View source for WBR0916

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|MainCategory=Inpatient Facilities, Emergency Room
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|MainCategory=Inpatient Facilities, Emergency Room
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal, Pediatrics
|Prompt=A 18 month old male child was brought to the ER by her mother with a complaint of crying for the past 6 hours.  When it started, his mother carried him and he settled down after a few minutes and then fell back asleep.  Over the next few hours, he woke up again intermittently crying and drawing his legs closer towards his abdomen.  He vomited once while on his way to the ER.  His vitals are blood pressure 90/60 mmHg, heart rate 118/minute, respiratory rate 24/minute and temperature 37 C.  On physical examination, his skin was found to be pink with brisk capillary refill, and  his oral mucosa was pink and moist.  His abdomen was soft and not distended, with normoactive bowel sounds, and no masses.  An abdominal X-ray revealed a soft tissue density, raising the suspicion of intussusception.  It was followed by a water-soluble contrast enema that identified an ileocolic intussusception at the hepatic flexure and was successfully reduced.  The child was then admitted for observation over the next 24 hours.  After 12 hours, the child began to have the same presentation due to recurrence of ileocolic intussusception.  What is the next best step in management of this child?
|Explanation=Patients with uncomplicated [[intussusception]] i.e. without any complications like ischemic or perforation are treated with non-operative reduction through ultrasonography or fluoroscopy guided hydrostatic (saline or barium) or air enema that serves both as a diagnostic and therapeutic tool.  After reduction, the patient is observed for the next 24 hours for any recurrence, which is common.  On recurrence, the patient is again managed with non-operative reduction.  Only after multiple unsuccessful non-operative reductions, operative reduction is considered.

'''Educational Objective:'''
Patients with uncomplicated intussusception i.e. without any complications like ischemic or perforation are treated with non-operative reduction through hydrostatic (saline or barium) or air enema.  After reduction, the patient is observed for the next 24 hours for any recurrence, which is common. On recurrence, the patient is again managed with non-operative reduction.  Only after multiple unsuccessful non-operative reductions, operative reduction (laparoscopic or open) is considered.  Laparoscopy or laparotomy and segmental resection with end-to-end anastomosis is the treatment of choice in patients with complicated intussusception i.e. intussusception with ischemia or perforation.

|AnswerA=Laparoscopic reduction of the intussusception
	

|AnswerAExp='''Incorrect'''-. Laparoscopic reduction of intussusception is the treatment of choice in patients with multiple unsuccessful non-operative reductions.  Laparoscopy is superior to open reduction because of faster recovery times, decreased length of stay, decreased time to full feeds, and lower requirements of pain medication.
|AnswerB=Open reduction of the intussusception
|AnswerBExp='''Incorrect'''-Open reduction of intussusception is the treatment of choice in patients with multiple unsuccessful non-operative reductions.  Laparoscopy is superior to open reduction because of faster recovery times, decreased length of stay, decreased time to full feeds, and lower requirements of pain medication.
|AnswerC=Laparoscopy and segmental resection with end-to-end anastomosis
|AnswerCExp='''Incorrect'''-Laparoscopy or laparotomy and segmental resection with end-to-end anastomosis is the treatment of choice in patients with complicated intussusception i.e. intussusception with ischemia or perforation.
|AnswerD=Laparotomy and segmental resection with end-to-end anastomosis
|AnswerDExp='''Incorrect'''-Laparoscopy or laparotomy and segmental resection with end-to-end anastomosis is the treatment of choice in patients with complicated intussusception i.e. intussusception with ischemia or perforation.
|AnswerE=Non operative reduction with either hydrostatic or air enema
|AnswerEExp='''Correct'''-On recurrence of intussusception, the patient is managed with another non-operative reduction.  Only after multiple unsuccessful non-operative reductions, operative reduction (laparoscopic or open) is considered.  Laparoscopy or laparotomy and segmental resection with end-to-end anastomosis is the treatment of choice in patients with complicated intussusception i.e. intussusception with ischemia or perforation.

|RightAnswer=E
|WBRKeyword=Intussusception, 
|Approved=Yes
}}