Snapshot A young mother brings her 2-year-old son to the pediatrician reporting that he has had recurrent "belly aches" for the past two weeks. The child experiences sudden, intermittent vomiting interspersed with periods of no complaints. The mother reports that she has seen him squatting with his knees to his chest, which seems to relieve him of his symptoms. Introduction Most common form of bowel obstruction in children Luminal lesion usually serves as focus point for looping bowels Involves the terminal ileum telescoping into the proximal large bowel in most cases ETIOLOGY Etiology unknown Associated with gastroenteritis Meckel's diverticulum gastric polyps adenovirus infection intestinal lymphoma hyperplasia of Peyers patches Epidemiology Most common in children 3 mos to 3 years of age Uncommon in adults Occurs in the large bowel Presentation Symptoms abrupt onset of classic triad (only observed in 1/3 of patients) colicky abdominal pain emesis currant jelly stool child may flex knees to chest to relieve pain infants may present with paleness and abdominal distention lethargy fever Physical exam abdominal distention and tenderness positive stool guiaic indicative of intestinal bleed sausage-shaped abdominal mass may be palpated in RUQ signs of shock may be evident Imaging Abdominal radiography may show small bowel obstruction (air fluid levels) rule out free air under the diaphragm (perforated viscus, surgical emergency) Ultrasound may show small bowel obstruction donut sign STUDIES Labs show leukocytosis Pneumatic decompression enema via fluoroscopy using air or carbon dioxide to push back intussusception now preferred over contrast-based enemas as risk of perforation lower, and lower radiation exposure needed additionally therapeutic Hydrostatic decompression enema via fluoroscopy traditionally used barium (can cause peritonitis), but now gastrografin or other water-soluble agents used instead reveals coil-spring sign additionally therapeutic can use saline with ultrasound guidance (no radiation exposure), unlike pneumatic technique Differential Small bowel obstruction, upper or lower GI bleed, mesenteric ischemia Treatment Prevention there are no preventive measures available at this time Non-surgical management Pneumatic decompression enema via fluoroscopy now preferred over hydrostatic (contrast-based) techniques, see above Hydrostatic decompression enema via fluoroscopy both diagnostic and therapeutic in many cases after successful reduction, child should be admitted for 24 hrs to monitor for recurrence or complications Surgical intervention surgical reduction only indicated when barium enema does not relieve obstruction must resect gangrenous/necrotic segments appendix usually removed to prevent confusion in the future Complications Bowel necrosis, followed by sepsis and death if left untreated Prognosis Very good to excellent if identified and treated early