A previously well child has developed sudden onset episodes of screaming and drawing up his legs; he has not opened his bowels recently, and looks very pale.
Q1: What is the likely differential diagnosis?
Q2: What issues in the given history support the given diagnosis?
Q3: What additional features in the given history would you seek to support a particular diagnosis?
Q4: What clinical examination would you perform, and why?
Q5: What investigations would be most helpful, and why?
Q6: What treatment options are appropriate?
Q1: What is the likely differential diagnosis?
Acute infantile colic.
Acute intussusception.
Acute gastroenteritis.
Testicular torsion (in boys).
Strangulated inguinal hernia.
Other cause of intestinal obstruction.
Urinary tract infection.
Non-accidental injury
Serious bacterial illness of any cause, e.g. meningitis, septicaemia.
Q2: What issues in the given history support the given diagnosis?
Acute intussusception is supported by the sudden onset of the condition in a previously well child, inconsolable pain, and drawing up of the legs.
Infantile colic would have presented earlier and be intermittent, with the child completely well between episodes.
Q3: What additional features in the given history would you seek to support a particular diagnosis?
Ask about any vomiting and diarrhoea which may occur in gastroenteritis and also intussusception.
What colour are the stools? (i.e. is there blood present)
Ask about pallor or any recent viral infection
Q4: What clinical examination would you perform, and why?
Assess the level of dehydration and shock (acute circulatory failure).
Examine the abdomen between bouts of pain for any tenderness or masses.
Listen for bowel sounds (in intestinal obstruction bowel sounds are characteristically tinkling).
Examine the hernial orifices and testes for erythema, tenderness or swelling.
Q5: What investigations would be most helpful, and why?
Check a blood sample for acidosis, urea and electrolytes, and full blood count.
A plain abdominal X-ray would assist in the diagnosis of obstruction.
Urinalysis, blood culture, full blood count.
Q6: What treatment options are appropriate?
If present, correct shock with intravenous fluids.
Reduction of the intussusception with air insufflation under radiological control.
An obstructed hernia will require urgent surgery.