Incessant crying, Drowsiness


Dr.Ghaniya K.C, Dr. C Jayakumar, Dr. Shilpa Radhakrishnan (Radiodiagnosis), Dr. Aswin Prabhakaran (Pediatric Surgeon) 
Aims – Kochi
A one-year, nine-month-old female child presented to the outpatient department accompanied her parents and grandfather with a complaint of incessant crying since 11 a.m. on 28/03/24. The mother, a senior resident in a tertiary care hospital, was not at home, and the father, who works from home, reported concerns regarding the child’s incessant irritable crying since 11 a.m., followed sleepiness and lethargy. The child again started crying after waking up, and the same cycle continued for three hours. Despite attempts to soothe her, the child’s crying persisted.Clinical Course: Upon arrival at 4:20 p.m., initial suspicion centered around potential poisoning the maid, given the abrupt onset of symptoms and the nature of the child’s distress. But the father informed the onset of cry before the arrival of the maid, who used to come for a few hours only, and the grandfather correctly described the cycle of crying during waking up and sleeping after that. The child had taken only 100 ml of fresh lemon juice after the onset of the first symptom and had passed motion during the morning before the symptom. No significant past history or surgical procedures. History is negative for fever, fall, earache, dysuria, limb movements, seizures, vomiting, or loose stools. Clinical examination revealed normal vitals, PICCLE, and no evidence of bruises or bite marks, and all systems were within normal limits. The abdomen was soft, no masses felt, and bowel sounds were appreciated but with a slightly increased frequency. At approximately 4:40 p.m., before any other investigation, an ultrasound of the abdomen was promptly conducted as it was time to close the outpatient sonographic facility, which revealed an ileocolic intussusception intussusception.
Recognizing the urgency of the situation, Pediatric surgery was called in, and pneumatic reduction was swiftly initiated, reducing the intussusception within a span of three hours. The proximal segment was said to be extending up to the hepatic flexure.Outcome: Following the reduction procedure, the child’s symptoms notably improved. Subsequent monitoring indicated a resolution of the irritable crying episodes, indicating successful intervention and alleviation of the underlying cause. The child is advised to be nil per oral for the next 48 hours. In this case, the cause of the crying was due to intussusception, and drowsiness was due to hyponatremia due to third space loss in intussusception, which is a well-known complication.
Conclusion: In summary, the case underscores the importance of prompt evaluation and intervention in pediatric emergencies, particularly when presented with symptoms such as irritable crying. Collaboration between medical professionals and timely diagnostic imaging facilitated the identification and management of the underlying pathology, ultimately leading to a favorable outcome for the patient. Continued follow-up and surveillance will be essential to ensure the child’s ongoing well-being and to address any potential complications.
Intussusception: mCategorized as permanent or fixed, which is common and almost always requires treatment; and spontaneous or transient reduction, which is less common, is having a short segment (<2 cm), seen in gastroenteritis, mostly ileoileal, and resolves spontaneously.Taking etiology into account, it can be classified into primary or idiopathic (95%) with hypertrophied Peyer’s patches acting as a lead point; and secondary (4-5%) associated with pathological lead points.In most of the cases, intussusception commences just proximal to the ileocecal valve (ileocolic). Less commonly, it can be jejunojejunal, jejunoileal, ileoileal, appendicocolic, cecocolic, and colocolic (found in parasitic diseases in children); and can be at multiple sites too.Management: Nonoperative Measures: (Radiological Reductions)Pneumatic reduction Hydrostatic reduction Delayed repeat enemaAir enema performed under GA allows intussusception reduction in more than 90% of patients. General anesthesia (GA) has been suggested to increase the rate of enema success. Pneumatic or Hydrostatic reduction is having a very good success rate.

Operative Measures: Exploratory laparotomy Laparoscopy
Complications:
Intestinal perforation 
Septic shock 
Intestinal necrosis 
Intestinal infection 
Internal bleeding, 
Peritonitis 
Small bowel obstruction 
Untreated ileal-colonic intussusception in infants is usually fatal; the chances of recovery are directly related to the duration of intussusception before reduction.
Carry-home message: 
A beautiful history helped to reach the diagnosis with the help of the sonologist promptly managed the pediatric surgeon.

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