Name: Intussusception — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Intussusception is the great mimic of pediatric emergencies: the classic triad shows up in a minority, currant-jelly stool is a late sign, and a lethargic infant who looks well between episodes is the trap. The defensible chart shows you considered it and reached for ultrasound.

01What's at stake

It's the most common cause of bowel obstruction in children from about 3 months to 6 years, and delay risks ischemia and perforation. The full triad — intermittent colicky pain, abdominal mass, and currant-jelly stool — is present in fewer than half of cases, and currant jelly is a late finding. Lethargy can be the only presenting sign. Anchoring on "milk-protein allergy" or "too old for it" is how it gets missed.

02Why it's missed

The well-appearing interval — the child can look completely well between painful episodes.
Lethargy / altered mental status may dominate and mislead toward a neurologic or septic workup.
Currant-jelly stool is late — frank hematochezia (~60%) or occult blood is far more common early.
"Too old" — it can occur at any age, and a pathologic lead point (Meckel, polyp, lymphoma, HSP) becomes more likely with age.

03History & exam

Episodic colicky pain with calm intervals (50%–80%), vomiting (60%–80%)? → intussusception
Lethargy/listlessness out of proportion to exam? → consider intussusception
An abdominal mass on a calm exam? → supports it
Confirm reported "bloody stool" with an occult-blood test; many foods/meds mimic it.

Skip the typing

Work the case in the Pediatric Vomiting Workup — it records the abdominal exam, glucose, and imaging decision, and assembles an MDM that documents intussusception (and malrotation/volvulus) were considered in the vomiting or lethargic child.

04Testing & management

Ultrasound first — sensitivity ~97%–100% (target/donut sign); spares radiation. A negative/inconclusive US in a suspicious case → CT.
Plain films are limited (~45% sensitive) and can read falsely reassuring.
Air or contrast enema is both diagnostic and therapeutic (perforation rate ≤1%); contraindicated with perforation, peritonitis, or shock.
Resuscitate the unstable child; surgery for irreducible cases, a pathologic lead point, or perforation/peritonitis.
After a simple successful reduction, a well-appearing child tolerating PO can be discharged with explicit return precautions — recurrence is ~5%–20%, often within 24–48 h.

05What to document

▼ weak

"Fussy infant, looks well now, no currant-jelly stool. Likely viral. Discharged."

▲ defensible

"7-month-old with episodic colicky pain and vomiting, well-appearing between episodes but intermittently lethargic — intussusception considered. Occult-blood positive. Ultrasound: no target sign, normal. Malrotation/volvulus also considered; abdomen soft between episodes. Discharged tolerating PO with strict return precautions for recurrent pain, vomiting, bloody stools, or lethargy, and next-day follow-up."

06Where charts fail

Anchoring on milk-protein allergy or a viral illness in the episodically-fussy infant.
Dismissing it by age without considering a pathologic lead point.
Waiting for currant-jelly stool — it's late, not a screening sign.
Delaying ultrasound/reduction in a "well-appearing" child (delay raises complications).
Discharging after reduction without explicit recurrence return precautions.

07Sources

Lumba AK, Conrad H. The young child with lower gastrointestinal bleeding or intussusception. Pediatric Emergency Medicine Practice (EB Medicine). 2012;9(1).
Yamamoto LG, Morita SY, Boychuk RB, et al. Stool appearance in intussusception: assessing the value of the term "currant jelly." Am J Emerg Med. 1997;15:293-298.
Bajaj L, Roback MG. Postreduction management of intussusception in a children's hospital emergency department. Pediatrics. 2003;112:1302-1307.
DiFiore JW. Intussusception. Semin Pediatr Surg. 1999;8:214-220.

Intussusception: documentation that holds up