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Yr 4 - Paediatrics > GI: Intestinal Obstruction > Flashcards

GI: Intestinal Obstruction Flashcards

1
Q

What are some causes of intestinal obstruction in paediatrics?

A
  • Meconium ileus
  • Hirschsprung’s disease
  • Oesophageal atresia
  • Duodenal atresia
  • Intussusception
  • Imperforate anus
  • Malrotation of the intestines with a volvulus
  • Strangulated hernia
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2
Q

Presentation of intestinal obstruction?

A
  • Persistent vomiting - may be bilious, containing bright green bile.
  • Abdominal pain and distention
  • Failure to pass stools or wind
  • Abnormal bowel sounds - can be high pitched and “tinkling” early in the obstruction and absent later.
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3
Q

What is the initial imaging of choice in intestinal obstruction?

A

AXR

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4
Q

What may an AXR show in intestinal obstruction?

A

This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction. There will also be absence of air in the rectum.

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5
Q

Management of intestinal obstruction in children?

A

1) Emergency referral to a paediatric surgical unit

2) NBM

3) Insert NG tube: paediatric surgical unit

4) IV fluids

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6
Q

What is Hirschsprung’s disease?

A

A congenital condition where there is an absence of ganglion cells from myenteric and submucosal plexuses in the distal bowel and rectum.

The myenteric plexus (Auerbach’s plexus), forms the enteric nervous system. It is the brain of the gut.

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7
Q

What is the myenteric plexus responsible for?

A

Stimulating peristalsis of the large bowel.

The aganglionic section of the colon in Hirschsprung’s does not relax, causing it to becomes constricted –> loss of movement of faeces and obstruction in the bowel.

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8
Q

What is the key pathophysiology in Hirschsprung’s disease?

A

The absence of parasympathetic ganglion cells towards the end of the colon.

During fetal development these cells start higher in the GI tract and gradually migrate down to the distal colon and rectum. Hirschsprung’s occurs when the parasympathetic ganglion cells do not travel all the way down the colon, and a section of colon at the end is left without these parasympathetic ganglion cells.

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9
Q

In Hirschsprung’s disease, the length of colon without innervation varies between patients from a small area to the entire colon.

What is it called when the entire colon is affected?

A

Total colonic aganglionosis

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10
Q

Risk factors for Hirschsprung’s?

A

1) FH

2) Can be associated with other syndromes:
- Down’s syndrome
- Neurofibromatosis
- Waardenburg syndrome
- Multiple endocrine neoplasia type II

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11
Q

What is Waardenburg syndrome?

A

A genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair.

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12
Q

Presentation of Hirschsprung’s?

A

The severity & age depends on the extent of the bowel that is affected.

  • Can cause acute intestinal obstruction shortly after birth
  • Delay in passing meconium (more than 24 hours)
  • Chronic constipation since birth
  • Abdominal pain and distention
  • Vomiting
  • Poor weight gain and failure to thrive
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13
Q

What is Hirschsprung-associated enterocolitis (HAEC)?

A

Inflammation and obstruction of the intestine that occurs in around 20% of neonates with Hirschsprung’s disease.

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14
Q

How does HAEC present?

A

Typically within 2-4 weeks of birth with:
- fever
- abdo distension
- diarrhoea (often bloody)
- features of sepsis

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15
Q

What are some complications of HAEC?

A

Life threatening and can lead to toxic megacolon and perforation of the bowel.

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16
Q

Management of HAEC?

A
  • Urgent Abx
  • Fluid resuscitation
  • Decompression of obstructed bowel
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17
Q

What investigation is used to confirm the diagnosis of Hirschsprung’s?

A

Rectal biopsy

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18
Q

What will the rectal biopsy show in Hirschsprung’s?

A

An absence of ganglionic cells.

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19
Q

1st line management of HAEC?

A

IV Abx

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20
Q

Management of Hirschsprung’s?

A
  • initial fluid resuscitation
  • management of intestinal obstruction
  • rectal washouts, followed by anorectal pull through procedure
  • surgical removal of aganglionic section of bowel
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21
Q

What is the definitive management of Hirschsprung’s?

A

Surgical removal of aganglionic section

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22
Q

What is oesophageal atresia?

A

A congenital condition in which the oesophagus terminates in a blind-ended pouch.

Often associated with a tracheo-oesophageal fistula (an abnormal connection between the trachea and oesophagus).

23
Q

How can oesophageal atresia present antenatally?

A

As polyhydramnios

24
Q

How can oesophageal atresia present postnatally?

A
  • respiratory distress
  • distended abdomen
  • choking & cyanotic spells following aspiration
  • problems with swallowing
  • difficulty in passing NG tube
25
Q

What are the 3 different types of oesophageal atresia?

