PAED SURGERY 2 Flashcards
What is intestinal obstruction?
What can it cause ?
Intestinal obstruction is where a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back-pressure through the gastrointestinal system, causing vomiting
It can cause absolute constipation, where the patient is unable to pass stools or wind.
Causes of Intestinal obstruction?
- Intussusception (most common in children)
- Meconium ileus
- Hirschsprung’s disease
- Oesophageal atresia
- Duodenal atresia (common in downs)
- ileal atresisa
- Imperforate anus
- malrotation of small bowel
- Malrotation of the intestines with a volvulus
- Strangulated hernia
How does intestinal obstruction present?
- Persistent vomiting-may be bilious
- Abdominal pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. (high pitched / “tinkling” early in the obstruction and absent later.)
Investigations and findings for diagnosis of intestinal obstruction?
Imaging:
Abdominal xray
* dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction.
* Absence of air in the rectum.
Management of intestinal obstruction in children
- emergency referral to paediatric surgical unit
- nil by mouth
- NG tube - drain stomach / stop vommitting
- IV fluids - fluid / electroyle disturbance
When does Pyloric stenosis present?
typically 2-4 weeks of life with vomitting rarely up to 4 months
What is the pyloric spinchter?
With this in mind, explain the pathoysiology of pyloric stenosis and thus how it presents the way it does
What?
* pyloric sphincter is a ring of smooth muscle the forms the canal between the stomach and the duodenum.
Pathophysiology:
* Hypertrophy and narrowing causes pyloric stenosis. Food cannot travel from the stomach to the duodenum as normal.
Why presents as it does:
* After feeding, powerful peristalsis tries to push food from stomach into the duodenum. Its force ejects the food into the oesophagus, out of the mouth and across the room- “projectile vomiting”.
Features of pyloric stenosis?
Hungry / thin baby
pale
weight loss
dehydration - (mild to shock)
failing to thrive
projectile vomitting
Examination / observation and findings in pyloric stenosis?
Test feed
* with an NG tube in situ and stomach aspirated.
* observe left - right peristalsis of Left upper quadrant can see persitalsis on the abdomen.
Examine : Palpate
* firm, round mass in upper abdomen “olive sized” mass (hypertophic muscle)
* stand on left of baby and palpate with left hand at the lateral border of the right rectus in RUQ, during bottle / breast feed.
What might electrolyte / fluid status of a baby with pyloric stenosis be?
What should you test? why?
Severe H20 and NaCl deficit
Oxhandbook adds :hypochloraemic hypokalaemic metabolic alkalosis
Test:
urine output
plasma Cl-, K+
PH
Na (high or low)
Imaging: Abdo US to confirm diagnosis
Blood gas : hypochloric metabolic alkalosis
Why?:
to guide resuscitation and determine if surgery is safe.
Management of pyloric stenosis?
Before surgery:
* NG tube to correct electrolyte and metabolic distrubance
Surgery:
* laparoscopic pyloromyotomy (known as “Ramstedt’s operation“).
* An incision is made into the smooth muscle of the pylorus, widening the canal.
* Prognosis is excellent following the operation.
RF for pyloric stenosis?
Male
Family Hx
https://teachmepaediatrics.com/surgery/abdominal/pyloric-stenosis/
RF for pyloric stenosis?
Male
Family Hx
https://teachmepaediatrics.com/surgery/abdominal/pyloric-stenosis/
What does this blood gas show?
explain the pathophysiology behind electrolyte shifts
hypokalaemia, hypochloraemic metabolic alkalosis for a pt with pyloric stenosis
Patho:
The loss of HCL with repeated vomiting of stomach acid causes a hypochloraemia and metabolic alkalosis. The kidneys will then exchange potassium to retain protons to attempt to compensate, leading to a hypokalaemia.
Differentials for pyloric stenosis?
- Gastroenteritis
- Gastro-oesophageal reflux, including Sandifer syndrome
- Over-feeding
- Sepsis
- UTI
- Food allergy
If bilious vomiting is reported, don’t forget to think malrotation!
https://teachmepaediatrics.com/surgery/abdominal/pyloric-stenosis/
Complications of surgery for pyloric stenosis?
(Ramstedt’s pyloromyotomy)
Pre and post op (teach me paeds)
Pre-operative:
* Hypovolaemia
* Apnoea – secondary to hypoventilation associated with metabolic acidosis
Post-operative:
* Wound dehiscence
* Infection
* Bleeding
* Perforation
* Incomplete myotomy
What is Intussusception?
Where is it most common?
The telescoping of one bowel segment (the bowel folding inwards ) into another can lead to intestinal obstruction.
can occur anywhere but 90% of cases are of the ileo-colic type - where distal ileum passes into the caecum through ileo-caeceal valve.
Epidemiolgy of Intussuception?
Intussusception usually affects infants between 6-18 months old.
Boys are affected twice as often as girls
Risk factors for intussusception?
Most idiopathic
25% have a underlyinf cause - creating a lead point allowing the bowel to telescope
- Meckel diverticulum (most common)
- Polyps
- Henoch-Schönlein purpura
- Lymphoma and other tumors
- Post-operative
(Suspect a pathological cause if child is older or has a high recurrence rate)
Clinical features in the history for Intussusception?
- intermittent, severe, crampy, progressive abdominal pain
- sudden onset episodic intermittent inconsolable crying episodes
- drawing up legs (colic) and turning pale
- vomitting
- PR blood (redcurrant jam -late sign)
Clinical features on examination of intussusception?
Abdo exam Assess::
- Distention
- A palpable ‘sausage-shaped’ abdominal mass which can be found in the right upper quadrant (ileo-ceceal type) which is thickened bowel
- Signs of peritonism
- Presence of bowel sounds
- Signs of dehydration or shock to assess severity.
What conditions is Intussusception asosciated with?
- Concurrent viral illness
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
- Meckel diverticulum
Differencial diagnosis for intussusception?
- Colic (excessive crying and drawing up of legs in otherwise well infant)
- Testicular torsion (always check testes in a male infant presenting with excessive crying)
- Appendicitis (tends to occur in older children. Pain might be localised to right iliac fossa)
- Gastroenteritis
- Volvulus