Paediatrics- Gastroenterology Flashcards
What is pyloric stenosis
Hypertrophy of the pyloric muscle causing gastric outlet obstruction
Most common cause of non-bilious vomiting in children
Pyloric stenosis
Age of presentation of pyloric stenosis
• Typically presents at 4-6 weeks old
Risk factors for pyloric stenosis
RISK FACTORS:
• Male
• Firstborn child
• Family history
• Maternal smoking
• Preterm birth
• Erythromycin: Use in the first two weeks of life has been shown to increase risk
• Associated with Turner’s syndrome
Presentation of pyloric stenosis
• Projectile non-bilious vomiting:
◦ During or just after feeding
• Infant hungry immediately after vomit: can be irritable
• Constipated: due to lack of food
• Weight loss/inadequate weight gain
• Dehydration:
• Sunken fontanelles
• Sunkun eyes
• Dry mucous membranes
• Poor skin turgor
• Lethargy
• Decreased urine output
• Mobile olive-sized mass:
• Non-tender
• RUQ
• Visible peristalsis waves:
• From LUQ to RUQ
• Late sign
• Would lead to subsequent vomiting
Investigations for pyloric stenosis
• Can be clinical diagnosis: if mass felt
• Ultrasound scan:
◦ Would find increased pyloric thickness and length
◦ ‘Target Sign’: due to hypertrophied muscle around mucosa
• Urea + Electrolytes:
◦ Can see hypochloraemic, hypokalaemic dehydration with metabolic alkalosis
◦ Vomiting expels HCl
◦ Kidneys try to retain H+ by exchanging out Na+ and K+ (leading to hyponatraemia and hypokalaemia)
Management of pyloric stenosis
• Fluid Resuscitation:
◦ Surgery must be delayed until fluid balance is corrected
◦ Slow IV fluids
◦ 1.5x maintenance with 5% dextrose
• Ramstedt Pyloromyotomy:
• Only once electrolyte disturbance has been corrected
• Splitting of muscle to increase lumen size, excellent prognosis
What is intussusception
Segment of the intestine telescopes/invaginates into an adjacent segment
Age of incidence of intussusception
• Predominantly occurs between 3 months- 2 years old
Most common location of intussusception
• Terminal ileum into caecum (ileo-colic) intussusception most common
• Can lead to obstruction and infarction of vasculature (causing necrosis)
Risk factors for intussusception
RISK FACTORS:
• Anatomical lead points:
◦ Polyps
◦ Meckle’s diverticulum
◦ Tumours
◦ Hyperplasia of Peyers patches
• Infections:
‣ Viral or bacterial gastroenteritis can increase risk due to enlargement of lymphoid tissue in bowel
Presentation of intussusception
• TRIAD: (not always all present)
‣ Colicky abdominal pain: Baby draws up legs
‣ Vomiting: Non-bilious
‣ Red currant-jelly stools: Late sign due to necrosis and perforation
• Lethargy or reduced consciousness
• Palpable abdominal mass:
• Typically in RUQ
• Sausage-shaped
• Episodic screaming
Investigations for intussusception
• Abdominal Ultrasound:
‣ Gold-standard
‣ Characteristic ‘target sign’: representing layers of intestine
• Abdominal X-Ray:
◦ Can show paucity of air in RUQ + large bowel
◦ Thickened wall due to oedema
◦ Poorly defined liver edge
◦ Dilated small bowel loops
◦ Normal x-ray does not exclude diagnosis
• Consider barium enema: only in stable patients with no peritonitis
Management of intussusception in stable, non-peritonitic patient
• Non-operative reduction: Pneumatic or contrast enema under US guidance
• Can be diagnostic and therapeutic
• Small risk of recurrence
Management of intussusception in peritonitic or non-operative reduction unsuccessful patients
• Surgical reduction:
◦ immediate laparotomy
◦ Manual reduction of bowel and resection of non-viable segments
◦ Risk of short bowel syndrome
IV fluids, electrolyte management and pain control should be given
