The diagnosis depends on the direct demonstration of bowelwithin-bowel. A simple way of showing this is by abdominalultrasound. If the ultrasound is positive, or if good visualization has not been achieved, a pneumatic or contrast enemaunder fluoroscopy is indicated. This is a potentially useful wayto both identify and treat intussusception. Air and barium canshow the intussusception quickly and, when administered withcontrolled pressure, usually can reduce it completely. The success rate for pneumatic reduction is probably a bit higher thanhydrostatic reduction with barium and approaches 90% if donewhen symptoms have been present for less than 24 hours. Thepneumatic enema has the additional advantages over barium ofnot preventing subsequent radiologic studies and having no riskof causing barium peritonitis if perforation occurs. Nonoperative reduction should not be attempted if the patient is unstableor has evidence of pre-existing perforation or peritonitis.
Therapy must begin with placement of an IV catheter and a nasogastric tube. Before radiologic intervention is attempted, the child must have adequate fluid resuscitation to correct the often severe dehydration caused by vomiting and third space losses. Ultrasound may be performed before the fluid resuscitation is complete. Surgical consultation should be obtained early as the surgeon may prefer to be present during nonoperative reduction. If pneumatic or hydrostatic reduction is successful, the child should be admitted to the hospital for overnight observation of possible recurrence (risk is 5% to 10%). If reduction is not complete, emergency surgery is required. The surgeon attempts gentle manual reduction but may need to resect the involved bowel after failed radiologic reduction because of severe edema, perforation, a pathologic lead point (polyp, Meckel diverticulum), or necrosis.
Appendicitis is the most common surgical emergency in childhood. The prevalence of appendicitis varies by age with the peak between the ages of 10 and 12 years. It is much less common in children under the age of 5. Appendicitis begins with obstruction of the lumen, most commonly by fecal matter (fecalith), but appendiceal obstruction also can occur, secondary to hyperplasia of lymphoid tissue associated with viral infections or rarely the presence of neoplastic tissue, such as an appendiceal carcinoid tumor. Trapped bacteria proliferate and begin to invade the appendiceal wall, inducing inflammation and secretion. The obstructed appendix becomes engorged, its blood supply is compromised, and it finally ruptures. The entire process is rapid, with appendiceal rupture usually occurring within 48 hours of the onset of symptoms.
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