Reducing the intussuscepted colon.

T he Case The 3-month-old female infant began vomiting on a Thursday afternoon. The mother telephoned her pediatrician, who advised the mother to watch the infant carefully and to call back if the vomiting did not subside. The infant seemed to improve over the next 36 hr. but on Saturday morning, the mother brought the infant to the pediatrician’s office because the vomiting resumed and low-grade fever had now developed. The pediatrician examined the infant and, finding no evidence of abdominal mass, fever, or dehydration, determined that the infant had gastroenteritis. The vomiting had by now subsided, and the mothertook the infant home. Later that day, at 5:00 P.M., the mother again telephoned the pediatrician, informing him that the vomiting and fever had recurred. The mother also reported that now the infant had diarrhea and blood-streaked stool. The pediatrician instructed the mother to bring the child to the hospital, where he would arrange to have the infant admitted. The pediatrician called the pediatric nursing supervisor at the hospital and asked her to conduct an initial assessment of the infant’s condition and report back to him. Soon thereafter, the nurse advised the pediatrician that the child did not appear to be acutely ill. The pediatrician, therefore, did not go to the hospital to examine the infant but, instead, ordered laboratory tests. At 2:00 AM. the next morning, the pediatric nurse telephoned the pediatrician and informed him that the child’s physical condition had deteriorated. The pediatrician then called a surgeon for consultation. The surgeon ordered radiographs of the abdomen, which were transmitted by teleradiology to the home of the radiologist who was on call. The radiologist interpreted the study as showing a partial bowel obstruction, without evidence of specific mass or free air. Establishing a tentative diagnosis of intussusception, the surgeon requested that the radiologist come to the hospital to confirm the diagnosis and attempt to reduce the intussusception radiologically. The radiologist responded promptly and arrived at the hospital within 30 mm. In the presence of the surgeon and with the parents of the infant waiting in an adjacent room, the radiologist performed a barium enema examination and confirmed the presence of an ileocolic intussusception. However, on this first study he was able to only partially reduce the intussusception. The radiologist made a second attempt to reduce the intussusception, this time administering glucagon and using a bulb syringe to introduce “three or four puffs” of air. He did not use a manometer to gauge the air pressure. The infant suddenly stopped breathing and experienced cardiac arrest during the procedure. Cardiopulmonary resuscitation was immediately instituted and normal breathing and pulse rates were restored. The infant was then taken to the operating room where the surgeon found an ileocolic intussusception, complicated by a perforation of the transverse colon and a segment of gangrenous and necrotic bowel. The infant never regained consciousness and died 12 hr later. Autopsy revealed multiple areas of hemorrhagic infarcts, necrosis, and thinning of the distal small bowel. Cultures of blood and from abdominal contents had positive findings. The pathologist concluded that the infant died of sepsis associated with infarcts of the small bowel and perforation of the colon.