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  #1  
Old 11-13-2011
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GIT Intussusception question

I will make it very short and not writte the entire clinical scenario because it's an easy one but the question and answer made me a little bit confused. the description is a very classic case of child intussusception and the question is:

Which of the following diagnostic test would be the best to perform through the ED before considering discharge of the patient?

A. Abdominal plain film
B. Air or water soluble enema
C. CT scan of the abdomen
D. Technetium 99m scan
E. Ultrasound of abdomen


Please explain why you choose that specific answer and if it's possible the source of your information. Thanks guys!
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  #2  
Old 11-14-2011
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Dont really understand why you would discharge a patient of intuseseption directly from the ED.maybe the question is misworded?


Initially the best diagnostic test is the Air or water soluble enema it is the best as its diagnostic as well as theraputic.

Or they could be asking after treatment what is the best confirmation the patient is cured/ or that no complications have occured, and in that case i would choose ultrasound but that is just a guess on my side.
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  #3  
Old 11-15-2011
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Quote:
Originally Posted by docnas View Post
Dont really understand why you would discharge a patient of intuseseption directly from the ED.maybe the question is misworded?


Initially the best diagnostic test is the Air or water soluble enema it is the best as its diagnostic as well as theraputic.

Or they could be asking after treatment what is the best confirmation the patient is cured/ or that no complications have occured, and in that case i would choose ultrasound but that is just a guess on my side.

this is the main reason why I post this topic....I really wanted to see if anybody gives the right answer. I posted on 2 different forums and so far nobody got the right answer....if you look at MTB for step 3 on page 359-360, you will see that the best initial step is to do a plain abdominal film to rule out obstruction and after this you do an air enema which confirm and is also therapeutic.

on the other hand, the official explanation for this question is this(I will quote everything regarding the air enema, plain abdominal film and abdominal ultrasound)


'this patient's presentation is concerning for possible intussusception, which is the telescoping of a proximal portion of intestine into a more distal portion of the intestine'....next they describe the possible complications, most likely clinical presentation, clinical findings on physical exam, etc. next are the explanation for the right and wrong answers:

'the most commonly used to either confirm or exclude a diagnosis of intussusception in the acute setting is the ULTRASOUND(Choice E), which has a sensitivity and a specificity approaching 100%, assuming the sonographer is well-trained in the technique. A target of pseudokidney appearance are the characteristic ultrasound findings

(Choice A) abd. plain films are frequently the first test performed in patients with suspected intussusception as they are easy to take and rarely may demonstrate findings of intussusception that are specific enough to proceed directly to air or water enema without the use of ultrasound. However, a normal plain film is present in most cases of intussusception, so it cannot be used to exclude the diagnosis and an ultrasound will still bbe necessary in most cases.

(Choice B) while and air or water soluble enema can confirm and potentially treat intussusception, it is more invasive and time consuming than ultrasoudn. Air or water enema are reserved for the treatment of intussusception already vizualized by ultrasound at most institutions.'

I do have some questions now:

1. the explanation said that indeed plain abd x rays are frequently the first test to be done in a suspected intussusception, even though they don't give any kind of specific signs and many times they are normal; should be just 'jump' to ultrasound or take an abd. Xrays even though might not give us any kind of informations?. In this case, Conrad Fisher could be right because, like I said before, MTB for step 3 says that best innitial test in a suspected intussusception is an abd. xray to exclude obstruction. It is well known that MTB for step 3 has many mistakes(I am not talking about spelling mistakes, I mean management mistakes)....could this be another one of them?

2. in a suspected intussusception we should not jump to air/water enema as an initial test....we should do ultrasound or abd. xray, depending on the source of the information. Who should we belive/who is right?

3. one point which sound a little strange to me.....ultrasound has a sensitivity and a specificity approaching 100%, assuming the sonographer is well-trained in the technique; we should presume that this person who did the US is well-trained??? what if is not well-trained? should we go straight to air enema or do a xray if the US is normal/negative???

4. my opinion: everybody can be wrong from time to time.....should we belive this explanation and follow it? some might ask which is the source of this explanation.....I will give it a little bit later but I would like to see if the management could be follow without knowing who gave these explanations(I don't want the answer to be influenced by knowing which is the source)


I do think we can debate on this topic and obviously somebody is right and some are wrong.....
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Old 11-26-2011
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Quote:
Originally Posted by docnas View Post
Dont really understand why you would discharge a patient of intuseseption directly from the ED.maybe the question is misworded?


Initially the best diagnostic test is the Air or water soluble enema it is the best as its diagnostic as well as theraputic.

Or they could be asking after treatment what is the best confirmation the patient is cured/ or that no complications have occured, and in that case i would choose ultrasound but that is just a guess on my side.
When the clinical history and physical findings suggest intussusception = US first...

the reason? increases the yield of diagnostic or therapeutic enemas and reduces unnecessary radiation exposure in children with negative ultrasound examinations.

From Nelson Textbook of Pediatrics, 19th ed. 2011
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  #5  
Old 07-31-2012
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Default Best Diagnostic?, Initial Diagnostic???

So you asked "Which of the following diagnostic test would be the best to perform through the ED before considering discharge of the patient?"
You did not ask best initial test. Your answer maybe correct, but not for this question.
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  #6  
Old 07-31-2012
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Jason Family practice says that just severe abdominal pain is enough for intussusception, Ultra Sound first always, a young child should not have that many Xray exposure
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  #7  
Old 08-01-2012
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Correct Answer

Abdominal X-ray are done in intussusception first to rule out any perforation(not to r/o obstruction).Most accurate in pediatric patients is ultrasound.In rare case of perforation surgery is the procedure of choice.You need to r/o perforation before going for Contrast enema.
Though Intussusception is more a clinical diagnosis and confirmed with US;AXR is to r/o complications such as perforation and may be r/o Volvulus and other possible differentials.
Recurrences are common in first 12 hours,therefore observation must and no discharge till 12-24 hrs.Recurrences are treated with non surgical methods and tried sometimes before considering surgery.......

Last edited by doc.mav; 08-01-2012 at 11:48 AM.
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  #8  
Old 08-01-2012
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Correct Answer

I will agree with bebix that US should be first.
**in above post in first line don't consider AXR as first**,but just the reason why it is performed.
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