Intussusception

Here’s a story to help remember some of the details of intussusception. Remember to try and really picture this event, in your garden. If you can use children that you’ve seen or know, it will help make the story stick better. If you can make it even more ridiculous than I have, then go for it – the weirder the better!

Two boys and a girl are playing in the garden at a family barbecue. The boys are 6 months and 18 months old, and the girl is 12 months old.

  • Typically affects children between 6 and 18 months
  • Boys are twice as affected as girls

They’re all dancing, and doing a special dance where they have to jump as high as they can, and bring their knees up to their chest. As they’re doing this, they all turn completely white and start rolling around on the floor complaining of pain in their abdomen.

  • Child complains of abdominal pain
  • Often characteristically draws knees up to chest
  • Pale
  • Characteristic ‘Dance’s Sign’

One of the boys then does a poo. Unfortunately all he’s been eating is jelly, so he blasts jelly all over the other two. They both vomit, but since they’ve just been eating sausages from the barbecue, there’s now jelly and sausages all over the garden.

  • Vomiting
  • Blood-stained faeces (like jelly)
  • Sausage like mass palpable in the lower right quadrant

The children then all start screaming, but they’re screaming at such a high pitch that it’s causing all the windows to smash, so you then have to go on a trip to Target to buy replacements.

  • Ultrasound is the primary imaging modality
  • Characteristic ‘target’ sign seen

The Background

Intussusception is a medical emergency in which part of the bowel collapses into the adjacent part like a telescope (or extendable selfie-stick for those born after 1994). It can lead to obstruction and perforation, and then sepsis and shock.

The reason it’s dangerous is because the segment of bowel that is drawn in can have its blood supply cut off, and become necrotic and then perforate. The ischaemic bowel loses its mucosa into the bowel lumen, and this forms the characteristic ‘red jelly’. In reality, any type of blood in the stool should have intussusception on the differential diagnosis, especially if the child is between 6 and 18 months.

Causes

A variety of things can cause intussusception, although how it is that they do it isn’t well understood. It is thought that enlarged lymphoid tissue after an infection may play a role, and this would also explain why intussusception is relatively rare in the first three months of life, while the infant is still protected by passive immunity.

The different types include:

  • ileocolic (90%)
  • ileoileocolic (less common)
  • ileoileal (rare)
  • colocolic (rare)

Diagnosis

The diagnosis is made based on:

  • clinical examination
    • PR exam can be very helpful in children
  • history
  • Dance’s sign
    • emptiness in the lower right quadrant
    • sausage shape in right upper quadrant
  • Ultra-sound Scan
    • diagnostic imaging modality of choice
    • gives a characteristic target shape

If you google intussusception you get some awesome radiographs

I can’t put any on here because I don’t own them

sad face

Breastfeeding drug contraindications

Which drugs should be avoided when breastfeeding?

Amy is on a low-carb diet. She is aspiring to be a supermodel

  • amiodarone
  • carbimazole
  • aspirin

Amy was breastfeeding her baby and sipping her drink by the swimming pool, when a mercedes benz followed by four bicycles plunged into the pool.

  • ciprofloxacin
  • chlorampenicol (chlorine in pool)
  • benzodiazepines
  • tetracyclines

The bicycles exploded in two huge clouds of sulphur, while the mercedes exploded because it was made of lithium.

  • sulphonamides
  • sulphonylureas
  • lithium

It was all very excyting.

  • cytotoxic drugs

The following drugs should be avoided:

  • antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • psychiatric drugs: lithium, benzodiazepines
  • aspirin
  • carbimazole
  • sulphonylureas
  • cytotoxic drugs
  • amiodarone

Neonatal Hypoglycaemia risk

Some babies are at risk of hypoglycaemia. The following story should help you to remember the relevant risk factors!





It’s really early in the morning, and two babies wake up to find their mum collapsed on the floor. 

One baby is really small and the other is fecking massive. 

The mother has collapsed because she’s in DKA. 

She’s banged her head on the way down and there’s a lot of blood on the floor. 

Big baby thinks to slow the heart down to stop the bleeding and gives her beta blockers. 

The little baby doesn’t respond for 5 mins, and even then is hardly speaking. 

In fact all he does is pull a silly face and poo all over the floor.

  • preterm
  • low birthweight
  • large birthweight
  • diabetic mother
  • polycythaemia
  • mother on beta-blockers
  • APGAR <7 in first 5 mins
  • dismorphic face – suspected inborn error of metabolism

RTFQ


Read the full question

This is drilled into any student from a young age, and it never ceases to be true. Exam papers are minimalistic, they rarely contain any information that they don’t need (unless they’re testing your ability to sift through useless information…). This means that everything in the question is there for a reason, so analyse every bit


Eg. A 48 year old lady from Africa presents with…   


They’re not writing this for fun! This is saying ‘I want you to think about the risk factors for this age group and this nationality – use the information they’re giving you!

Keep the needle out of the flame


Don’t put a needle in inflamed tissue

This may sound obvious, but it applies all over the body. Needles hurt anyway, so sticking a needle into an infected or inflamed area is going to hurt a lot more, and risk spreading the infection. This applies to local anaesthetic, injection of botox into an overactive bladder, or injecting steroids into a painful joint.

The example of local anaesthetic:

Lidocaine doesn’t work well in an acidic inflamed environment, and the blood vessels in inflamed tissue are dilated to improve supply and drainage to the area, meaning the systemic spread is massively increase. Finally, the effective half life plummets as it all gets washed away. 

 

Follow me


Let the patient guide you

Searching for a diagnosis is like trying to find a certain room in a large building complex. The quickest and easiest way is to ask the person who knows where the rooms are and who has the keys to all the rooms.

This person is the patient.

Ask them where to go, and let them lead you. Don’t try and jump ahead, just follow them to the correct destination. If you start jumping, and thinking ‘I think this is pneumonia’, you’re essentially running ahead to a random room and asking ‘is it in here?’. Wait till the patient has told you everything, and see where you’ve ended up.

 

Burn, baby burn


My pre-OSCE hand wash

I get very nervous before exams, and I always have. I’ve been told it’s a normal response. Usually by the time the exam has started I’m alright, but the nerves before hand get very stressful. One thing that happens before OSCEs is my hands get really cold and clammy. Not only do I notice this, realise that it means I’m nervous, and get even more stressed out, but when I then go to shake a patient’s hand, it’s unpleasant for them and shows them that I’m nervous as well, and probably impacts on my global score. So I started a routine of finding a sink five or ten minutes beforehand and running my hands and wrists under the hottest water I can bear for about two minutes. It makes them go bright red, but forces them to vasodilate as well as warming them up directly. It might not make much of a difference come station #12, but it chills me out knowing my hands aren’t freezing cold.