Transcript Document 7221642
Clinical Pathological Conference
2004-12-29
三軍總醫院 小兒科部 劉家宏
/
華一鳴
Case Presentation
Present Illness
This one-year-six-month-old boy came to our pediatric emergency department with the chief compliant of
bilious vomiting
and
intermittent irritable crying
since
4
hours ago.
Case Presentation
Personal and Family History
Past history: Before this presentation,the child was in good condition without any compliant of abdominal symptoms.
Case Presentation
Physical Examination
Vital sign:
PR:
↑
136 /min
(70-110), RR: 20 /min(20-30), BT: 35.7 ºC BP:
↑
112/70(90-105,50-70), decreased urine output.
HEENT: dehydration with
dry lip
.
Abdomen :
soft, neither sign of peritonitis nor hepatosplenomegaly
.
Case Presentation
Radiologic & Lab Findings
Plain film of abdomen : showed a nonspecific local
ileus
pattern over
right upper quadrant .
Laboratory data: white blood count:
↑ 25300
/nl (6000-17500/nl) with 75% segment(54-62%) and 18% lymphocyte(25-33%).
Case Presentation
Radiologic & Lab Findings
Serum biochemistry:
Sodium :145 (139-146)mEq/L
Potassium :4.5 (3.5-5.0)mEq/L
Chloride :
↑ 130
(98-106)mEq/L
BUN :19 mg/dl, Creatinene :0.4(0.2-0.4)mg/dl
C reative protein level :0.1mg/dl
.
Case Presentation
Radiologic & Lab Findings
Abdomen sonography :revealed a
soft tissue mass over right lower quadrant
,
but
no
evidence of sign of
target
appearance; besides, the relationship of superior mesentery artery and superior mesentery vein was in
right
position.
Case Presentation
Hospital Course-I
Under the impression of intestinal obstruction, he was admitted to our pediatric department for further evaluation and management.
After admission, this patient had persistent bilious vomiting.
Case Presentation
Hospital Course-II
Twelve hours later
, heart rate increased to 150-180 per minutes.
Meanwhile
, decreased urine output and downhilled blood pressure
happened to him despite of intravenous fluid supplement.
Under the impression of intestinal obstruction complicated with shock , our pediatric surgeon arranged
emergency laparotomy
.
Case Presentation
Hospital Course-II
Post-operative course was relative smooth,and started feeding on the
4 th
day
of lapatotomy smoothly.
His condition was stable during the follow-up period at our out patient clinics.
Major Problems Minor Problems Bilious vomiting A soft tissue mass over right lower quadrant Downhilled blood pressure(shock) Intermittent irritable crying Decreased urine output Leukocytosis Hyperchloremia Local ileus pattern over right upper quadrant Tachycardia Hypertension
Questions –
about past, personal, family history Birth history?
History of trauma? Child abuse? Operation history? foreign body aspiration?
Drug history? Food history?
Family history about tumor? About cystic fibrosis?
Questions-
about Physical Examination and laboratory data Anemic conjunctiva? Lymphoadenopathy?
RLQ soft tissue mass movable or non movable?
Bowel sound? Hyperactive to be replaced with hypoactive bowel sounds?
Stool rontine examination? occult blood? WBC? pattern? Blood smear? blast cell?
Questions
-about radiologic finding Plain film of abdomen :further finding? Foreign body/Bezoars? Abdomen Sonography: further finding? Appendix? Ascites?Kidney? Any finding about tumor?
Bilious vomiting
Vomitus or nasogastric aspirate containing bile which in children almost always indicates bowel obstruction
distal to the sphincter of Oddi
.
By contrast, infants with
pyloric stenosis have non-bile-stained vomiting
.
Intestinal obstruction
Intraluminal :polyp, mass, parasites, and tumor.
Intramural :stricture, tumor, hematoma.
Extrinsic :postoperative adhesion, adhesion from peritonitis, hernia, volvulus,and tumor.
Clinical Classification of Shock
Septic shock : bacterial ,Viral,Fugal..
Cardiogenic shock : ischemia, cardiomyopathy ,congestive heart failure Distributive shock : toxins ,anaphylaxis… Hypovolemic shock :enteritis, hemorrhage , Obstructive shock :tension pneumothroax
Hyperchloremia
Pathophysiology
Metabolic Acidosis with a normal Anion Gap
Causes
Artifact (low Anion Gap) Metabolic and Endocrine Hyperparathyroidism , Renal Tubular Acidosis, Hypernatremia.
