Peds Flashcards
GI
A 2-day-old male newborn is brought to the emergency department by his mother because of irritability and vomiting for 2 hours. During this period, he has vomited bilious fluid three times. He has not yet passed stool. The mother has breastfed the newborn every 2 hours. He has wet two diapers during the last 2 days. He was born at term and was delivered at home.
Pregnancy and delivery were uncomplicated. The mother had no prenatal care during pregnancy. The patient currently weighs 3100 g (6 lb 13 oz) and is 50 cm (19.6 in) in length. The newborn appears restless. His temperature is 37.3°C (99.14°F), pulse is 166/min, respirations are 60/min, and blood pressure is 60/45 mm Hg. There is no redness or warmth around the umbilical cord stump. Cardiopulmonary examination shows no abnormalities. Bowel sounds are sparse. The abdomen is distended. Digital rectal examination shows no abnormalities. An x-ray of the abdomen with contrast shows dilated small bowel loops, a microcolon, and a mixture of gas and meconium located in the right lower quadrant. A nasogastric tube is placed and fluid resuscitation is begun. What is the most appropriate next step in the management of this patient?
Gastrografin enema is both diagnostic and therapeutic for meconium ileus and will allow visualization of the rectum and bowel to rule out other anatomical causes for bowel obstruction (e.g., intestinal atresia or volvulus) and, in the case of meconium ileus, can reveal the Neuhauser sign, microcolon, or meconium pellets. The contrast agent can also induce a laxative effect as the increase of osmolarity within the lumen of the bowel results in the breakdown and passage of the meconium obstruction. More than 90% of patients with meconium ileus will have cystic fibrosis (CF). For unknown reasons, newborn screens for CF in patients with meconium ileus are often initially negative and require additional testing. Infants with meconium ileus should undergo diagnostic testing for CF through a sweat test or, if sufficient amounts of sweat cannot be obtained, through genotyping.
What are common differential diagnoses for painless lower GI bleeding in children?
Meckel’s diverticulum.
Juvenile polyps.
Infectious gastroenteritis.
Inflammatory bowel disease (IBD).
What is the most common congenital gastrointestinal anomaly?
Meckel’s diverticulum.
What is the rule of 2s associated with Meckel’s diverticulum?
2% prevalence.
Located 2 feet from the ileocecal valve.
Typically 2 inches in length.
Symptomatic by 2 years of age (though older children and adults can present later).
Contains 2 types of ectopic tissue (gastric > pancreatic).
What is the most common presentation of Meckel’s diverticulum in children?
Painless lower gastrointestinal bleeding.
What is the diagnostic test of choice for suspected Meckel’s diverticulum?
Technetium-99m pertechnetate scan (Meckel scan).
Technetium-99m Pertechnetate Scan Sensitivity: The sensitivity decreases if the ectopic gastric tissue is minimal, which may require additional imaging or surgical exploration if clinical suspicion remains high.
What tissue does the Technetium-99m pertechnetate scan detect in Meckel’s diverticulum?
Ectopic gastric mucosa.
what can cause the Technetium-99m pertechnetate scan to decrease its sensitivity?
lower concentrations of gastric mucosa.
will need to use another imaging modality with high clinical suspicion.
What is the diagnostic test for Meckel’s diverticulum during an active bleed?
Mesenteric angiography for acute/active bleeding.
What complications can arise from Meckel’s diverticulum?
Gastrointestinal bleeding (due to ectopic gastric acid secretion causing ulceration).
Intestinal obstruction (e.g., intussusception, volvulus).
Inflammation (mimicking appendicitis).
How is Meckel’s diverticulum treated if symptomatic?
Surgical resection (diverticulectomy).
Management of Asymptomatic Meckel’s Diverticulum is controversial. Intraoperative discovery during unrelated surgeries may warrant resection in young patients due to the risk of future complications.
Why is microcytic anemia a potential finding in Meckel’s diverticulum?
Chronic blood loss from ulceration of the adjacent intestinal mucosa due to ectopic gastric acid secretion.
