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3. PEDIATRICS > PEDIATRIC Section 7: Luminal GI (Bowel Obstruction in Neonate) > Flashcards

PEDIATRIC Section 7: Luminal GI (Bowel Obstruction in Neonate) Flashcards

1
Q

Think of bowel obstruction in the nonate as __ or ___.

A

High or Low

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2
Q

When you say high bowel obstruction, think about these

A
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3
Q

When you say LOW bowel obstruction, think about these

A
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4
Q

Why might you think the question is leading you toward obstruction?

A

Anytime you are dealing with a neonate, and the history mentions
“vomiting,”
“belly pain,” or
“hasn’t passed a stool yet.”

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5
Q

Think of this algorithm when dealing with Bowel Obstruction:

A
  1. Bubbles
  2. Upper GI patterns
  3. Low Obstruction in Neonate
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6
Q

What are the 9 possible pattern when you think of Bubbles in Neonatal Obstruction?

A
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7
Q

Single Bubble =

A

Gastric (Antral or Pyloric) atresia

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8
Q

Double bubble =

A

Duodenal Atresia (Highly Specific)

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9
Q

Associated conditions in Duodenal Atresia?

A
  • 30% have Downs
  • 40% have polyhydramnios and are premature
  • The“single atresia” - cannulation error
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10
Q

In Duodenal Atresia, Double bubble can be shown on what trimester? in what modality?

A

On multiple choice test the “double bubble” can be shown on 3rd trimester OB ultrasound, plain film, or on MRI.

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11
Q

Triple Bubble =

A

Jenunal Atresia

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12
Q

When you call jejunal atresia, you often prompt search for additional atresias - what are they?

A

Colonic Atresia

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13
Q

What casuses Jejunal atresia?

A

Vascular insult during development

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14
Q

“Mulliptle Atresia” =

A

Vascular error

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15
Q
  1. Single bubble + distal gas?
  2. Single bubble + distal gas + bilious vomiting?
  3. Next step?
A
  1. Can mean nothing
  2. Can be midgut volvulus
  3. Upper GI
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16
Q
  1. Double bubble + distal gas?
  2. Next step?
A
  1. Exclude duodenal atresia.
    DDx:
    a. Duodenal web
    b. Duodenal stenosis
    c. midgut vovlulus
  2. Next step UPPER GI
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17
Q
  1. Multiple diffusely dilated loops =
  2. Next step?
A
  1. Low obstruction (ileum or colon)
  2. Contrast enema - if normal –> Upper GI to exclude atypical look for midgut volvulus
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18
Q

Mildly Dilated, Scattered Loops =

A
  1. “Sick Belly” - can be seen in proximal or distal obstruction
  2. UPPER GI and contrast enma
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19
Q

What are the UPPER GI patterns in Neonates?

A
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20
Q

Normally, the developmental rotation of the gut places the ligament of Trietz to the LEFT? or to the RIGHT?

A

Normally, the developmental rotation of the gut places the ligament of Trietz to the LEFT of the spine at the level of duodenal bulb

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21
Q

If mother nature fucks up and this normal rotation doesnt happen, you end up with the duodenum to the right of the midline (spine), you end up with this

A

Malrotation

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22
Q

Malrotation increase the risk of these conditions:

A

Midgut volvulus
Internal hernias

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23
Q

Malrotation + bilious vomiting =

A

Midgut volvulus

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24
Q

Malrotation is associated with these condetions:

