electrolyte or glucose abnormalities too. Unless these are corrected, those affected are at risk of arrest, brain damage or death.

This case also has another problem – nutritional deficiency of iron and vitamin D. These are common in children and may be found incidentally. Co-morbidity is common in medicine, especially in the elderly, but can occur at any age. There are clues to this on the initial blood tests, and subsequent blood tests identify this more precisely.

It is not always easy to make the diagnosis of iron deficiency as measuring body iron stores is not straightforward. Ferritin is widely used, but because it is an acute phase reactant, levels will rise when a patient is seriously unwell. Here the level is low normal, and would probably be below normal range when the child is well.

As for the vitamin D deficiency, this can be identified from the chest radiograph, as well as the bloods.

Optimal management of the case requires first identification that there is a surgical problem that needs prompt investigation and management, using an ultrasound, but also that there is a need to properly address the deficiencies.

Slow identification of the underlying problem leads to Charlie becoming progressively more unwell, eventually having an arrest in ultrasound, from which she suffers some hypoxic brain harm. Slow identification also makes the correction of the intussusception harder and more invasive.

Delayed treatment of the deficiency can lead to a range of problems, from poor growth to seizures to cardiac dysrythmias.

Errors possible in this case are multiple.

Ignorance of the features of an acute abdomen will see the child started on antibiotics as sepsis might be suspected. Correct use of investigations will not happen if there is ignorance of how acute abdomens are investigated in children.

Playing the odds may see the child sent home with a possible self-limiting viral infection, or started on antibiotics for the more common bacterial infection.

Sloth and lack of skill may result in not picking up the abnormal chest radiograph or blood tests.

Lastly, mis-triage will overlook the need to resuscitate the child, stablise and find the cause rather than make referrals to social services or send the child to ultrasound.

Charlie has an intussusception. It is one of a range of fairly uncommon causes in children of an acute abdomen. The distinctive features are the ‘redcurrant jelly stool’ and the spasmodic nature of the pain and clinical features. Intussusception is caused by a section of bowel being pulled inside another, by peristalsis. Eventually the bowel becomes ischaemic and obstructs. The condition is most common at the ileo-colic valve, and so the presentation is that of small bowel obstruction. The redcurrant jelly stool occurs after infarction.

Key to management of these children is first identification of the acute abdomen and a sensible investigation. Ultrasound is preferable in all causes of acute abdomen for its diagnostic ability and speed. It would be expected that students and trainees are able to identify the acute abdomen and arrange an appropriate test. Other causes of acute abdomens are managed similarly to this stage.

Once identified, an (early) intussusception can be managed with an air enema – physically pushing the bowel back into its correct position. More advanced cases will not be reduced in this way, and an open operation will need. Sometimes a section of dead bowel will need to be removed.

The other key in management is resuscitation. Children with an acute abdomen are often dehydrated and shocked. They may have electrolyte or glucose abnormalities too. Unless these are corrected, those affected are at risk of arrest, brain damage or death.

This case also has another problem – nutritional deficiency of iron and vitamin D. These are common in children and may be found incidentally. Co-morbidity is common in medicine, especially in the elderly, but can occur at any age. There are clues to this on the initial blood tests, and subsequent blood tests identify this more precisely.

It is not always easy to make the diagnosis of iron deficiency as measuring body iron stores is not straightforward. Ferritin is widely used, but because it is an acute phase reactant, levels will rise when a patient is seriously unwell. Here the level is low normal, and would probably be below normal range when the child is well.

As for the vitamin D deficiency, this can be identified from the chest radiograph, as well as the bloods.

Optimal management of the case requires first identification that there is a surgical problem that needs prompt investigation and management, using an ultrasound, but also that there is a need to properly address the deficiencies.

Slow identification of the underlying problem leads to Charlie becoming progressively more unwell, eventually having an arrest in ultrasound, from which she suffers some hypoxic brain harm. Slow identification also makes the correction of the intussusception harder and more invasive.

Delayed treatment of the deficiency can lead to a range of problems, from poor growth to seizures to cardiac dysrythmias.

Errors possible in this case are multiple.

Ignorance of the features of an acute abdomen will see the child started on antibiotics as sepsis might be suspected. Correct use of investigations will not happen if there is ignorance of how acute abdomens are investigated in children.

Playing the odds may see the child sent home with a possible self-limiting viral infection, or started on antibiotics for the more common bacterial infection.

Sloth and lack of skill may result in not picking up the abnormal chest radiograph or blood tests.

Lastly, mis-triage will overlook the need to resuscitate the child, stablise and find the cause rather than make referrals to social services or send the child to ultrasound.

Charlie has an intussusception. It is one of a range of fairly uncommon causes in children of an acute abdomen. The distinctive features are the ‘redcurrant jelly stool’ and the spasmodic nature of the pain and clinical features. Intussusception is caused by a section of bowel being pulled inside another, by peristalsis. Eventually the bowel becomes ischaemic and obstructs. The condition is most common at the ileo-colic valve, and so the presentation is that of small bowel obstruction. The redcurrant jelly stool occurs after infarction.

Key to management of these children is first identification of the acute abdomen and a sensible investigation. Ultrasound is preferable in all causes of acute abdomen for its diagnostic ability and speed. It would be expected that students and trainees are able to identify the acute abdomen and arrange an appropriate test. Other causes of acute abdomens are managed similarly to this stage.

Once identified, an (early) intussusception can be managed with an air enema – physically pushing the bowel back into its correct position. More advanced cases will not be reduced in this way, and an open operation will need. Sometimes a section of dead bowel will need to be removed.

The other key in management is resuscitation. Children with an acute abdomen are often dehydrated and shocked. They may have electrolyte or glucose abnormalities too. Unless these are corrected, those affected are at risk of arrest, brain damage or death.

This case also has another problem – nutritional deficiency of iron and vitamin D. These are common in children and may be found incidentally. Co-morbidity is common in medicine, especially in the elderly, but can occur at any age. There are clues to this on the initial blood tests, and subsequent blood tests identify this more precisely.

It is not always easy to make the diagnosis of iron deficiency as measuring body iron stores is not straightforward. Ferritin is widely used, but because it is an acute phase reactant, levels will rise when a patient is seriously unwell. Here the level is low normal, and would probably be below normal range when the child is well.

As for the vitamin D deficiency, this can be identified from the chest radiograph, as well as the bloods.

Optimal management of the case requires first identification that there is a surgical problem that needs prompt investigation and management, using an ultrasound, but also that there is a need to properly address the deficiencies.

Slow identification of the underlying problem leads to Charlie becoming progressively more unwell, eventually having an arrest in ultrasound, from which she suffers some hypoxic brain harm. Slow identification also makes the correction of the intussusception harder and more invasive.

Delayed treatment of the deficiency can lead to a range of problems, from poor growth to seizures to cardiac dysrythmias.

Errors possible in this case are multiple.

Ignorance of the features of an acute abdomen will see the child started on antibiotics as sepsis might be suspected. Correct use of investigations will not happen if there is ignorance of how acute abdomens are investigated in children.

Playing the odds may see the child sent home with a possible self-limiting viral infection, or started on antibiotics for the more common bacterial infection.

Sloth and lack of skill may result in not picking up the abnormal chest radiograph or blood tests.

Lastly, mis-triage will overlook the need to resuscitate the child, stablise and find the cause rather than make referrals to social services or send the child to ultrasound.