Paeds Flashcards
Differentials for abdo pain according to age
- Everyone gets infections
- Neonates get congenital things
- Older kids get DKA and adulty things
- Don’t forget constipation
A 5 year old with frequent exacerbations of asthma comes in to the ED unable to speak from breathlessness. How would you manage this patient in the acute and long term setting? How would you explain to the parents what “asthma” is, and the side effects of common medications?
- kids w SOB: asthma, anaphylaxis, FOREIGN BODY, infection
- look for silent chest
- give fluids, remembering that oral > NG > IV
- Mx: nebulised SABA and oral pred (if tolerated)
- Add ipratropium if moderate/severe
- Try Mag sulfate, IV SABA if reeaaall serious; have to give steroids IV
- long term management
- side effects: beta agonist (irritability, tachy, palpitations), steroids (growth, healing, obesity, DM, thin skin, increased infections, depression,
A 2 year old girl with inspiratory stridor and barking cough presents breathless to ED. How would you assess the severity and manage this patient? If this is the patient’s 3rd episode of stridor this week, what condition could this be and how can you assess this further?
PDx: croup (unusual less than 6 months old)
DDx: bacterial croup, epiglottitis, asthma, anaphylaxis, foreign body
1) Primary survey
- assess severity of group: behaviour, stridor, RR, accessory muscles, O2
- give steroids, and then nebulised adrenaline if real serious; PICU if no improvement
- avoid unnecessary distressing things (eg O2, o/e) because distress will worsen airway obstruction
2) History and exam
(investigations unnecessary unless differentials not excluded)
3) Discharge criteria: child feeling better, no stridor at rest four hours after nebs
A 7 year old girl with a history of peanut allergy presents to the ED after having collapsed. She had eaten an ice cream which may have contained nuts. How would you manage this child?
- anaphylaxis = hypotension +/- upper/lower airway +/- skin +/- GI
- give adrenaline (1:1000) every 5 min: 0.15mL upto 6 years; 0.3mL from 6-12yo; 0.5mL over 12yo
infusion if no response and NS for shock
anti-histamines after stabilisation for pruritis - Watch for at least 4 hours
- EDUCATION - anaphylaxis action plan, epipen Jnr (<20kg), medicaid bracelet
- paed immunology referral
A 4 year old boy is brought in by his mother for poor appetite and weight loss. He also has a history or persistent low-grade fever and bruising. His examination findings reveal pinpoint macules on the mucosa of his mouth, generalized lymphadenopathy and hepatosplenomegaly. Assess and manage.
A 4 year old girl presents with a 4 week history of bone pain and a limp, with a 2 day history of petechiae, purpura and bruising. On examination, she had hepatosplenomegaly. Her WCC is 211 x 109/L and her platelets are 52 x 109/L. Discuss your differential diagnoses and management.
PDx: ALL
DDx: AML, non haem malignancy with bone marrow involvement (neuroblastoma, rhabdo), primary haem condition eg aplastic anaemia, ITP; infection: EBV, CMV
1) History and exam
- don’t forget to check testes
2) Investigations
- don’t forget to do LP (CNS involvement), UEC (tumour lysis)
- consider CXR for mediastinum, testicular U/S if enlarged
3) Management
- chemo involves induction, consolidation, maintenance
+/- INTRATHECAL
- supportive care: nutrition
- social support
A 10 year old boy presents with a 2-day history of fever and acute abdominal pain which later localises to the RIF. How would you assess and manage this child?
PDx: appendicitis
DDx: mesenteric adenitis, gastro, IBD, obstruction, malignancy - don’t forget DKA and testicular torsion as abdo pain differentials
1) history and exam: incl does it hurt when you cough 2) Ix "aPPenDiCItis iS a CliNicAL diAGnoSIs" - U/S > CT 3) Management - supportive care: fluids, analgesia - peritonitis empirical abx: gent + amp + met - lap app
A 4 month old with 1st episode wheezing with a temperature of 38 degrees is in ED with breathlessness and taking only 1/3 of feeds. He has no past history of chronic lung disease. What is the acute management for this episode and when will the patient be discharged? How would you advise the parents about this condition?