A

1) a pure oesophageal atresia (10%)

2) a blind proximal oesophagus, while the distal oesophagus communicates with the trachea via a fistula (85%)

3) fistulae in both the proximal and distal parts of the oesophagus (5%)

26
Q

What causes polyhdramnios in oesophageal atresia?

A

The baby’s inability to swallow and absorb amniotic fluid due to the blind-ending oesophagus can lead to excessive accumulation of this fluid, resulting in polyhydramnios.

27
Q

Management of oesophageal atresia?

A

Surgical intervention to correct the anatomical abnormalities.

28
Q

What is intussusception?

A

A paediatric emergency when a section of the bowel telescopes into its neighbouring distal section, causing bowel obstruction and potentially compromised blood flow.

29
Q

What is the most common site of intussusception?

A

Ileocaecal valve (ileocolic intussusception).

30
Q

What is the most common cause of intestinal obstruction in infants and young children?

A

Intussusception

31
Q

Which age group is intussusception most common in?

A

Children aged 6 months to 2 years.

32
Q

Are males or females more commonly affected by intussusception?

A

Males

33
Q

What can intussuscpetion often be preceded by?

A

A viral infection

34
Q

Around 10% of cases of intussusception occur due to the presence of a pathological lead point.

What is this?

A

This is an abnormal area in the bowel which is caught and pulled by peristalsis, thus leading the intussusception.

35
Q

Intussusception due to a pathological lead point is more likely to present in which patients?

A

Patients presenting OUTSIDE the typical age range

or

Where intussusception occurs away from the ileocaecal valve.

36
Q

what are some examples of pathological lead points and other secondary causes of intussusception?

A

1) viral infection

2) an enlarged Peyer’s patch acting as a ‘lead point’

3) Meckel’s diverticula (and other congenital bowel defects)

4) intestinal polyps

5) lymphomas and leukaemias

6) Henoch-Schonlein purpura (HSP)

37
Q

What is Henoch-Schonlein purpura (HSP)?

A

The most common type of small vessel vasculitis in children, particularly in those aged 3-5 years.

38
Q

What is Henoch-Schonlein Purpura (HSP) often preceded by?

A

Viral URT infection

39
Q

How does Henoch-Schonlein Purpura (HSP) present?

A
  • purpura or petechiae
  • abdo pain
  • arthralgia
  • nephritis
40
Q

What typical triad of symptoms is seen in intussusception?

A

1) Intermittent, severe abdominal pain

2) Vomiting: becomes bilious in later stages when bowel obstruction occurs

3) Redcurrant jelly stool

Note - In clinical practice, only one-third of patients present with all three of these symptoms.

41
Q

How may abdo pain present in intussusception?

A

May present as screaming episodes during which the child is inconsolable and draws their knees up to their chest.

The child may appear well between episodes but will become more lethargic over time as dehydration worsens.

42
Q

What causes redcurrant jelly stool in intussusception?

A

This is a late feature that occurs when ischaemic mucosal tissue is sloughed off and is excreted in the stool, mixed with blood and mucus (it is a rare presenting feature).

i.e. mix of blood and mucus

43
Q

Clinical features of intussusception?

A
  • Severe, colicky abdominal pain
  • Pale, lethargic and unwell child
  • “Redcurrant jelly stool”
  • Right upper quadrant mass on palpation - “sausage-shaped”
  • Vomiting
  • Intestinal obstruction
44
Q

Typical child in exam with intussusception:

A

Will have had a viral upper respiratory tract infection preceding the illness.

Will have features of intestinal obstruction (vomiting, absolute constipation and abdominal distention).

45
Q

What is the initial investigation of choice in intussusception?

A

US

46
Q

What will an US show in intussusception?

A

‘target sign’ or ‘doughnut ring’ - representing the telescoping bowel segments.

47
Q

What 2 investigations can be diagnostic in intussusception?

A

1) US

2) Contrast enema

48
Q

Role of enemas in intussusception?

A

Can be both diagnostic and therapeutic.

Therapeutic enemas can be used to try to reduce the intussusception. Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position.

49
Q

Who should contrast enemas NOT be performed in in intussusception?

A

Unstable patients with an signs of perforation or pertionitis.

50
Q

What is the management of intussusception if enemas do not work?

A

Surgical reduction

51
Q

What is the management of intussusception if the bowel becomes gangrenous (due to a disruption of the blood supply) or the bowel is perforated?

A

Surgical resection

52
Q

What are some complications of intussusception?

A

1) obstruction

2) gangrenous bowel

3) perforation

4) death

53
Q

What are the causes of bilious vomiting in neonates?

A

1) duodenal atresia

2) malrotation with volvulus

3) jejunal/ileal atresia

4) meconium ileus

5) necrotising enterocolitis

54
Q
A

Yr 4 - Paediatrics (78 decks)

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