INTERMITTENT INTUSS X RAP

INTERMITTENT INTUSSUSCEPTION1 AS A CAUSE OF ABDOMINAL PAIN IN CHILDREN. Rita Steffen, Douglas Laman, Marilyn Goske, Cleveland Clin Fdn, Cleveland,OH. A five year old boy with chronic, intermittent abdominal pain for approximately four weeks was evaluated with serial radiographic techniques. The pain was located in the periumbilical and left upper quadrant areas and was non-radiating. There were discreet episodes of moderately severe, cramplike pain of relatively short duration. The patient had no associated fever, nausea, vomiting, or change in bowel habits. His usual stool pattern was about three bowel movements per week. The pain would occassionally cause a decrease in his usual activity level, and the patient would sometimes have to lie down. As a neonate he had hypertension secondary to a dysplastic kidney, and had undergone a left nephrectomy with no further problems. An ultrasound was performed during an episode of pain, and demonstrated an abnormal ring-like loop of bowel in the left upper quadrant suspicious for intussusception. There was no evidence of bowel dilatation proximal to the area, and no lead point could be identified. He was taken to the CT scanner nearby where 5 mm spiral images were performed while the patient was still present during the same episode of pain. The findings corroborated an intussusception in the same area of the left upper quadrant. The pain immediately resolved completely, whereupon the radiologist administered oral contrast. Images of the proximal jejunum demonstrated a single loop of bowel with thickened folds and mild dilatation. At this time the patient was pain-free, suggesting that the intussusception had spontaneously reduced itself, with some residual from localized edema and swelling. Abdominal pain is a frequent reason for referral to pediatric gastroenterologists. This case is reported because the sequence of clinical events was fortuitous because the patient was being imaged at the time of his symptoms, and multiple radiologic imaging resources were available and done simultaneously with the occurrence of the intussusception and its subsequent reduction. The patient has had no further pain in six months of follow-up. Intussusception may be an underrecognized cause of abdominal pain in children, as it may occur more often, possibly in association with viral infections of the gastrointestinal tract, than is appreciated. This suggests that evaluation at the time of the pain, particularly with screening ultrasound, may increase the diagnostic yield for this entity as a subset of abdominal pain in children, and possibly reduce the number of cases that are assigned to an idiopathic or functional group