PDx: bronchiolitis
DDx: pneumonia, croup etc
Assess
- primary survey and resus
- severity
- risk factors: young, prem, CF, CHD, smoking exposure
- sx of other respiratory tract symptoms
- investigations only if unclear diagnosis
Mx
- supportive: O2 if necessary, rehydration (PO > NG > IV)
- transfer to tertiary centre if severe
- parent education and counselling
A 3 year old boy presents with three rashes. How would you manage each of these?
A. Crusting weeping lesions
B. Lazy erythematous rash on check
C. Dry scaly itchy skin lesions on flexors with signs of cracking.
General principles
- check vitals for toxicity, do systems exam for location
- consider fluid MCS
A. impetigo:
- look for primary skin injury
- Mx: saline baths, isolation and abx - in non-remote areas give mupiricin topical or fluclox PO if widespread/recurrent
B. slapped cheek:
- check for aplastic crisis in Hbpathy kids
- Mx: symptomatic (analgesia, topical antihistamines), avoid sun
C. atopic dermatitis:
- ask about atopy
- Mx: avoid irritants, moisturiser and wet dressings, dilute bleach baths, topical steroids
V1. A 2 month old presents with an audible murmur. She gets breathless and sweaty with feeds and takes a long time feeding. There is a history of poor weight gain. Discuss your management including long term prognosis and possible complications.
V2. A 1 month old baby brought in by mum complaining of very poor feeding, sweating during feeds and breathless. On examination, the baby has a loud systolic murmur, is tachycardic and has an enlarged liver. How do you assess and manage?
- with murmurs it’s usually nothing, but if it is it’s probably VSD
- if it’s soft and systolic, be a bit reassured
- if they’re symptomatic, be suspicious
- look for the signs - ‘holosystolic murmur at lower left parasternal edge’
- check for FTT
- small VSD heals by itself, but give abx to prevent IE
PDx: congenital heart disease (VSD)
DDx: innocent murmur
Assessment
- hx of CHD symptoms: colour, heart failure sx, resp sx, FTT
- CHD risk factors: caught on U/S, perinatal insults, Down’s, FHx
- rest of history
- examine for murmur and heart failure, growth
- ECG, consider CXR, echo
Management: depends on lesion and size (?persisting at 2 months with FTT means likely surgery)
- small: wait for it to close, give abx (amoxycillin to prevent IT
- large: frusemide to treat pulm oedema, surgery, postop abx
7 year old girl presents with her mother, complaining of constipation. All examination and investigation findings are normal. Discuss management.
DDx
- usually functional with behavioural component
- could be meds
- most organic causes (neuro, metabolic, GI anatomy, coeliac) will usually present much younger eg infancy
Assessment
- Bristol Stool Chart
- reassuring: incontinence, withholding behaviour
- growth n dev, abdo, DRE, lower limb neuro
- RED FLAGS: fever, bleeding, severe distension, FTT, neuro sx
- NO AXR other other ix except as per suspicion on hx
Management
- start with conservative mx (incl a diary)
- consider toilet retraining: unhrried, correct position, encourage 2-3/day regardless of need
. then start an osmotic/lubricant laxative if conservative mx not working, to get porridgey stools
During the newborn examination, a 2-day old neonate was found to have a right dislocatable hip. Discuss your management.
PDx: DDH
Assessment
- History of risk factors (things which mean the hips are squished - oligohydramnios, breech), leg problems
- Barlow is first (B before O), Bringing the knees together, then Ortolani is next, taking the knees Out
- Then imaging: U/S if less than 6 months, xray if more than 6 months
Management:
- Pavlik harness 24/7 for 6 weeks and then only at night if under 10 months old (check position with U/S after 2-3 weeks, stop after clinically stable hip and U/S shows acetabulum)
- Closed/open reduction and spica cast for 6-9 weeks if older
6 year old boy with vomiting and worsening abdominal pain, tachycardic, tachypnoeic and hypotensive. Patient is in shock. Assess and Manage.
A child presents to the ED with diabetic ketoacidosis. Discuss your management of this child.
A 6 year old boy with vomiting and worsening abdominal pain is brought to the ED by his mother. He is tachycardic, tachypnoeic and hypotensive. How would you assess and manage this child?
