Abdominal Pain with Vomiting

Question 1

What is the presentation of malrotation volulus?

Answer 1

Malrotation Volvulus

• arises because mesentery doesn’t migrate and the two bases (ileocaecal and duodenal jejunal junction) are too close together
• Degree of twist is important:
  
  • 360 twist = venous and lymphatic engorgement + bile-stained vomit
  • 720 twist = arterial ischaemia

Presentation:

• bile stained vomit with grassy green colour.
  
  • bile oxidised in stomach
• feeding difficulty
• late game - passing blood in stool.

Question 2

What investigations will you do for malrotation volvulus?

Answer 2

• Do an AXR but its not useful
• US - whirl sign +/- test feed (not done at RCH)
• Contrast study
  
  • C sign = incomplete - conservative management
  • S sign = complete rotation (go to surg)

Question 3

What are the types and complications of malrotation volvulus?

Answer 3

• degree of twist is important:
  
  • 360 degrees - venous + lymphatic engorgement + bile-stained
  • 720 degrees - arterial ischaemia
• complications:
  
  • ischaemic gut
  • necrotic gut
  • intestinal obstruction (5-10%)
  • intussusception
  • mortality (3-9%)
  • 5% recurrance

Question 4

What is the treatment of malrotation volvulus?

Answer 4

surgical

• LADS procedure - derotate and widen mysentery
• can get ischaemic reprofusion phenomenon
• rarely need to resect bowel
• Do an appendicetomy at the same time (atypical presentation and might be missed - small bowel on right).

conservative:

• monitor for sepsis and feed intolerance

Question 5

What is the epidemiology of pyloric stenosis?

Answer 5

• most common cause of intestinal obstruction
• very common in boys (85% males)

Question 6

What is the Presentation of Pyloric Stenosis

Answer 6

• Non-bilious vomiting
  
  • projectile (forceful)
  • progressive
  • with every feed
  • will want to feed after vomiting (unlike sepsis)
• dehydrated
• LOW
• decreased stool
• Examination
  
  • visible peristalsis
  • dehydrated
  • palpable olive = pyloric hypertrophy
    *

Question 7

What are some non-surgical differentials? Why are they dangerous?

Answer 7

• mesenteric adenitis - common cause of abdo pain
• GORD - oesophagitis
• gastroenteritis (stools too - high volume and watery)
• Cow’s milk protein allergy

Are these dangerous?

• yes - can still get dehydrated and need fluid resus
• malnutrition

Question 8

What are the metabolic derangements in Pyloric Stenosis?

Answer 8

• vomiting out HCL and NaCl, K
  
  • no hyponatremia - preserve sodium body will conserve.
• metabolic alkalosis
• K+ and Cl low
• paradoxical aciduria - try to retain Na+

Question 9

What is the treatment for Pyloric Stenosis?

Answer 9

Medical emergency not surgical:

• Medical
  
  • fluids
  • correct metabolic derangement
  • NBM
• Fluid regime
  
  • 150ml/kg/day
  • NaCl and dextrose
  • add 20mmol KCl/L after confirming K level
• Surgical
  
  • tear the pyloris - tear along one side and ripe it enough so it becomes a C so the mucosa can pouch. 1-2% chance to tear to much or little
• Post-op Mg
  
  • not great neurodevelopmental outcome (vomiting, hypokalaemia, alkalosis)
  • discharge once on full feeds.
  • start low volume

Question 10

What investigations would you do for pyloric stenosis?

Answer 10

• Metabolic derangements
  
  • UEC - low K+ and low Cl-
  • metabolic alkalosis
  • paraxocial aciduria
• US
  
  • lengthening pylorus and thickening of wall.
  • thickening of the terminal stomich
    
    • length channel >16mm
    • muscle thickness >4mm
    • total diameter >12mm

Question 11

What is Intussusception? What is it caused by?

Answer 11

• most common cause outside pyloric stenosis
• bowel invaginated on itself proximal into distal, then distended bowel peristalses. Once it goes into large bowel thats a problem.
• everyone has it, small bowel to small bowl and self resolves.
• Causes
  
  • enlarged LN and inflamed Peyer’s patches (6mths)
  • pathological lead point (uncommon) - not all kids are idiopathic
    
    • Meckel’s diverticulum
    • Polyp = Peutz-Jeghers syndrome
    • Vascular malformation (HSP) - bleeds into bowel.
    • Duplication cyst
  • 90% of adults will have pathological lead point. Most of which is cancer.

Question 12

Epidemiology of Intussusception?

Answer 12

• RFs at age 5-7months:
  
  • immune system is changing
  • antigenic exposure is increasing
  • spring and autumn (viral peaks)
  • rotavirus vaccination

Question 13

What is the Presentation of Intussusception?

Answer 13

• colicky abdominal pain
• vomiting
• lethargy
• posturing
  
  • foetal position
  • up-drawn legs
• 5-7 mth old (3mths - 3 years)
• pale + sweaty
• dehydration
• red-current jelly stool = late sign (40% due to a bit of ischaemia)
• abdominal mass (early sign) - sausage shape

Dehydration, BO, bowel ischaemia (late), 10% recurrence

Question 14

What is the Management of Intussusception?

Answer 14

Ix:

• US - target sign on the right usually

Treatment:

• conservative - gas enema (80-90% success)
  
  • done if <48 hours Hx
  • stable
  • no peritonitis
  • dude holds but cheeks closed, so no gas escapes.
• surgical
  
  • >48 hours
  • peritonitis/septicemia