Case 9 An infant with bloody diarrhoea
Jamie, an 8-month-old infant, is referred to the paediatric rapid referral clinic with a 24-hour history of vomiting and diarrhoea. Diane, his mother, reports that there is blood in the stool. There is no history of travel or of contact with anyone with diarrhoea. On examination Jamie has a temperature of 37.8°C and appears lethargic. He is not dehydrated and there are no abdominal signs.
What is your differential diagnosis and what investigations would you do?
The registrar considers the differential diagnosis to be gastroenteritis, intussusception or haemolytic uraemic syndrome (HUS). He orders a FBC, U and E’s and a blood culture, stool for virology and bacteriology, urine for microscopy and culture and arranges for Jamie to be admitted.
On the ward Jamie is noted to be lethargic with intermittent bouts of whimpering. He has a poor appetite and has a bilious vomit. The FBC and U and E’s are normal and the urine dipstick is clear, ruling out a diagnosis of HUS. An iv infusion is commenced with maintenance fluids.
Overnight, Diane’s concerns prompt a review by the registrar. Jamie still has a low grade fever and is very lethargic and the registrar orders a complete septic screen including a LP but excluding a CXR. The FBC shows a WBC count that is slightly raised at 17 × 109/L (normal 4–11 × 109/L), but the U and E’s, LP and urine dipstick are normal. Intravenous ceftriaxone is commenced. The following morning, a Saturday, Jamie is reviewed by the consultant. He has had two further bilious vomits overnight but there has been no diarrhoea or blood in the stool since admission and there are no abdominal signs. The consultant considers doing an abdominal US but as the consultant radiologist on call is not one of those with a paediatric interest and as Jamie has not got an abdominal mass, the consultant does not pursue this option. Diane is told that Jamie has gastroenteritis.
Do you agree with the consultant’s view?
Later that afternoon Diane requests a further review as she feels her child is getting worse. The registrar sees Jamie and thinks that there may be a mass on the right side of the abdomen and orders an US. The consultant radiologist states that he has little experience with abdominal US in children but is willing to do the US. The US demonstrates an intussusception (Case Figure 9.1).
Case Figure 9.1 A transverse US of an intussusception demonstrating the target appearance of the intussusception. The outer dark ring represents the outer bowel wall surrounding the inner loop of bowel which is intussuscepting into it.