PDx: DKA
DDx: infective gastroenteritis, bowel obstruction and perforation
1) Primary survey and resus
C: DKA Mx
- Insulin
- K if normal/low
- Watch glucose carefully, give glucose after corrected
- Give fluid very carefully - could lead to cerebral oedema
- DO AN ECG IN CASE OF HYPERKAL
2) Detailed history and exam after stable
- confirm DKA
- look for precipitating cause
3) Continuing management
- supportive: fluids, electrolytes, consider NG if continuing to vomit
- definitive: insulin
- monitoring and consider transferral to tertiary centre: (brain sequelae - comatose, seizures, signs of cerebral oedema)
Liam is a 2 year old boy who is receiving treatment for acute lymphocytic leukaemia. 13 days after his last chemotherapy treatment he develops a fever. Discuss your approach to management.
Febrile neutropaenia until proved otherwise:
- resus
- IV tazocin
- thorough look for all possible sites of infection (CV, resp, GI incl mouth, skin, iatrogenic, MENINGITIS)
- assess for other contributors to infection risk
- septic screen but NO LP because thrombocytopaenia?
- fluid resus and abx until negative blood cultures for 48 hours
(??source)
Patrick an 18 month old child is referred to you from his GP because of 2 consecutive days of fevers of 40oC. He has been feeding poorly and tired. He has been otherwise well. He has no vomiting, diarrhoea, cough or runny nose. Discuss your approach to his management and comment on the seriousness of this presentation.
DDx:
- easily missed infections (meningitis, IE, viral)
- non-infectious (cancer, drug reaction)
Resus if necessary Assessment - changes in eat/sleep/pee/poo/play - systems review - infection risk factors - rule out cancer and drug reaction - septic screen, consider LP
Management
- sepsis empirical abx = CEFOTAXIME (plus amp if <2 months; plus gent and vanc if critically ill)
An 18 month old boy presents with 24 hours of diarrhoea and vomiting. He has reduced feeding to <50% of normal intake and his mother is concerned he is lethargic. How would you manage this child?
PDx: viral gastro DDx: acute abdo: appendicitis, intussusception, bowel obstruction, Hirschsprung's sepsis: UTI, meningitis, pneumonia, AOM raised ICP if no diarrhoea
Assessment
- infection hx and exam
- rule out non-infective gastro - red flags are toxicity, vomiting without diarrhoea, bilious vomiting, PR bleeding, diarrhoea for more than 10 days, abdo pain
Management
- fluids + electrolytes: PO/NG/IV
- monitor: EUC and BSL every 6-8 hours if moderate to severe
- start feeding in 24 hours as vomiting settles
- discharge home: if dx of infective gastro, child rehydrated and minimal ongoing losses (urinated in past 4 hours), trust parents
- education
- F/U with GP in 48 hours
A 3 year old boy presents with bouts of coughing ending with a vomit, these are worse at night and after feeding. Discuss your provisional diagnosis and management.
PDx: pertussis
DDx:
viral URTI
atypical pneumonia
Assessment
- check for toxicity
- vaccinated children can get less severe disease
- diagnosis is NPA/swab PCR
Management
- PICU if serious (apnoea, cyanosis, encephalopathic)
- otherwise, abx treatment is to minimise transmission ie only give in first three weeks: azithro
- PREVENT TRANSMISSION - abx prophylaxis for contacts, notify, isolate, vaccinate
A 3 year old boy presents with irritability and found to be tugging his right ear. On examination, discharge was found coming from his right ear. Manage this child.
PDx: acute otitis media
DDx: chronic, OME, otitis externa, secondary sepsis/meningitis
Assessment
- confirm diagnosis
- CHECK HEARING AND DEVELOPMENT
Management
- if they’re otherwise fine, (incl socially) give supportive care INCLUDING EDUCATION about re-presenting
- if they’re systemically unwell/<6 months old/unlikely to represent, consider amoxycillin
- ENT referral if recurrent or have developed hearing/learning issues
btw, >3 months = chronic
A 2 year old girl comes in with a history of fever to 39oC and later generalized twitching for 5 mins followed by post ictal drowsiness. Her parents commenced mouth to mouth resuscitation when she developed transient cyanosis. Now she is running around in the ED. What is your management?