Bromide intoxication Nervine, Sominex Acetazolamide Carbonic anhydrase inhibition Boric acid , Triamterene , Ammonium Chloride Excess IV Normal Saline
Hyperchloremia
Gastrointestinal Dehydration Prolonged Diarrhea Loss of pancreatic secretion Ileal loops Ureteral colonic anastomosis
(From: Pediatric Decision-making Strategies accompanied by Nelson)
Acute
Signs or symptoms suggestive of an acute abdomen
Yes History and physical exam
Vomiting
Surgery Consult
Malrotation with volvulus Appendicitis Other causes of intestinal obstrution Congenital structural abnormalities Postsurgical adhesions Foreign body/Bezoars Meckels diverticulum Incarcerated inguinal hernia Meconium ileus Intussusception Hirschsprungs disease Superior mesenteric artery syndrome Duodenal hematoma Testicular or ovarian torsion
No Sign or symptoms suggestive of increased ICP?
Yes No Chronic Sign or symptoms suggestive of increased ICP
Malrotation with volvulus Appendicitis Congenital structural abnormalities Postsurgical adhesions Foreign body/Bezoars Meckels diverticulum with bleeding Incarcerated inguinal hernia Meconium ileus Intussusception Hirschsprungs disease Superior mesenteric artery syndrome Duodenal hematoma Testicular or ovarian torsion
(From: Pediatric Decision-making Strategies accompanied by Nelson) Yes Abdomen US Abnormal result No Neonate?
History and physical exam
Abdomen mass
Hepatomegaly or splenomegaly present
Yes No Yes Lower abdomen mass in female No Perform abdomen US Normal result Perform Abdomen CT
Not neonate , Not female with lower abdomen mass
Splenomegaly Wilms tumor Adrenal cortical neoplasms Pancreatic masses/cysts Neuroblastoma Hydronephrosis Rhabdomyosarcoma Urinary retention Hepatic lesion Teratoma Bezoar Appendiceal abscess Intestinal tumor Mesenteric cyst Omental cyst Lymphangioma Lymphoma Choledochal cyst Constipation Inflammatory bowel disease Retroperitoneal hematoma
Foreign body/Bezoars Meckels diverticulum Hirschsprungs disease Appendicitis Intestinal tumor Neuroblastoma Rhabdomyosarcoma Lymphoma
Congenital structural abnormalities
Foreign body/Bezoars
( bezôr) An accumulation of exogenous matter in the stomach or intestine. peak incidence between the ages of 6 mo and 3 yr 90% of foreign bodies are
opaque .
vomiting, anorexia, and weight loss
. An
abdominal plain film may suggest the presence of a bezoar
, which can be confirmed on ultrasound or CT examination.
Gastric tricho
bezoar
Pediatric Emergency Care. 19(5):343-7, 2003 Oct.
On plain abdominal radiographs, the bezoar will appear as a mottled heterogenous mass that may be mistaken for a food-filled stomach. The classic sonographic appearance is described as a band of increased echogenicity in the region of the stomach with complete loss of posterior echoes.
Small bowel obstruction and covered
perforation
in childhood caused by bizarre
bezoar
s and foreign bodies.
Small bowel obstruction with perforation is an unusual and rare complication of
bezoar
s.
Israel Medical Association Journal: Imaj. 2(2):129-31, 2000 Feb.
Hirschsprungs disease
Abnormal innervation of the bowel .
Most common cause of lower
intestinal obstruction
in neonates .
Usually begin at birth of meconium
. with the
delayed passage
Some infants
pass meconium normally
but subsequently present with a history of
chronic constipation
.
Hirschsprungs disease
Failure to thrive
, with hypoproteinemia from a protein-losing enteropathy, is a less common presentation.
Rectal examination
demonstrates normal anal tone and is usually followed by an
explosive discharge
of foul-smelling feces and gas.
Hirschsprungs disease
Rectal manometry
and
rectal suction biopsy
are the easiest and most reliable indicators of Hirschsprung disease.
Barium enema
examination is useful in determining the
extent of aganglionosis.
Sonography may also help in determining the dynamic or adynamic state of fluid-filled or solid-filled bowel loops .
Meckels diverticulum
Remnant of the embryonic yolk sac Arise within the 1st 2 yr of life .
Intermittent painless rectal bleeding
by
ulceration
of the adjacent normal ileal mucosa.
Meckels diverticulum
Brick colored or currant jelly colored
.
Obstruction
occurs when the diverticulum acts as the
lead point of an intussusception.
A Meckel diverticulum may occasionally become
inflamed
(
diverticulitis
) and present similarly to acute appendicitis.
