A Bowel Inside a Bowel: Intussusception

The Case

A 14 month-old female with no significant PMH who presented to the Emergency Department with vomiting. Per mom, patient was well yesterday, but today has been refusing food, crying and vomiting. Patient has had no known sick contacts and her vaccinations are up to date. A review of systems was performed and was otherwise negative.

Physical Exam

Vital signs were within normal limits. Patient was listless with decreased responsiveness, but not in distress. No evidence of respiratory compromise. Abdominal exam was unremarkable, with no focal tenderness and no guarding, rigidity or rebound. During the time the examiner was present in the room, the patient had one episode of crying inconsolably and then vomiting.

An abdominal ultrasound was performed and the diagnosis was revealed to be Intussusception

Ultrasound

Ultrasound has been shown to be 97.9% sensitive and 97.8% specific for diagnosing ileocolic intussusception. To evaluate for intussusception, start with the high frequency low penetration linear transducer. In most young children this transducer will provide adequate depth. In an older child, you may have to use the higher penetration curvilinear transducer. If available, use warm gel to minimize patient discomfort and thereby increasing your changes of obtaining clear images. Begin in the transverse plane and slide your probe up to the right upper quadrant, across, and then down the left side, interrogating for the intussusception (Figure 1).

Figure 1: Suggested path of the ultrasound transducer to evaluate for intussusception.  (https://www.acep.org/how-we-serve/sections/emergency-ultrasound/news/september-2018/pediatric-emergency-ultrasound-deep-dive-on-pocus-for-intussusception/)

Figure 1: Suggested path of the ultrasound transducer to evaluate for intussusception.

(https://www.acep.org/how-we-serve/sections/emergency-ultrasound/news/september-2018/pediatric-emergency-ultrasound-deep-dive-on-pocus-for-intussusception/)

Most of the intussusceptions will be found on the right hand side, and are described as a “target sign” when you are viewing the intestinal intussusception in transverse or the “sandwich sign” in long axis.  The “lawn-mower” approach can be used, similar to the approach for SBO, and graded compression along your path can help move bowel gas out of the way to better evaluate the intestine. The hyperechoic rings are the mucosa and muscularis and the hypoechoic portion is the submucosa.  

Case Discussion

Intussusception is the most common abdominal emergency in early childhood, with the majority of cases occurring in patients <2 years of age. It occurs when the bowel telescopes in on itself and gets stuck. The peristaltic waves of the bowel causes waves of pain in the patient. The classic triad is described as pain, vomiting and bloody stools. Ultrasonography is the preferred diagnostic modality to evaluate for intussusception, given the high sensitivity and specificity (97.9% and 97.8% respectively) when performed by a skilled clinician. Ultrasound also has a high negative predictive value (approaching 99.7%) and can rule out intussusception in a majority of patients. Intussusception presents on ultrasound as a peripheral hypoechoic ring surrounding a central echogenic focus described as either a "target sign” or a “doughnut sign.” (Figure 2a) The visualized doughnut represents the layers of the intestinal wall that have invaginated into themselves. Color doppler can be applied to evaluate for tissue ischemia. (Figure 2b) The most common type of intussusception, ileocolic (as in this case) is usually found in the right lower quadrant. There is usually associated focal tenderness in the right lower quadrant (though this patient was non-tender). Treatment of a non-perforated intussusception typically consists of reduction via air enema, but sometimes operative management is indicated.

Figure 2: Ultrasound image of intussusception

Figure 2: Ultrasound image of intussusception

Achilles Tendon Rupture

CASE

A 41 year-old male without significant past medical history presents to the emergency department after sudden onset right leg pain while playing soccer. The patient reports jumping for the ball, landing on his feet, and immediately feeling sharp pain in his right ankle.  On exam, he has mild swelling to the posterior ankle overlying the Achilles tendon, and the area is tender to palpation. Plantarflexion is absent with calf squeeze, neurovascular exam is normal, and the remainder of patient’s exam is unremarkable. Bedside ultrasound is used to confirm the suspected diagnosis (Figure 1):

Figure 1: Ultrasound showing Achilles tendon rupture. Image courtesy of Dr. Timothy Boardman.

Figure 1: Ultrasound showing Achilles tendon rupture. Image courtesy of Dr. Timothy Boardman.


Why ultrasound?

  • US is useful to determine complete vs. partial rupture

  • It is not necessary for diagnosis

Provocative Testing: The Thompson Test (Figure 2)

  • Lack of plantar flexion when calf is squeezed with patient in prone position (sensitivity 0.96; specificity 0.93)

Figure 2: Diagram illustrating The Thompson Test. http://www.aidmyachilles.com/

Figure 2: Diagram illustrating The Thompson Test. http://www.aidmyachilles.com/

CASE OUTCOME

The diagnosis of Achilles tendon rupture was made. The patient was evaluated by orthopedics in the ED. He was placed in a posterior splint in resting equinus and discharged with instructions for non-weight-bearing with crutches. Orthopedic follow-up in 7-10 days was advised.