PDx: febrile convulsion
DDx: organic seizure - CNS path (infection, stroke, SOL), ADR, metabolic (glucose, electrolytes)
Assessment
- want to rule out organic causes - CNS infection/tumour/epilepsy/congenital
- red flags: focal, >10min, recurrence same day, not completely better by 1 hour
- workup underlying infection (make sure you’re happy that the underlying infection is viral - rule out sepsis or its possibility)
Management
- PARENTAL EDUCATION - what it is, what to do if it happens again, what it means long term (only slightly above population risk)
- symptomatic: panadol, tepid sponging
A 3 month old baby is brought in by his parents who are concerned about his vomiting and poor feeding. Discuss assessment and management.
PDx: reflux
DDx: bowel obstruction (pyloric stenosis, atresia, Hirschsprung’s), allergy (CMPA, eggs?), infection/raised ICP
Assessment
- look for red flags: ATLEs, bilious vomiting, haematochezia/haematemesis, abdo pain/distension, toxicity, failure to thrive, diarrhoea, seizures, fever/lethargy/organomegaly
Management
- education
- conservative: horizontal feeding, smaller more frequent meals (don’t lie them prone because SIDS)
- consider mother avoiding diary and eggs; alternative formulas if formula-fed - thickened, hypoallergenic
- PPI trial
V1. While doing a newborn check, you hear a cardiac murmur. What other relevant examination findings do you want to know and how will you further assess and manage?
V2. You hear a heart murmur on a postnatal baby check. Discuss your assessment and management.
PDx: innocent murmur (soft, systolic, L sternal edge, no thrills or systemic symptoms)
DDx: other CHD
Assessment
- hx of CHD symptoms: inadequate perfusion (incl FTT), resulting heart failure
- hx of RF: picked up on U/S, perinatal insults, Down’s etc, FHx (including sudden unexplained death)
- examine growth, heart, ?failure
- ECG, CXR, echo if suspicious
Management
- paed cardiologist
- consider conservative vs surgical repair
A 15 month old girl is brought in by her mother for a fever and refusal to drink. On examination she was found to have vesicles on her posterior oropharynx, hands and feet. How would you assess and manage this child?
PDx: hand, foot and mouth
DDx: chicken pox, HSV,
Primary survey if dehydrated
Assessment
- check for toxicity, dehydration
- confirm characteristic presentation: low grade fever, yellow/red vesicles (not clear), painful not itchy, not anywhere else (maybe bum), loss of appetite
- consider swab PCR
Management
- supportive: fluids (eg NG), electrolytes, analgesia (eg topical local), antipyretics, education (usually resolves in 10 days)
- isolation
- safety net
A 5 year old child presents with a purpuric rash distributed mainly on buttocks and extensors of lower limbs and abdominal pain. What is the most likely diagnosis and how would you manage?
PDx: henoch schonlein purpura!
DDx: sepsis (eg from meningitis), coagulopathy secondary to ITP or malignancy
Assessment
- rule out toxicity
- confirm characteristic presentation: preceding URTI/vax/med/bites, abdo pain (?with nausea and vomiting), non-blanching palpable rash, (?arthralgia, nephrotic/nephritic syndrome)
- rule out differentials
- urinalysis, UEC - consider urine ACR, MCS, skin/renal biopsy if diagnosis not clear
Management
- symptomatic: analgesia, pred if severe abdo pain/n+v/scrotal pain/severe oedema
- IV steroids/immunosuppressants/plasmapheresis /transplant if significant renal disease (as per nephro)
- safety net: repeat urinalysis regularly over first 6 months
Hypoglycaemia
PDx: increased glucose use (insulin OD, increased metabolic rate)
DDx: starvation, inborn errors of metabolism
Presentation: SNS, neuro: lethargy, headache, visual disturbance, slurred speech, dizziness, coma, convulsions
Primary survey and resus
- DO BSL
- TAKE CRITICAL SAMPLES (5-10mL blood, first urine)
- Give glucose - oral if tolerated, otherwise IV - repeat if BSL not coming up
- Check insulin and ketones
- Check acid-base, lactate
Assessment
- History of symptoms - fed or fasted? What foods previously? What associated symptoms?