A

Heterotaxy syndromes
Omphaloceles

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25
Diagnosis
Malrotation Classic Malrotation: * Small bowel follow through shows all the bowel on one side * The duodenum does not cross the midline
26
Diagnosis?
SMA at the right of SMV
27
What makes UGI fals positive on UGI?
Distal Bowel obstruction displaceing the duodenum (ligamentous laxity)
28
When I say "Non-bilious voming" - you say? next step?
Hypertrophic Pyloric Stenosis Ultrasound
29
When I say "Bilious vomiting", - you say? Next step?
Mid Gut Volvulus (Til proven otherwise) Upper GI
30
Diagnosis?
Corkscrew Duodenum
31
this is diagnostic of midgut volvulus (surgical emergency)
Corckscrew Duodenum
32
In older children (or even adults) obstruction in the setting of malrotation will present as? what is the caus?
intermittent episodes of spontaneous duodenal obstruction. The cause is not midgut volvulus (a surgical emergency) but rather kinking from Ladd’s Bands.
33
What is a Ladd's Band?
a fibrous stalk o f peritoneal tissues that fixes the cecum to the abdominal wall, and can obstruct the duodenum.
34
What's the procedure to prevent midgut volvulus? How is it done?
Ladd's procedure
35
Absent distal air
Complete duodenal Atressia
36
Complete duodenal atresia is strongly associated with what condition?
Midgut volvulus
37
If the kid is vomiting this might be from extrinsic narrowing (Ladd band, annular pancreas), or intrinsic (duodenal web, duodenal stenosis). You can’t tell.
Partial Duodenal Obstruction
38
An anatomic variant where the portal vein sits anterior the 2nd part of the duodenum.
Preduodenal Portal Vein
39
Associated with duodenal obstruction 50% of the time.
Preduodenal Portal Vein (It isn’t the cause, it just happens to be present with other things (Ladds Bands, Annular Pancreas, etc..).
40
Thickening of the gastric pyloric musculature, which results in progressive obstruction.
Hypertrophic Pyloric Stenosis
41
Non-bilius vomiting that does NOT occur at birth or after 3 months
Hypertrophic Pyloric Stenosis
42
DIagnosis? Describe the criteria?
Thickening of the gastric pyloric musculature 4 and 14 mm 4mm in thickness (single wall) 14 mm in length
43
Specific age range of Hypertrophic Pyloric Stenosis?
2-12 weeks (peak at 3-6 weeks).
44
What is the primary differential of Hypertrophic Pyloric Stenosis?
pylorospasm (wich will relax during the exam.
45
What is the common pitfall in Hypertrophic Pyloric Stenosis during US?
gastric over distention, which can lead to displacement of the antrum and pylorus - leading to false negative. False positive can result from off axis measurement.
46
Paradoxic aciduria occurs in what condition?
Paradoxic aciduria occurs in hypertrophic pyloric stenosis and in adults with gastric outlet obstruction.
47
Diagnosis? Sign?
Hypertrophic Pyloric Stenosis "Caterpillar sign" - Multiple areas of peristalsis in the stomach NExt step? - USD
48
Treatment of Hypertrophic Pyloric Stenosis
Pyloromyotomy
49
What are the two (2) types of Gastric Volvulus?
Organoaxial and Mesenteroaxial
50
what is Organoaxial Gastric Volvulus?
greater curvature flips over the lesser curvature (rotation along the long axis).
51
Diagnosis?
Organoaxial Gastric Volvulus?
52
What is Mesenteroaxial Gastric Volvulus?
Twisting over the mesentery (rotation along short axis). The antrumflips near the GE junction.
53
What is seen in old ladies with paraesophageal hernias?
Organoaxial Gastric Volvulus? "O" for older
54
Mesenteroaxial Gastric volvulus can cause?
Ischemia and needs to be fixed
55
This type of Gastric volulus is more common in kids
Mesenteroaxial
56
WHat is the clinical picture of gastric volvulus?
Think of Borchardt Triad: Inability to pass NGT Severe epigastric pain Retching without vomiting
57
This is best thought o f as “almost duodenal atresia. ”
Duodenal Web
58
Where is the duodenal web located?
Distal to ampulla of vater - Bile stained emesis
59
Duodenal web is associated with what condition?
Downs syndrome
60
Diagnosis?
Duodenal web
61
Essentially an embryologic screw up (failure of ventral bud to rotate with the duodenum), = encasement of the duodenum
