A 2-year-old male presents to your office with his father complaining that the patient has had intermittent crying followed by episodes of profound lethargy during which he is difficult to arouse. The father relates that the patient will sometimes clutch at his abdomen and roll into the fetal position during episodes. These episodes have been going on for about 4 hours. He has had no fever, no vomiting, and no diarrhea. Nobody else at home has been sick. He is developmentally normal and has no significant past medical history.
His exam reveals that he is afebrile and lethargic but can be aroused. His abdominal exam is benign. The rest of the exam is unremarkable. Given his presentation, your clinical suspicion is for:
A) Meningitis.
B) Renal colic.
C) Intussusception.
D) Gastric outlet obstruction.
E) Appendicitis.
Answer and Discussion:
The correct answer is “C.” Intussusception.
The patient may have intussusception. The combination of abdominal colic plus mental status changes should suggest intussusception. The etiology of the mental status changes is not clear, but mental status changes are one of the classical findings of intussusception.
“A,” meningitis, should still be a consideration in a patient with mental status changes, but abdominal pain is not usually part of the presentation. Additionally, the patient is afebrile and his symptoms are intermittent, making meningitis less likely.
“B” Renal colic is not associated with mental status changes.
“D” and “E” usually present with some abnormal findings on abdominal exam.
HELPFUL TIP: Fewer than 15% of patients with intussusception present with the classic triad of colicky abdominal pain, palpable sausage-shaped abdominal mass, and currant jelly stool.
“Currant jelly stools” are a late finding in intussusception and are a reflection
of mucosal ischemia. You really want to make the diagnosis before you see “currant jelly” per rectum. (Hey, have you ever actually seen currant jelly? It is bright red and gloopy, kind of like grandma’s cranberry sauce.)
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