- Past history: DM, similar episodes especially perinatally, other conditions, stressors
- Paeds: HEEL PRICK results
- FHx: unexplained fetal deaths
- Examine for weight and height, infection, hepatomegaly/hypotonia, dysmorphic features
- Investigations: BSL, UEC, LFTs, drug screen, insulin, C-peptide, lactate, others; glucagon stimulation test
Katie and Shane bring their 6 week old baby Mackenzie to ED because Mackenzie cries incessantly. Mackenzie was born by emergency CS because of failure to progress. Mackenzie had Apgar scores of 9 and 9. Katie developed a uterine infection and spent 7 days in hospital. Since coming home Mackenzie has “cried non-stop” but this has increased in the last two weeks. Mackenzie is growing well. He is predominantly breastfed, supplemented by one bottle during the night. Steve has just returned to work as a mechanic in the last fortnight. Katie and Steve are exhausted and distraught and don’t know what to do. Discuss your approach to management?
PDx: infantile colic
DDx: infection, reflux, feeding problems (under/overfeeding, CMPA, lactose intolerance)
Assessment
- Characterise irritability - when, how resolved - what’s a typical day
- Rule out reflux, feeding issues, infection (incl mother’s GBS status)
- Thorough history
- Check growth, NAI
- Consider septic screen if suspicious
Management: education
- baby not sick, not in pain: excessively sensitive to stimuli
- crying not due to physical problem
- will settle down with time
- minimise environmental stimulation
- try soothing: patting, rocking, gentle massage, dummy, swing
- optimise feeding
- keep crying diary for further assessment
A 16 year old girl comes into the clinic with enlarged cervical LNs. She has been complaining of feeling tired with a flu-like illness. She has a very sore throat. What is the most likely diagnosis and how would you manage this child?
PDx: EBV DDx: - infection: CMV, HIV, viral URTI including influenza, bacterial URTI, toxo - haem cancer - inflammatory disease
Assessment
- Characterise symptoms: fatigue, ‘flu-like illness’ - viral prodrome for 3-5 days before sore throat, glands etc
- Infection history (sexual history in HEADSS)
- Rule out differentials: URTI sx, cancer sx, SLE sx
- Thorough paeds history
- Examine growth, ENT, LN, hepatosplenomegaly and jaundice, and then as per history
- Investigations: EBV/CMV serology (positive monospot -
heterophile antibody test), FBC (atypical lymphocytosis), CRP,
Management: supportive
- analgesia, antipyretics, fluids
- rest: as per patient’s energy level
- no contact sports for 4 weeks since onset of symptoms
- education: careful for upper airway obstruction, splenic rupture, meningitis etc
A previously healthy 9 month old boy presents with a history of paroxysmal screaming, episodic pallor, vomiting and pulling up of knees for 8 hours. His mother is panicked and has brought him to the ED where he has passed red currant jelly stools. How would you assess and manage him? What are the contraindications for barium enema?
PDx: intussusception
DDx: other acute abdomen eg appendicitis, infective gastro, Meckel’s diverticulitis
Primary survey and resus if hypovolaemic
Assessment
- confirm dx and rule out differentials
- toxicity, degree of unwellness
- assess hydration and perforation (peritonitis), palpable mass
- imaging: U/S for target sign, AXR for perforation
- bloods if unwell
Management
- air enema if stable
- surgical air enema fails, if perforation suspected
Kawasaki Disease
DDx
- viral infection (URTI, other with skin manifestations)
- bacterial eg strep, staph
- other sepsis
Assessment
- characteristic presentation: high fever for 4 days or more PLUS rash, peripheral oedema, conjunctivitis, strawberry tongue, cervical LN
- rule out differentials incl sepsis on investigation AND do echo +/- angiography for coronary artery aneurysms (and again 6-8 weeks later)
Management
- IVIg + aspirin (repeat IVIg if fever persists/recurs, if fever persists/recurs after that, pred)
- IV abx until sepsis excluded
- Supportive care: analgesia, antipyretics
- Education: usually self-limiting
- Follow up cardiac imaging
Discuss the differential diagnosis of a boy of 8 years with a limp other than Perthes disease. Assess and manage as Perthe’s Disease. Please also cover the Salter Harris classification and revise greenstick fractures.
