Bloody diarrhea in a baby and no U/S tech on-call

Dr Daren Lin from Guelph, Ontario posted a great case in the last few days on the CEUS discussion list. With his permission, we have reposted it here on the EDE blog. Take it away , Daren!

Last night on my evening shift at a community hospital, I had a 13 month old who presented with clear vomiting >20 times and three episodes diarrhea since the morning. The child would cry a bit before a diarrhea or vomiting, and then have the vomiting/diarrhea, and settle. There was one episode of bright red blood-tinged mucous loose stool in the morning before the ED visit. Child was fully immunized and healthy. Lives with an older sibling and both parents. Sibling and Mom just had gastro and their symptoms were resolving. On exam, child was afebrile and HR 155, other vitals in normal range. Very tired, resting in mom’s arms. HEENT, Resp, CVS exams normal. Child did not appear to be dehydrated with cap refill, mucous membranes, turgor, eye appearance all normal. Abdomen was scaphoid, no mass, not tender, tolerated deep palpation without pain. WBC was 19. Other blood work and urine normal. AXR normal. I put the curved array probe on the abdomen, and I see this image:

I was able to advocate for the radiologist to call a tech in to get an elective US (we actually had no tech on call but someone agreed to come in). An hour later, the child was on en route to the referral Pediatric Hospital after the ultrasound technologist also saw findings consistent with intussusception, with the classic target sign of hypoechoic rim around a hyperechoic centre.