GI #13 Flashcards
What is a Meckel’s (Ileal) Diverticulum?
Persistent portion of the embryonic vitelline duct in the small intestine
True or False: A Meckel’s Diverticulum is the MC congenital anomaly of the GI tract
True
Explain what the Rule of 2’s means in terms of a Meckel’s Diverticulum
- 2% of the population
- 2x more common in males
- 2 years old is MC presentation
- 2 inches in length
- 2% symptomatic
- 2 types of ectopic tissue (gastric MC and pancreatic)
Symptoms of a Meckel Diverticulum
- Usually asymptomatic
- Painless rectal bleeding or ulceration
How do you diagnose a Meckel Diverticulum?
- Meckel scan: look for ectopic gastric tissue in ileal area
- Mesenteric arteriography
How do you manage a Meckel Diverticulum?
Surgical excision if symptomatic
What is duodenal atresia?
-Complete absence or closure of a portion of the duodenum, leading to gastric outlet obstruction
What are some risk factors for duodenal atresia?
- Polyhydramnios (increased amniotic fluid)
- Down Syndrome
Symptoms of duodenal atresia
- Neonatal intestinal obstruction: within 24-48 hours of life
- Bilious vomiting
- Abdominal distention
What is seen on abdominal radiographs for duodenal atresia?
Double bubble sign (distended air filled stomach and smaller distended duodenum separated by pyloric valve)
What is definitive management for duodenal atresia?
Duodenoduodenostomy
A volvulus is _______ and MC involves what two parts?
- Twisting of any part of the bowel at its mesenteric attachment site
- sigmoid colon and cecum
Symptoms of a volvulus
- Obstruction: crampy pain, nausea, distention, vomiting, tympanitic abdomen with tenderness to palpation
- Impaired vascular supply: rigidity, rebound tenderness, fever, tachycardia
- Neonates: bilious vomiting, colicky pain
Abdominal CT for volvulus shows
-Dilated sigmoid colon (bird beak appearance at site of volvulus)
Abdominal radiograph for volvulus shows
bent inner tube or coffee bean sign (U shaped appearance of air filled closed loop of distended colon with loss of haustral markings)
What is the management for a volvulus?
Endoscopic decompression (proctosigmoidoscopy) is initial -Decompression followed by elective surgery due to recurrence
MC etiology of small bowel obstruction
Post-surgical adhesions
Other etiologies of small bowel obstructions
- incarcerated hernias
- Crohn’s Disease
- Malignancy
Symptoms of a small bowel obstruction
- Crampy abdominal pain
- Abdominal distention
- vomiting
- Obstipation (no flatus)
- High pitched tinkles on auscultation
- Visible peristalsis (early obstruction)
- Hypoactive bowel sounds (late obstruction)
What is seen on exam with early obstruction vs late obstruction?
Visible peristalsis in early and hypoactive bowel sounds in late
Abdominal radiographs for small bowel obstruction shows
-Multiple air fluid filled levels in a step ladder appearance, dilated bowel loops
Treatment for a small bowel obstruction
- Nonstrangulated: NPO, bowel rest, IVF, Bowel decompression if severe and vomiting
- Strangulated: surgical intervention
Which organ is the MC organ injured during trauma?
Spleen
Symptoms of a splenic rupture or laceration?
kehr sign: referred left shoulder pain due to irritation of diaphragm and phrenic nerve
What is a paralytic (adynamic) ileus?
Decreased peristalsis WITHOUT structural obstruction
Etiologies of paralytic ileus
- Postoperative State
- Medications: Opiates
- Metabolic: Hypokalemia, hypercalcemia
- Hypothyroidism, Diabetes
Symptoms of paralytic ileus
- Symptoms similar to small bowel obstruction
- Decreased or absent bowel sounds
- No peritoneal signs
Plain radiographs of paralytic ileus shows
-Dilated loops of bowel with no transition zone
How does imaging for a small bowel obstruction and paralytic ileus differ?
CT scan for small bowel obstruction shows transition zone from dilated loops with contrast to areas of bowel with no contrast
Paralytic ileus does not have transition zones
Treatment for paralytic ileus
- Supportive care: NPO or dietary restriction
- Electrolyte and fluid repletion
- NG suction if moderate or persistent with vomiting
What is intussusception
-Telescoping (invagination) of an intestinal segment into adjoining distal intestinal lumen leading to bowel obstruction
Where does intussusception MC occur?
At ileocolic junction
True or False: Intussusception is the MCC of bowel obstruction in children 6 months - 4 years of age?
True
Risk factors for intussusception
- Children
- Males
- After viral infections
MC etiology of intussusception
Idiopathic MC
Triad of symptoms of intussusception
- Vomiting
- Abdominal pain
- Passage of blood per rectum (currant jelly stools: blood and mucus)
What is unique about physical exam of a patient with intussusception?
Sausage shaped mass in the RUQ and emptiness in the right lower quadrant (Dance’s Sign) due to telescoping of the bowel
Best initial test for intussusception
US: shows target or donut sign
What other diagnostic test is done for intussusception?
Air or contrast enema: both diagnostic and therapeutic
Treatment for intussusception
- Fluid and electrolyte replacement initially
- NG decompression next (pneumatic or hydrostatic with saline or contrast)
- Admit for observation
What is Hirschsprung Disease?
Congenital megacolon due to absence of ganglion cells, leading to functional obstruction
Hirschsprung Disease is MC in what area?
Distal colon and rectum
Risk factors for Hirschsprung Disease
- Males
- Down Syndrome
- Chagas Disease
- MEN II
Pathophysiology of Hirschsprung Disease
-Failure of complete neural crest migration leads to absence of enteric ganglion cells (Auerbach and Meissner Plexuses)
Symptoms of Hirschsprung Disease
- Meconium Ileus (no meconium passage > 48 hour) in full term infant
- Bilious vomiting, abdominal distention
- Failure to thrive
- Vomiting, diarrhea, chronic constipation in older kids
Diagnostics for Hirschsprung Disease
- Contrast enema: transition zone between normal and affected bowel
- Anorectal manometry: increased anal sphincter pressure and lack of relaxation
- Rectal biopsy: definitive
Treatment for Hirschsprung Disease
-Resection of affected bowel segment
True or False: appendicitis is the MCC of acute abdomen in children 12-18 years old
True
Common etiologies of appendicitis
- Fecalith and lymphoid hyperplasia (MC)
- Inflammation
- Malignancy
Symptoms of Appendicitis
- Anorexia and periumbilical pain followed by RLQ pain
- Vomiting, Nausea
Appendiceal inflammation stimulates nerve fibers around ______ causing vague periumbilical pain
-T8-T10
What are 4 specific physical exam findings and tests for appendicitis?
- Rovsing Sign: RLQ pain with LLQ palpation
- Obturator Sign: RLQ pain with internal and external hip rotation with flexed knee
- Psoas Sign: RLQ pain with right hip flexion/extension (raise leg against resistance)
- McBurney’s Point: 1/3 distance from anterior superior iliac spine and navel pain
In adults, _____ is the preferred imaging of choice for appendicitis
CT scan
In children, _____ is often obtained prior to imaging to determine whether imaging is needed for appendicitis
surgical consult
Treatment for appendicitis
-Appendectomy (laparoscopic when possible is preferred)
