CH 7 Pediatric Gastrointestinal

Question 1

*Haustra

Answer 1

indentations in the colon.

Question 2

Lesser Sac

Answer 2

located anterior and superior to the pancreas

Question 3

Retroperitoneal space

Answer 3

between the posterior parietal peritoneum and the posterior abdominal wall muscles.

Question 4

Bowel malrotation

Answer 4

due to abnormal positioning of the bowel during the embryologic phase. presents in the neonatal period.

bilious vomiting is the presenting symptom, because the obstruction is distal to the entry of the bile duct at the sphincter of oddi.

scanning- concentrate on orientation of SMA and SMV.
if malrotation is accompanied by a volvulus (twisting of the short mesentery around the SMA, the vessel and bowel become obstructed)

sono- classic “whirlpool” sign is seen.

Question 5

pyloric stenosis (HPS)

Answer 5

progressive pyloric muscle hypertrophy, which narrows and elongates the pyloric canal.

more common in first born caucasian males.

*presents with projectile vomiting and a palpable “olive shaped” epigastric mass.

Question 6

pyloric stenosis measurements

Answer 6

*positive
Muscle thickness >3 mm
canal length >17 mm (15-17)

“antral nipple” or “cervix” sign: the pyloric mucosa prolapsing into the stomach antrum.

Question 7

Meckel’s diverticulum

Answer 7

outpouching of bowel in the ileum.

Lining of this piece of bowel is made of pancreatic tissue or an acid-secreting tissue. The result may be an obstruction, intussusception or a volvulus.

Question 8

*Most common causes of neonatal bowel obstruction

Answer 8

ileal atresia
meconium ileus
meconium plug
hirschprung’s: congenital megacolon

Question 9

Bezoars

Answer 9

mass trapped in the GI system, usually the stomach

Lactobezoars: infants, formula not diluted properly
Trichobezoars: ingestion of hair

Question 10

Hernias:

Answer 10

tissue bulging from a weak part in the body. most hernia in young children are due to embryonal abnormalities; older children due to sports injuries.

Reducible: can be reduced with a transducer.
Irreducible: (incarcerated) unable to be reduced with transducer.

Question 11

Indirect Inguial hernia

Answer 11

Most common. congenital. more common in males, may occur in females due to incomplete closure of the Canal of Nuck.

*Neck lies superior and lateral to the proximal inferior epigastric artery.

more likely to extend into the scrotum or labia major.

Question 12

Direct inguinal hernia

Answer 12

2nd most common. aquired, typical for athletes.
neck is wider and rarely becomes incarcerated.

*neck lies inferior and medial to the proximal inferior epigastric artery.

Question 13

Femoral hernia

Answer 13

rare, more common in females after pregnancy.
often bilateral

*lie medial to the CFV and are superior to the saphenofemoral junction.

Question 14

Spigelian hernia

Answer 14

anterior abdominal wall hernias, occur within 2 cm of the internal inguinal ring. mushroom shaped.

*lie lateral to the inferior epigastric vessels.

Question 15

Duplication cysts (enteric cyst)

Answer 15

rare focal congenital cystic malformation of the GI tract which presents within the first year of life. due to incomplete canalization of bowel.

fluid-filled mass, more common in jejunum and ileum.
spherical, ovoid or dumbbell shaped. echogenic mucosa and hypoechoic muscular layer seen.

Question 16

Duplication cysts (enteric cyst) clinical presentation

Answer 16

palpable abdominal mass, abdominal distension, vomiting secondary to bowel obstruction, and hemorrhage secondary to peptic ulceration.

complication: perforation, intussusception, bowel obstuction and volvulus.

surgical excision preferred treatment.

Question 17

Intussusception

Answer 17

segment of bowel telescopes into a more distal section. commonly within the ileum. common 3mo-3yr

seasonal and related to mesenteric adenitis and rotovirus.

Question 18

Intussusception patient presents with

Answer 18

acute abd pain (knees drawn to chest), vomiting, palpable abd mass, and *red currant jelly stool.

Question 19

Intussusception sono:

Answer 19

target, hamburger, onion skin, or donut sign in cross-section and pseudokidney sign in long axis.

no peristalsis and poor vascularity.

treatment: air or barium enema

Question 20

Mesenteric adenitis

Answer 20

inflammatory process affecting the mesenteric lymph nodes in the RLQ; mimics appendicitis.

Question 21

Appendicitis

Answer 21

most common pediatric emergency, occurs late childhood.

Clinically- periumbilical pain radiating to the RLQ (McBurney’s point) anorexia, leukocytosis and rebound tenderness. retrocecal appendix will cause R flank pain (up to 65% of cases)

Question 22

Appendicitis sono:

Answer 22

use high resolution linear transducer and graded compression.

inflamed appendix will show hyperemia on color flow doppler (CFD). may also see appendicolith (appendix stone)

typical appy location: posterior to the terminal ileum and anterior to the iliac vessels.

