Paediatric GI - Malrotation, Hernias and Appendicitis Flashcards
Where do the caecum and duodenojejunal flexure lie in a normal abdomen?
Caecum - RIF
Duodenojejunal flexure - left of midline
Where do the caecum and duodenojejunal flexure lie in a child with malrotation?
Caecum - RUQ
Duodenojejunal flexure - midline
How does the mesentery run and act in a normal abdomen?
Mesentery runs diagonally and is tight to provide stability
How does the mesentery behave in a child with malrotation?
The mesentery is mobile and can lead to a volvulus
How is a malrotated gut generally picked up?
Incidental finding on abdominal imaging
How does a malrotated gut generally present?
It is normally asymptomatic
If a malrotated gut is picked up early, how is it managed?
Ladd’s procedure
What is a volvulus?
High intestinal obstruction at the duodenal level followed by infarction of the entire midgut
How does a volvulus present?
Bile stained vomit
Tender abdomen
What investigations would you request if you suspect a volvulus?
AXR
GI contrast study
What would you see on AXR in a volvulus?
Double bubble sign - dilated stomach and duodenum
No other air-fluid level
Few small pockets of residual gas in bowel
What would you see on GI contrast study in a volvulus?
Bird beak obstruction
Corkscrew duodenum
How is a volvulus managed if healthy bowel?
Urgent laparotomy to untwist volvulus
Ladd’s procedure done
How is a volvulus managed if the bowel is not viable?
Urgent laparotomy to remove gut and place child on permanent IV feeds
What happens in a congenital diaphragmatic hernia?
Diaphragm fail to fuse properly
Herniation of intestines through diaphragm
Pulmonary hypoplasia and hypertension
Apparent dextrocardia due to mediastinal shift
Lack or surfactant
What signs would be present in congenital diaphragmatic hernia?
Bowel sounds in chest
Scaphoid abdomen seen - abdomen sucked inwards
Signs of respiratory distress
How is congenital diaphragmatic hernia normally picked up?
A lot in antenatal screening - preparations for birth put in place
What types of congenital diaphragmatic hernia are there?
Morgagni - anterior
Bochdalek - posterior (more common)
How is a congenital diaphragmatic hernia managed?
Sedation and mechanical ventilation at birth
Resus done in head up position
Surgical repair after a few days if baby still alive
Why is resuscitation done avoiding bag-mask ventilation?
Not having head up position and using a bag-mask ventilation would dilate the intestines leading to further compression of the lung
What complications are associated with congenital diaphragmatic hernia?
Chronic lung disease
Neurological damage –> hypoxia
GORD
What causes an umbilical hernia in a child?
Failure of the muscle wall to close after midgut rotation
What is the normal lifecycle of an umbilical hernia?
Common in newborns and will normally resolve by 3 years
When are you likely to refer a child for repair of an umbilical hernia?
<2cm and asymptomatic - 4/5yo
> 2cm or symptomatic - 2/3yo
What risk factors are associated with umbilical hernia?
Afro-caribbean
Down’s syndrome
Who is an inguinal hernia more likely to affect?
Males - testis migration
If an inguinal hernia presents in the first few months of life, what do you do and why?
Urgent herniotomy due to risk of strangulation
If an inguinal hernia presents after 1 year old, what do you do?
Elective herniotomy due to low strangulation risk
What risk is associated with a herniotomy?
Risk of apnoea in neonates and pre-terms
Who is appendicitis most common?
In Males between 10-20 yo
Why is appendicitis less common in infants?
Appendix wider and well drained
What can cause appendicitis?
Obstruction - faecolith
Inflamed by lymphatic hyperplasia
Stasis - bacterial overgrowth
What is the classical presentation of appendicitis?
Periumbilical pain (splanchnic visceral nerves)
Localise to right iliac fossa (peritoneal involvement)
Nausea, vomiting and low grade fever
What signs are present in classical appendicitis?
Rebound tenderness at McBurney’s point
Rovsing’s sign
Where is McBurney’s point?
2/3 between umbilicus and ASIS
What is Rovsing’s sign?
Pain in RIF when LIF palpated
Why must you be wary of appendicitis in children?
Often doesn’t present in a classical way
40-45% present atypically
What symptoms can be seen in infants with appendicitis?
Watery diarrhoea
Vomiting
What symptoms can be seen in young children with appendicitis?
Vague abdominal pain
Anorexia
How would a pelvic appendix present?
Pain initially in RIF
Pain on urination - can be suprapubic
Profuse diarrhoea
How would a retrocaecal appendix present?
Pain localise to:
Psoas muscle
Flank
RUQ
How would a retroileal appendix present?
Testicular pain due to irritation of the spermatic artery or ureter
How would an appendix with a long tip present?
Pain in left lower quadrant
How would a perforated appendix present?
Generalised abdominal pain
Tachycardia
High fever >38
What investigations are useful when diagnosing appendicitis?
Diagnosis is clinical!
Contrast CT
USS
CXR
FBC, U&E, CRP, ESR
Urine dip
Pregnancy test
What are the pros and cons of a contrast CT and USS in appendicitis?
CT
Pros - sensitive and specific
Cons - radiation and long
USS
Pros - quick and no radiation
Cons - can be inconclusive esp. if overlying bowel gas
What should you be aware of when diagnosing a child with appendicitis if they have had pain for >48 hours?
It is likely to have perforated
How is appendicitis risk scored?
Paediatric Appendicitis Score
RIPASA
Alvarado
What is the paediatric appendicitis scoring system?
Migration of pain - 1 Anorexia - 1 Nausea - 1 RIF tenderness - 2 Fever - 1 Leucocytosis - 1 Raised immature white cells - 1 Coughing, hopping, percussion pain - 2
Total 10
What places a child at low risk in the paediatric appendicitis scoring ? What does it mean?
<4
Low likelihood of appendicitis
What places a child at medium risk in the paediatric appendicitis scoring? What does it mean?
4-6
Further monitoring req.
Imaging useful
What places a child at high risk in the paediatric appendicitis scoring? What does it mean?
> 6
Refer to surgical team
Highly likely appendicitis
How is appendicitis initially managed?
IV access
Fluid resus
Contact surgical team - discuss IV antibiotics and putting child NBM
What is the surgical management for appendicitis?
Appendicectomy - can be laparoscopy or a laparotomy
What are the key complications of appendicitis to be aware of?
Perforation Peritonitis Abscess Sepsis Death