Annular pancreas
62
Diagnosis?
Annular pancreas Look for pancreatic tissue (same enhancement as the nearby normal pancreas) encircling the descending duodenum.
63
When you see annular pancreas in: Kids = think of? Adults = think of?
Kids = Duodenal obstruction Adults = Pancreatitis
64
Diagnosis?
Look for an extrinsic narrowing of the duodenum. Obviously this is non-specific (typical barium - voodoo), use the location and clinical history to bias yourself.
65
How do you approach lower obstruction?
Pattern-based method
66
What are the "Low obstuction" patterns in Neonate?
Normal Short Microcolon Long Microcolon Caliber change
67
Low Obstruction pattern
Normal: * This is what normal looks like:
68
Low Obstruction pattern
Short Microcolon (think of colonic atresia)
69
Low Obstruction pattern
Long microcolon - Meconium ileus - distal ileal atresia
70
Low Obstruction pattern
Caliber change
71
Diagnosis?
Colonic Atresia
72
Meconium ileus can only be seen in patients with? why?
ONLY in patients with Cystic Fibrosis result of thick sticky meconium causing obstruction of the distal ileum.
73
Diagnosis? Describe
Meconium Ileus Contrast will reach ileal loops, and demonstrate multiple filling defects (meconium).
74
Treatment of meconium ileus?
This can be treated with an enema -enema is both diagnostic and therapeutic.
75
Diagnosis? Describe
Distal ileal Atresia Contrast will NOT reach ileal loops.
76
Distal ileal atresia is a result of? What is the treatment?
This is the resuh of intrauterine vascular insult. This needs surgery.
77
Caliber change in distal obstruction is seen in what conditions?
Small left colon syndrome or Hirshprungs
78
This is a transient functional colonic obstruction, that is self limited and relieved by contrast enema.
Small Left Colon (Meconium Plug) Syndrome
79
What is the difference between a meconium plug and meconium ileus?
Meconium plug is NOT associated with Cystic Fibrosis
80
Small Left Colon (Meconium Plug) Syndrome is seen in?
1. Infants of Diabetic mothers 2. Mom received magnesium sulfate for Eclampsia
81
Failure o f the V ganglion cells to migrate and innervate the distal colon.
Hirschsprung Disease
82
Hirschsprung Disease is: Common in what gender? Associated with what condition? Diagnosis is made by?
Hirschsprung Disease is: Common in boyes 4:1 Associated with Downs Diagnosis is made by rectal biopsy
83
Diagnosis?
Hirshprung -Enema - Rectum smaller than the Sigmoid “Recto-sigmoid ratio < 1” -Enema - Rectum with “sawtooth pattern” Represents bowel spasm
84
Diagnosis?
Small Left Colon (Meconium Plug) Syndrome
85
Presentation of Hirshsprung?
(1) Newborn who fails to have BM > 48 hours (or classically > 72 hours) (2) “Forceful passage of meconium after rectal exam” (3) One month old who shows up “sick as stink” with NEC (Necrotizing Enterocolitis) bowel
86
This is a super rare variant of Hirschsprungs, and can mimic microcolon.
Total Colonic Aganglionosis The piece of commonly asked trivia is that it can also involve the terminal ileum.
87
This is a potential complication of bowel atresia or meconium ileus.
Meconium Peritonitis:
88
Characteristic look of Meconium Peritonitis? explain
It’s a calcified mass in the mid abdomen - result of a sterile peritoneal reaction to an in-utero bowel perforation. Usually, the perforation seals off prior to birth and there is no leak.
89
Diagnosis?
Meconium Peritonitis
90
imperforate or Ectopic Anus range
This can range from simple membranous anal atresia to an arrest of the colon as it descends through the puborectalis sling.
91
what is the thing to know when you talk about Imperforate or Ectopic anus?
fistula to genitourinary tract
92
Imperforate anus is also associated with What condition?
Imperforate anus is also associated with a tethered cord (probably need a screening ultrasound).
93
When I say "Baby with no asshole" you say?
VACTERL
94
Why do you screen a Baby with no asshole in US?
Screen for tethered cord.
95
Opinions are like Assholes Everyone has One Unless you have an Imperforate Anus Then you probably have?
VACTERL and a Tethered Cord

3. PEDIATRICS (32 decks)

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