Paediatric Gastroenterology Flashcards
Acute Abdomen
In half of children admitted, pain resolves undiagnosed; Appendicitis is far most common of surgical causes; Important to also look for Testes, Hernial Orifices and Hip Joints
• Important Medical Causes include – Lower Lobe Pneumonia, Primary Peritonitis (in patients with ascites), Diabetic Ketoacidosis, UTI (check Dipstick) and Pancreatitis (check Lipase)
Surgical Causes of Acute Abdominal Pain
Acute appendicitis Intestinal obstruction including intussusception Inguinal Hernia Peritonitis Inflamed Meckel Diverticulum Pancreatitis Trauma
Medical Causes of Acute Abdominal Pain
Non specific abdominal pain Gastroenteritis Urinary Tract: UTI, acute pyelonephritis, hydronephrosis, renal calculus Diabetic Ketoacidosis SCD Hepatitis IBD Constipation Recurrent Abdominal pain of childhood Gynaecological in pubertal females Psychological Lead poisoning Unknown
Extraabdominal causes of Acute Abdomen
URTI
Lower lobe pneumonia
Torsion of testes
Hip and Spine
Uncomplicated Acute Appendicitis: Presentation
Uncommon under 3 years
Uncomplicated: Anorexia, vomiting, characteristic abdominal pain (central then colicky due to midgut colic then localising to RIF)
Complicated Acute Appendicitis: Presentation
Presence of Mass, Abscess or Perforation
Diagnosing Acute Appendicitis
Fever, Abdominal Pain aggravated by movement, Persistent Tenderness with RIF Guarding over McBurney’s Point; NB: If Pelvic Appendix, might have few abdominal signs
o Diagnosis more difficult in younger children, especially if early; Faecoliths more common and can be seen of AXR; Perforation more rapid as Omental is less developed, and signs are easy to underestimate
• Repeated observation and clinical review every few hours;
No laboratory investigation or imaging is consistently helpful in making diagnosis
o Neutrophilia not always present; Pyuria not uncommon due to proximity
o Ultrasound may support clinical diagnosis – Thickened, non-compressible Appendix, increased blood flow; Identify complications such as Abscess, Perforation or Mass
• Laparoscopy for diagnosis in some centres;
Management of Appendicitis
Appendectomy is uncomplicated in appendicitis
• Perforation – Fluid resuscitation and Abx given prior to Laparotomy
• If palpable mass in RIF and no signs of Generalised Peritonitis, for Conservative Management with IV Abx and Appendectomy performed after several weeks; Laparotomy if persistent
Non specific Abdominal Pain
Abdominal Pain which resolves in 24-48hrs; Pain less severe than Appendicitis, and RIF tenderness is variable; Often accompanied with UTRI with Cervical LNA
o In some children, Abdominal signs do not resolve and Appendectomy performed
Mesenteric Adenitis
Large Mesenteric LN seen on Laparoscopy, and Appendix normal; Although unsure if true diagnostic entity
Intussusception
Invagination of the Proximal Bowel into Distal Segment; Most commonly Ileum into Caecum through Ileocaecal valve; Peak age 3/12 – 2yrs;
o Most common cause of Obstruction in infants after Neonatal period
Complications of Intussusception
Most serious complication is Vascular Compromise; Stretching and constriction of Mesentery leading to Venous Obstruction; Engorgement and Bleeding from Bowel Mucosa
o Leads to Bowel Perforation, Peritonitis and Gut Necrosis
Presentation of Intussusception
Presents with Paroxysmal, Severe Colicky Pain with Pallor (especially Perioral); Recovery between episodes but eventual Lethargy; Anorexia, Vomit (might be Biliary), Sausage-shaped Mass often palpable; Redcurrant stool (Blood stained mucous; Characteristic, but tends to occur later and after PR examination); Distention and Shock
Causes of Intussusception
Usually, no underlying cause found; Some evidence that viral illness leading to Peyer Hypertrophy related to Intussusception
o Identifiable lead points, such as Merkel’s Diverticulum or Polyp more likely if >2yrs
Investigating Intussusception
AXR shows distended Small Bowel and absence of gas in Distal Colon or Rectum
• Ultrasound useful for diagnosis (Target/Donut sign) and check response to treatment`
Management of Intussusception
Managed by Rectal Air Insufflation if no Peritonitis signs; 75% success rate; Performed by radiologist in presence of paediatric surgeon in case of need for laparotomy
o Remaining 25% for Operative reduction; Overall Recurrence less than 5%
o Peritonism – Severe pain, Generalised Guarding/Rigidity, Rebound Tenderness
Merkel’s Diverticulum
Rule of twos: 2% of individuals have Ileal Remnant of Vitello-Intestinal Duct; 2 inches long, 2 feet from Ileocaecal valve, 2/3s contain ectopic tissue (Gastric or Panc), 2% symptomatic
Presentation of Merkels Diverticulum
o Most asymptomatic, but can present with severe rectal bleeding; Acute ↓Hb
o Classically described as neither bright red, nor true Melaena
• Can also present as Intussusception, Volvulus or Diverticulitis (Mimics Appendicitis)
Management of Merkel’s Diverticulum
o Tc scan – Increased uptake by ectopic gastric mucosa in 70% of cases
o Treatment by Surgical Resection
Malrotation
incomplete rotation of the bowel during foetal development leading to the formation of Ladd’s bands
There can be associated bowel infarction alongside obstruction
Presentation of Malrotated Gut
Obstruction with Bilious vomiting is usual presentation in first few days of life; Requires urgent Upper GI Contrast study
Management of Malrotation
Unless signs of vascular compromise = Urgent Laparotomy (Very unwell, Severe Abdominal Pain, Peritonism); Volvulus – SMA supply compromised, possibly leading to infarction
• Operative management – Volvulus resolved, Duodenum mobilised to Duodenojejunal Flexure; Caecum and Appendix placed into the left; This broadens the Mesentery
o Appendix generally removed if symptoms suggestive of appendicitis
Inguinal Hernia
Common; 5% of boys, even more common in premature babies; Persistent Patent Processus Vaginalis; Emerges from Deep Inguinal Ring through Inguinal Canal = Indirect
o In Premature babies, Direct hernias more likely than in older children
How does an inguinal hernia present?
Presents as Lump in Groin, that may extend into Scrotum or Labia
o Typically, Asymptomatic; May be Intermittent, visible only during straining
o Often with Palpable lump, or thickened cord structures