 

OVERVIEW OF ACHILLES TENDON RUPTURES

Anatomy:

  • Largest tendon in the body

  • Formed by the soleus, medial gastrocnemius, and lateral gastrocnemius tendons

  • Blood supply from the posterior tibial artery

Epidemiology:

  • Incidence: 18:100,000 per year

  • Demographics:

    • Men > Women

    • Ages 30-40 most common

    • Most often secondary to overuse and/or mechanical overload

  • Risk factors:

    • Intermittent athletes, “weekend warrior”

    • Older age

    • Fluoroquinolone use

    • Local steroid injection

Mechanism:

  • Sudden forced plantar flexion

  • Violent dorsiflexion in a plantar flexed foot

Symptoms:

  • Patient may report a “pop” or describe a feeling like being kicked in the leg

  • Weakness and difficulty walking, especially with plantar flexion

  • Heel pain

  • Patient usually cannot perform a single heel raise

The presence of at least two physical exam findings establishes the diagnosis:

  • Positive Thompson test

  • Palpable defect in the tendon

  • Decreased ankle plantar flexion strength and increased ankle dorsiflexion

Imaging:

  • Not necessary for diagnosis

  • MRI may be useful in cases of equivocal physical exam findings or chronic ruptures, but is not necessary in the ED setting

  • Ultrasound can help differentiate between complete and partial ruptures

Management: nonoperative vs. operative management is controversial.

  • Nonoperative

    • For acute injury; patient/provider preference; elderly/frail patients

      • Splint or cast in resting equinus

      • Early range of motion exercises

      • Re-rupture rates similar to those of tendon repair with fewer complications

  • Operative: End-to-end Achilles tendon repair

    • For acute injury (<6weeks); patient/provider preference

      • Improved strength

      • Higher percentage of patients who return to sports

TAKE HOME POINTS

  • Achilles tendon rupture tends to occur in older men who participant in strenuous activities on an occasional basis

  • Often a clinical diagnosis. Imagining is generally unnecessary for diagnosis but may help differentiate between partial and complete tears.

  • Patients can be discharged in splint or cast in resting equinus with close orthopedic follow-up.

  • Management is controversial and may be surgical or nonoperative based on several factors.

Faculty Reviewer: Jeffrey P. Feden, M.D.


REFERENCES:

  1. Karadsheh M. Achilles Tendon Rupture. Orthobullets [Internet]. Available from http://www.orthobullets.com/foot-and-ankle/7021/achilles-tendon-rupture. Accessed June 2017.

  2. Egol KA, Koval KJ, Zuckerman, JD. Handbook of Fractures, 5th ed. Wolters Kluwer Health, 2015. 490-493 p.

  3. Kadakia AR, Dekker RG, Ho BS. Acute Achilles Tendon Ruptures: An Update on Treatment. Journal of the American Academy of Orthopaedic Surgeons: January 2017;25(1): 23-31.

  4. Chiodo CP, Glazebrook M, Bluman EM, et al. Diagnosis and Treatment of Acute Achilles Tendon Rupture. Journal of the American Academy of Orthopaedic Surgeons: August 2010; 18(8): 503-510.

  5.  Tintinalli JE. Achilles Tendon Rupture, Chapter 272. Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill, 2011. 1867 p.

AEM Early Access 30: A Qualitative Study of the Newly Homeless ED Patients

Welcome to the twenty-ninth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON TITLE FOR FULL TEXT, OPEN ACCESS THROUGH SEPTEMBER 30):

“It wasn’t just one thing”: A qualitative study of newly homeless emergency department patients.” Kelly M. Doran, MD, MHS, Ziwei Ran, MSW, Donna Castelblanco, MBE, Donna Shelley, MD, MPH, and Deborah K. Padgett, MA, PhD, MPH

LISTEN NOW: INTERVIEW WITH FIRST AUTHOR KELLY DORAN

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Kelly Doran, MD, MHS

Assistant Professor

Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, NYU School of Medicine

ABSTRACT

Objectives

Emergency departments (EDs) frequently care for patients who are homeless or unstably housed. One promising approach taken by the homeless services system is to provide interventions that attempt to prevent homelessness before it occurs. Experts have suggested that health care settings may be ideal locations to identify and intervene with patients at risk for homelessness, yet little is known even about the basic characteristics of patients who might benefit from such interventions.

Methods

We conducted in‐depth, one‐on‐one qualitative interviews with ED patients who had become homeless within the past 6 months. Using a semistructured interview guide, we asked patients about their pathways into homelessness and what might have prevented them from becoming homeless. Interviews were digitally recorded and professionally transcribed. Transcripts were coded line by line by multiple investigators who then met as a group to discuss and refine codes in an iterative fashion.

Results

Interviews were completed with 31 patients. Mean interview length was 42 minutes. Four main themes emerged: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected.

Conclusions

These findings demonstrate gaps in current homeless prevention services and can help inform future interventions for unstably housed and homeless ED patients. More immediately, the findings provide rich, unique context to the lives of a vulnerable patient population commonly seen in EDs.