The most sensitive study is a
Meckel radionuclide scan
Meckel
's
diverticulum
.
Internal hernia and adhesions without gastrointestinal bleeding--ultrasound and scintigraphic findings .
US study was particularly helpful in this case because it shows a nonperistaltic region , which is consistent with a diverticulum or an internal hernia.
Clinical Nuclear Medicine. 21(12):938-40, 1996 Dec.
Meckel's
diverticulum
mimicking infantile colic: sonographic detection.
Abdominal sonography at 6 months of age demonstrated an abdominal
mass
with an anechoic center and a double-layered wall, surrounded by bowel loops. Histologic examination of the resected
mass
revealed a Meckel's
diverticulum
with a perforation sealed off by the neighboring bowel and mesentery to form an inflammatory
mass
.
Journal of Clinical Ultrasound. 28(6):314-6, 2000 Jul-Aug
Gastrointestinal bleeding in infants and children: Meckel's diverticulum and intestinal duplication.
Seminars in Pediatric Surgery. 8(4):202-9, 1999 Nov .
Meckel's diverticula and
intestinal duplication
s may cause gastro
intestinal
bleeding in almost any age group and require a high index of suspicion for diagnosis.
Appendicitis
The risk of
perforation
is greatest in
1- to 4 yr -old
children (70–75%) and is lowest in the adolescent age group (30–40%) .
The classic triad consists of
pain, nausea with vomiting
, and
fever .
The progression from onset of symptoms to
perforation usually occurs over 36–48hr .
Appendicitis
History included
onset of pain before vomiting or diarrhea
, loss of appetite, migration of pain
from periumbilical to right lower quadrant.
Auscultation may reveal normal or
hyperactive bowel sounds
in early appendicitis
,
to be replaced with
hypoactive
bowel sounds to perforation
.
as it progresses
Appendicitis
Findings of appendicitis on abdominal films include
calcified appendicolith
, small bowel distention or obstruction, and soft tissue mass effect .
Graded compression ultrasonography
is a noninvasive study with false-negative and false positive rates of 8–10% .
CT is more sensitive and specific ultrasonography than
and more likely to change patient management.
Pediatric
appendicitis
in "real-time": the value of
sonography
in diagnosis and treatment.
Pediatric Emergency Care. 17(5):334-40, 2001 Oct.
The natural progression in appendicitis from initial symptoms to perforation is about 36 to 48 younger child hours . However, perforation may occur more rapidly in the , sometimes within 6 to 12 hours .
Extensive necrosis of the appendix may render it difficult to visualize .
Pediatric
appendicitis
in "real-time": the value of
sonography
in diagnosis and treatment.
Pediatric Emergency Care. 17(5):334-40, 2001 Oct.
We may have to rely on the other ultrasound features of “ peri-appendiceal inflammation .” Studies have shown that the presence of loculated pericecal fluid, prominent pericecal fat , atonic bowel loops, thickened bowel walls, factors for and the circumferential loss of the appendiceal submucosal layer on ultrasound were the significant predictive perforation .
Distal Intestinal Obstruction Syndrome In the " older child or young adult with CF, the distal small bowel may by obstructed by thick stool. This condition was called meconium ileus equivalent " by Jensen in 1962 . Palpable mass in the right lower quadrant. Bilious vomiting the intestinal obstruction abdominal as a result of
Distal Intestinal Obstruction Syndrome Radiographs of the abdomen demonstrate dilated small bowel loops and a bubbly ileocecal soft tissue mass .
Carcinoid tumor
About 85% of carcinoid tumors develop in the gastrointestinal tract, usually the
appendix .
Carcinoid syndrome
:flushing,diarrhea, wheezing. Carcinoid crisis :generalized flush, tachycardia, severe diarrhea with abdominal pain, hypotension converting to coma and then death.
hypertension , and central nervous system changes leading to
Carcinoid tumor
Approximately 40% of the tumors occurred within
2 feet of the ileocecal valve
, with very few in the proximal small intestine. These tumors frequently elicit a mesenteric fibrosing reaction , in which the bowel becomes
shortened and kinked
, frequently causing partial small bowel obstruction
.
Carcinoid tumor
On CT, the mesenteric extension from carcinoid will usually appear as a soft tissue-density mesenteric mass . Calcification can be seen in up to 70% of cases .
Lymphoma from manual of pediatric hematology and oncology ,3 rd edition Non-Hodgkins lymphoma
:
peak age
5-15 years
,rick factor including genetic and poettransplantation immunosuppression.
Clinical feature:Head and neck(13%), medicatinum(26%) ,abdomen(35%) .
