Don, this is truly a big dilemma ! As you know the classic signs of the disease are present in only 50 % of the kids. My approach has become more conservative these days. 

The analogy I would use is of  r/o AMI in the face of a "good story", Nl exam and Nl EKG. In the latter, you would admit &/or do serial EKG/enzymes.

Similarly, if the "story" is good, which in this case I would assume it is, because it was witnessed by the PCP, I would pursue it further. Where your index of suspicion is low, as in this scenario, I would obtain an  ultrasound in my institution. It is quick, non-invasive, does not involve radiation and in experienced hands is very accurate. 

One question for you? There is considerable inter-reporter variability in the interpretation of a plain radiograph in this setting? When you state it is normal, I assume there were no subtle signs like abnormal gas patterns and/or absence of stool in the left colon etc. etc. This is one scenario where I actually have the radiologist review the film "real time" for a change!!

Thanks and keep us posted.

Jay Pershad, MD, FAAP
Asst. Professor
Division of Pediatric Emergency Medicine
UT College  of Medicine  
LeBonheur Children's Medical Center
Memphis, TN 38103
Pediatric Emergency Specialists, PC

From one who has missed the diagnosis and was shown the "Donut" sign of Intussusception on US, over a morning cup of coffee!!

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