Review Question - QID 220365

This child who presents with rash, joint pain, abdominal pain, and a bloody bowel movement most likely has intussusception in the setting of Henoch-Schonlein purpura. The most appropriate next step in treatment is an air enema.

Henoch-Schonlein purpura is an IgA-mediated vasculitis that affects small vessels. The disease typically follows a preceding infection and patients will present with arthralgias, colicky abdominal pain, and a rash that begins on the lower extremities/buttocks. The disease can be complicated by intussusception, which would present with colicky abdominal pain and bloody bowel movements, as well as nephropathy, which presents with hematuria, proteinuria, and an elevated BUN/creatinine. The treatment of uncomplicated Henoch-Schonlein purpura is supportive in nature as this condition self-resolves. Treatment of associated intussusception is with air enema with possible surgical exploration if the enema fails.

Little and Danzl review the evidence regarding the diagnosis and treatment of Henoch-Schonlein purpura. They discuss how this disease can be complicated by intussusception. They recommend treatment with an enema.

Figure/Illustration A is an abdominal ultrasound showing a target sign in the abdomen (red circle). This sign is classically seen in patients with Henoch-Schonlein purpura complicated by intussusception.

Incorrect Answers:
Answer 2: Broad spectrum antibiotics would be used in the treatment of a bacterial infection. This patient's abdominal pain is related to intussusception and they do not have findings consistent with sepsis.

Answer 3: Contrast enema can be used to image the colon. While this form of enema can also resolve an intussusception, an air enema is preferred because it does not introduce foreign material into the colon.

Answer 4: High dose corticosteroids can be used in patients who have Henoch-Schonlein purpura that is complicated by severe nephropathy. This disease would manifest with hematuria, proteinuria, and an elevated BUN/creatinine.

Answer 5: Surgical exploration should be used if an air enema fails to resolve an intussusception. Since many of these obstructions can be treated without surgery, non-operative management should be attempted first prior to surgical exploration.

Bullet Summary:
Henoch-Schonlein purpura with associated intussusception should be treated with air enema with possible surgical exploration if the enema fails.