Wednesday, April 1, 2009

Currant Jelly Stool

Intussusception Currant Jelly Stool  

This is a case I had and when the director of pediatrics heard about it I was asked to write it up and present it in lecture format to the 1st and 2nd year medical students. I thought I would share it here as well.

So the other night I received a call from a patient's father who explained to me that his 10 month old was not feeling well. He had diarrhea and currently no fever but had a fever earlier in the day of 101. The father had some questions about what could be the cause of the diarrhea and what to do about the diaper rash that had ensued from all the diarrhea and diaper changes. My initial gut felling was that there was something more to this case but I did not want to panic or cause panic of any kind. So I told the father how to care for the diaper rash and gave strict instructions to call if things got worse or if another fever developed. I know this father and I was sure he was a capable caregiver and a responsible parent.

The next morning while I was in a psychiatry lecture I received a call from the same father and this time there was a little more concern in his voice and he said I think that I can see blood in the stool and he told me that the diarrhea had continued through the night. I immediately recalled the uneasy feeling I had about this case the night before. Now armed with this new symptom, I asked the father to describe the blood and he explained it as a mucus like blood in the diaper with the stool. I immediately had a few good ideas of what this could be but without seeing the diarrhea and blood or the actual patient it was hard to say for sure. Many things could potentially cause these kinds of symptoms. I told the father that I thought it could be intussusception or maybe a bacterial diarrhea but that I needed to see the stool and the blood.

I asked the father to take a picture of the diaper with the stool and the blood and email it to my phone. He said he would do that and hung up the phone. About 2 minutes later I received the picture via my email on my phone. As soon as I opened the picture I had my diagnosis mostly nailed down. It was easy to see in the picture that the blood was a thick currant jelly like stool which is what is often seen in intussusception. There it is was (currant jelly stool) in the digital photo calling out to me. I immediately called the father and said you need to go into the hospital or to your doctors office immediately as this would require treatment. There was no way for me to know for certain through a picture and a phone call that it was intussusception for sure but I felt fairly certain that this seemed to be the diagnosis or less likely a bacterial diarrhea but either way treatment was necessary and if it was intussusception then it would require immediate treatment to prevent bowel necrosis and tissue damage.

After hanging up the phone and then again texting the father to reiterating the urgency of the situation I went back to the lecture I had been attending with the picture of the soiled diaper still fresh on my phone. A friend of mine looked at me and seemed to ask me with his eyes "what is all the commotion about". I approached him and said take a look at this picture and tell me what you think the disease might be. He is very bright so I was interested to see if he agreed with my diagnosis. He took a look at the picture and immediately said "first of all the picture is disgusting and second of all I think it is intussusception". I was glad he had the same thoughts because at this point the father was already on his way in to see his pediatrician. This friend of mine had done his pediatric rotation with me and we had seen a couple of cases of intussusception on our rotation. In addition to my pediatric rotation I had seen a few more cases while working on my emergency medicine rotation in the pediatric ER.

Later in the afternoon I got a call from the father and he said that he took his infant into the hospital and they confirmed that the diagnosis was in fact intussusception. I was elated to know that all this studying and working was seeming to work. Often you can miss a diagnosis so it always feels nice to get them right. However I was still concerned for the infant.

What is intussusception? Basically the intestine telescopes within itself like it is trying to digest the intestine itself. When this happens the blood supply can be cut of to the affected portion of the intestine and if it is not treated and fixed the bowel will begin to die and necrosis will set in. Essentially the intestine becomes blocked. Intussusception is considered a medical emergency for this reason and if left untreated a child can die with in 3 - 5 days or have significant loss of intestine due to necrosis. It is diagnosed officially and treated with the same process. Most hospitals use either an air enema to blow the telescoping intestine back out of the intestine it has gone into or a barium enema can be used to visualize and fix the intestine by pushing it back to its original location. In roughly 80% of the cases this is all the child needs and can be discharged home with instructions to rest the bowel (no solid foods) for a few days. 10 - 20% of the patients can have a reoccurrence of the intussusception and or those that reoccur 85 - 90% reoccur within the first 24 hours.

If there is a reoccurrence then a surgeon will surgically move the intestine back into place and may secure it so that it will not telescope again. In a small number of re-occurrences the surgeon may need to cut out a portion of the intestine. Classically the patient will present with the currant jelly stool and will be between the ages of 5 months - 1 year but sometimes the patient will not have the currant jelly stool and can be much older like 5 years old or even older. These atypical cases can be tough to figure out an the patient is at a higher risk of a delayed diagnosis and higher risk for loosing intestine due to necrotic damage.

The infants themselves will present with diarrhea, sometimes vomiting, crampy abdominal pain and abdominal tightness and fever. A good doctor may be able to feel the intestine portion that is blocked and it feels like an encased sausage. This can be a difficult diagnosis because the infants can't tell you what is wrong and where they hurt. They are just generally fussy and miserable.
How common is intussusception? The statistics state that there are about 1 - 4 cases per 1000 infants. Some areas may see more of this than other areas, so some pediatricians may not see it very often while others will see it more commonly. A few years ago the first rotavirus vaccine was thought to increase the incidence of intussusception so there were more cases popping up. The vaccine has since been replaced with a newer version that does not increase the incidence.


Anonymous said...

Thank you for your blog and the information of your personal experience. I love reading about medicine in the format of doctors' personal experiences. It makes for better reading than Harrison's. Thank you for helping to fight ignorance :)

samson said...

Thank you for the info! While this information is with out a doubt provides concise summery about intussusception, if the picture of the currant jelly stool was posted, it would have been more informative for those parents like me who have kids of that age group to associate the s/sx with a visual Dxs.

JJ said...

In response to Samson I have now uploaded a picture of currant jelly stool.

Jenny said...

Thank you for the information. I am a nurse, although not a pediatric nurse and had never heard of intussusception, or at least not until going with my daughter to the emergency room yesterday. I had taken care of my Grand-Daughter the night before and found a bloody mucus stool in her diaper the next morning. they did an X-ray and a sonogram... both negative, but still felt like it was intussusception that had corrected itself and she was sent home with instructions of what to do if it returns. I am believing God intercepted the intussusception.


bilal ghazal said...

Thnk u for this article and for sharing ur experience it was very question is that I was looking for pictures of "entamoeba histolytica" and this picture show this parasite can be the cause of intussusception in 10 minths old baby?