||Case 9 : The Stomach flu-The Target,Crescent and Absent Liver Edge Signs
View an atypical crescent sign.
Other non-specific radiographic signs that may suggest an intussusception are as follows:
Notice the dilated bowel segments. They exhibit smooth bowel walls lacking normal haustrations. This is suggestive of a small bowel obstruction. c. Paucity of gas: Distal to obstruction. d. Loss of subhepatic angle: The absent liver edge sign. The target and crescent signs are the most accurate in making the diagnosis of intussusception on a plain film. The target sign is seen twice as often as the crescent sign. An abdominal mass is most commonly seen on radiographs, but it is non-specific.
Abdominal mass: An absence of bowel gas in the area suggesting indirectly that something is pushing normal bowel out of the way.
Small bowel obstruction: Dilated bowel loops and air-fluid levels. Examine the flat plate (supine view of this case)
- Barium enema is the gold standard of diagnosis. It often results in a successful reduction of the intussusception as well. Ultrasound and air contrast enemas have also been used to diagnose intussusception. The two contraindications to performing a barium enema include shock and/or radiographic or clinical evidence of bowel perforation. Patients with hypovolemic shock should first have their intravascular volume restored before undergoing a barium enema. Any patient with evidence of bowel perforation should be taken immediately to surgery.
- Vomiting is a common reason to seek emergency or acute care. It is usually the result of a benign cause. However, it may be difficult to distinguish serious causes from benign causes if the evaluation is superficial. Whenever the chief complaint is vomiting, the diagnosis of intussusception should be considered. The history and examination should be directed at determining whether intussusception is possible based on clinical grounds. The chart should include comments in the history regarding the frequency of vomiting, the color of the emesis, the presence or absence of abdominal pain, the frequency of abdominal pain, and the activity level of the child. Intussusception is more likely if the emesis is bilious and/or frequent. Intussusception is more likely if the pattern of the pain is colicky in nature (intermittent and severe in regular cycles 5-20 minutes apart). Intussusception is more likely if the child exhibits lethargy. The absence of these symptoms does not rule out intussusception. Patients with intussusception may have all, some, or none of these symptoms. The physical exam portion of the chart should document the presence or absence of lethargy and an abdominal mass. The exam should include the testes (in males) and the inguinal region looking for incarcerated hernias. The rectal exam and stool guaiac results should also be recorded. Ideally, the chart should comment on whether the examiner has noted a colicky abdominal pain pattern observed during the evaluation period.
- Infants presenting purely with lethargy (no vomiting) have often been evaluated for possible sepsis. However, lethargy is a common presentation for intussusception despite the absence of all the other signs of intussusception.
Copyrighted:Radiology Cases in Pediatric Emergency Medicine Volume 6, Case 19
Loren Yamamoto, MD, MPH, Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine.Loreny@hawaii.edu
- Waisman Y. Intussusception. In: Barkin RM (ed). Pediatric Emergency Medicine Concepts and Clinical Practice. Chicago, Mosby Year Book, 1992, pp. 784-786.
- Schnaufer L, Mahboubi S. Intussusception. In: Fleisher GR, Ludwig S (eds). Textbook of Pediatric Emergency Medicine, third edition. Baltimore, Williams and Wilkins, 1993, pp. 1314-1316.
- Ratcliffe JF, Fong S, Cheong I. O'Connell P. The Plain Abdominal Film in Intussusception: The Accuracy and Incidence of Radiographic Signs. Pediatric Radiology 1992; 22:110-111.
Last created on 01-07-2006