PDx: transient synovitis
DDx: Perthes disease, septic arthritis, trauma and fracture/soft tissue injury, NAI, cancer if chronic, SUFE in older child, DDH in toddler
Assessment
- Perthes: pain, limited ROM, trendelenberg limp, shorter true leg length
- SUFE: activity worsened pain, external rotation
- Cancer: sx, chronic
- Trauma: hx of trauma, localised tenderness
- Assess impact: schooling etc
- Imaging: xray (see smaller epiphysis, wide joint space, maybe cracking if Perthes; ask for frog leg lateral to see a SUFE)
Management
- Supportive: pain relief
- Conservative: non-weightbearing, physiotherapy, splints to keep head in acetabulum
- Surgical (if older, poor prognosis): femoral head osteotomy and bone graft
Salter Harris: straight across, above, beLow, through, erased (crush)
Greenstick fractures: incomplete fractures of long bones
An infant boy refuses to weight bear with his right limb. Mum complains he is feverish and hard to settle. He has no previous history of trauma. How would you assess and manage this patient?
PDx: septic arthritis, osteomyelitis, rheumatic fever
DDx: DDH, NAI, malignancy, transient synovitis; referred pain from abdo/groin
Primary survey if unstable
Assessment
- time course of symptoms
- systemic unwellness: fever, eat/pee/poo/play/sleep
- joint symptoms and signs: hot, swollen, referred pain, limited ROM
- look for NAI signs/symptoms
- examine joint, heart (ARF murmurs), abdo exam - guarding, torsion
- Investigations: joint aspirate MCS, xray, blood cultures, FBC, CRP
Management
- supportive care: fluids, analgesia
- IV abx (fluclox)
- education
An 8 year old girl presents to the ED at 7am complaining of pain in her left hip during walking. She has a history of a cold last week and no history of trauma. She does not have a significant past medical or family history. How would you assess and manage her?
PDx: transient synovitis
DDx: reactive arthritis, osteomyelitis, septic arthritis, ARF
Primary survey and resus if necessary
Assessment
- rule out differentials by characterising symptoms, preceding illness and current toxicity
- xray, consider septic bloods
Management: supportive
- analgesia, return to full activity as tolerated (usually by 4 weeks)
A 7 year old boy fell over playing a game in school and lost consciousness for a few seconds. How would you assess and manage?
PDx: moderate TBI
DDx: subdural/epidural haematoma
1) Primary survey and resus
- C: do BSL, ECG, VBG
- D: also signs of raised ICP
2) MISTAMPLE (incl bleeding diathesis)
3) Secondary survey
- includes GCS and full neuro exam
- CT brain if any basal skull fracture signs, focal neuro deficits, GCS less than 8, dodgy breathing/airway, amnesia, seizures, known bleeding diathesis
4) More detailed history and exam
5) Supportive care
6) Observe for 4 hours with 30minutely obs (including neuro obs) before discharge home
7) Education and safety net
A 2 year old child was brought into ED with a focal seizure followed by increasing drowsiness and listlessness. On examination she was found to be febrile with a rising blood pressure and falling pulse with papilloedema. What is the acute management of this child?
PDx: raised ICP (Cushing’s reflex) secondary to meningitis
DDx: encephalitis, brain abscess, sepsis, tumour, hydrocephalus
Primary survey and resus
A: protect if reduced GCS, loss of protective reflexes
B: O2 if desatting, consider invasive ventilation
C: elevate head of bed, ECG, bloods incl cultures; fluid resus IF NECESSARY, treat fatal triad
D: AVPU, glucose, stat abx (ceftriaxone with dex) and acyclovir, consider head CT if focal neuro sx
E: look for nonblanchable rash, DON’T DO AN LP
History: symptoms, progression, meningitis risk factors
Exam: neuro, raised ICP (bulging fontanelle, fixed dilated pupils, papilloedema, repeated vomiting), other infectious foci
Ongoing management
- monitoring: obs and neuro obs, EUCs and BSL
- supportive. fluids, analgesia
- notification, audiology in 4-8 weeks
A 12 year old boy presents to ED with abdominal pain. He has a history of a viral illness. Discuss your assessment and management. How is the approach different to that of an adult?
PDx: mesenteric adenitis (diagnosis of exclusion!)
DDx:
gastro: appendicitis, meckel’s diverticulitis, infective gastroenteritis, IBD, coeliac, malignancy
non-gastro: UTI, EBV
Assessment
- History of vague, poorly localised pain, anorexia and fatigue, nausea, vomiting, fever, diarrhoea
- Examine for peritonitis, well localised pain
- Investigate to rule out differentials: abdo U/S, bloods if unwell (FBC, EUC, LFTs, CRP)
Management: supportive
- fluids, electrolytes, analgesia
- complications include suppuration, intussussception, rupture, peritonitis, abscess