Question 23

Appendix measurements

Answer 23

• normal diameter of appendix should be < 6m and should be compressible.
• inflamed mesentery or omental fat appearing as areas of increased echogenicity around the cecum are a reliable finding in >50% of children with appendicitis.

Question 24

Mucocele

Answer 24

collection of secretions within a chronically obstucted appendix. A large flui-filled sac like structure in the RLQ will be seen, with an “onion” skin appearance.

Question 25

Hirschprung’s disease

Answer 25

congenital meagacolon. congenital absence of nerves in parts of the intestine which cause severe constipation or blockage.

occurs more commonly in the upper rectum or sigmoid colon. surgical intervention is required.

Question 26

Causes of bowel wall thickening:

Answer 26

*normal intestinal wall measures 3-5 mm.

Lymphoma most common cause of bowel thickening
Other:
crohn's disease
necrotizing enterocolitis
peptic ulcer disease
henoch-schonlein purpura
typhlitis
lymphangiectasia
cystic fibrosis 
chronic granulomatous disease

Question 27

Primary neoplasms of peritoneala cavity

Answer 27

are rare in children. most are metastatic or from tumor rupture.

Question 28

Peritoneal fluid (ascites)

Answer 28

locations:

Pouch of douglas, paravesical recesses, paracolic spaces, morrisons pouch.

Question 29

Types of ascites:

Answer 29

clear ascites: urine, VP fluid

exudate ascites: associated with cancer, material- not anechoic

transudate ascites: due to cirrhosis

Question 30

Mesenteric cysts/lymphatic malformations

Answer 30

lymph filled cysts in the mesentery which may arise from the small or large bowel. develop from a proliferation of lymphatic tissue that fail to communicate with central lymphatic system.

lymphatic malformation/cyst- has septations

usually asyptomatic.

range in size from few mm to 40 cm, can be unilocular/multilocular, thin septations and fine calcifications. They may hemorrhage and become infected.

Question 31

Mesenteric abscess

Answer 31

localized collection of pus within the mesentery which are often secondary to infectious or inflammatory bowel disease, or ruptured appy.

abscess- fever, pain, leukocytosis, anaerobic gas (gas bubbles moving)

Question 32

peritoneal CSF collections

Answer 32

secondary to adhesion of a VP shunt in peritoneal cavity. located at distal end of VP (ventriculoperitoneal) shunt.

blockage occurs due to adhesion and abdominal distension and increased intracranial pressure result. most resolve, shunt revision or aspiration may be needed.

*reverb artifact may be seen when scanning a VP shunt

Question 33

Necrotizing Enterocolitis (NEC)

Answer 33

most common GI disease affecting preemies due to intestinal immaturity. intestines have compromised blood flow and feeding them immaturely causes tissue necrosis. occurs in the 1st or 2nd week of life.

greatest risk: <28 weeks gestation and < 1,000 grams birthweight.

20-40% mortality rate with NEC, 65% after perforation.

Question 34

Necrotizing Enterocolitis (NEC) clinical findings:

Answer 34

feeding intolerance, vomiting, bloody stool, abdominal distension, abdominal wall erythema (redness), unstble temp and BP, edema, diarrhea, lethargy, apnea.

Question 35

Necrotizing Enterocolitis (NEC) types

Answer 35

Intraluminal NEC- bubbles inside the bowel

Intramural NEC- bubbles within the bowel wall

Question 36

Necrotizing Enterocolitis (NEC) stages (doppler):

Answer 36

*doppler evidence of NEC shows initially as bowel wall hyperemia, progressing to ischemia and finally bowel wall thinning.

Severe cases of NEC, intestinal perforation, sepsis and death may result. air may also be seen in the portal veins (SMA, IMA drain bowel and combine with splenic vein to form PV)

tx: bowel rest and antibiotics, surgery in cases of perforation.

Question 37

Enteritis

Answer 37

inflammation of the small intestine. most common cause is ingesting contaminated water or food.
other causes: autoimmune diseases, radiation therapy and certain drugs may also cause enteritis.

sono: thickend bowel wall, enlarged lymph nodes and sometimes ascites.

Question 38

Direct Inguinal hernia

Answer 38

2nd most common groin hernia and are acquired, common for athletes.
Neck of hernia is wider, rarely becomes incarcerated.

*Neck of the direct inguinal hernia lies inferior and medial to proximal inferior epigastric artery.

Question 39

Femoral hernias

Answer 39

rare, more common in females after pregnancy. Often bilateral.

*medial to the CFV and are superior to the saphenofemoral junction.

Question 40

Spigelian hernia

Answer 40

anterior abdominal wall hernia. usually within 2 cm of internal inguinal ring.
sono: mushroom shaped

*lateral to the inferior epigastric vessels.