Non-Hodgkins lymphoma
The ileum is mostly involved due to a higher number of lymphocytes in the distal gut, accounting for about 50% of small bowel lymphomas Present with abdomen pain, vomiting and diarrhea, abdominal distension , palpable mass, intussusception,peritonitis, ascites , GI bleeding , hepatosplenomegaly.
Multidetector-row computed tomography and 3-dimensional computed tomography imaging of small bowel neoplasms : current concept in diagnosis. Lymphoma can appear as a single mass lesion , which varies in size.These can lead to intussusception, but rarely will result in obstruction because the masses are typically pliable and soft. Again, because the masses are characteristically soft , it is rare that the mesenteric vasculature is compromised.
Journal of Computer Assisted Tomography. 28(1):106-16, 2004 Jan-Feb .
Neuroblastoma
from manual of pediatric hematology and oncology,3 rd edition Give rise to adrenal medulla and the sympathetic ganglia.
Most common tumor in infancy ,peak incidence is
2 years
of age Clinical finding related to anatomic site of abdomen
:anorexia ,vomiting,abdomen pain
,massive involvement of the
liver
with metastasis (especially in the newborn)
Neuroblastoma
Paraneoplastic
manifestations : excessive catecholamine secretion (sweating,flushing,
paller
,palpitation,
hypertension
) ,VIP secretion (watery diarrhea
,abdomen distension,
hypokalemia ) ,and acute myoclonic encephalopathy.
Neuroblastoma
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed., A neuroblastoma is usually solid with a heterogeneous echotexture. Calcification evident by the presence of echogenic foci is with posterior acoustic shadowing. Anterior displacement and encasement of the aorta and inferior vena cava (IVC) by this retroperitoneal tumour is characteristic.
Rhabdomyosarcoma
from manual of pediatric hematology and oncology,3 rd edition Two age peaks :2-6 years and 15-19 years .
Rare primary sites for rhabdomyosarcoma include the
GI-hepatobiliary tract (3%)
, where in presents with
obstructive
jaundice and a
large abdomen mass
.
These tumors arise in the
common bile duct
and may extend into both lobes of the liver.
Final diagnosis
1.Meckels diverticulum with diverticulitis
or
congenital structural abnormalities 2.Ruptured Appendicitis
THANK YOU!!
Mesenteric cyst / Omental cyst They ranged in age from
1 month to 14 years
; 75% were younger than 5 years. The main presenting symptom is
abdominal pain
, followed by
nausea and vomiting
.
Some
mesenteric cyst
s may present as an acute abdomen due to a possible complication, such as
hemorrhage, rupture , or torsion
of the
cyst
.
Mesenteric cyst / Omental cyst Mesenteric cysts in children Surgery 1994;115:571-7 Acute symptoms are related to
compression of intra-abdominal organs
or stretching of the mesentery by rapid expansion .
Among these categories, the cystic lymphangioma is differentiated from the others because it is
far more common in children
.
Lymphangioma Five pathologic patterns account for most mesenteric cysts, namely, lymphangioma , enteric duplication cysts, enteric cysts, mesothelial, and nonpancreatic pseudocysts.
溴化物中毒之神經精神異常表現 陳建良、劉義聰、蔡瑞安、林自強 溴化物離子在各種膜性傳導系統上,可取代 的傳導。 氯離子,特別是在 神經系統,高濃度的溴化物,膜性抑制作用會逐漸損害神經元 長期服用含有溴化物藥劑,可能造成慢性溴化物中毒,而表現 出各式各樣神經精神異狀如意識混亂、躁動、頭暈、步態不穩、 運動失調、視力模糊、視野缺損、嗅覺障礙、短期記憶力障礙、 幻想、幻覺、麻木等週邊神經病變。 一般認為血中溴化物濃度超過 50 mg/dl(6.3 mEq/l) 將 產生一些 神經和精神症狀,實驗室檢 查發現除了溴化物濃度過高以外亦 可發現血 氯偏高及負陰離子間隙。 我們報告一病例因長期服用感冒糖漿造成溴化物中毒,臨床表 現出胸痛,呼吸急促與焦躁不安等症狀,起初血液檢 查顯示出 高血 氯,負陰離子間隙,因而聯想到溴化物中毒,經測血中溴 化物濃度高達 改善。 164 mg (臨床醫學 / dl ( 正常 值< 50 mg / dl) 。住院後給予 靜脈輸液利尿治療,一週後胸悶、胸痛、焦躁不安等症狀完全
2004; 54: 189-93
)
2003.12.27 【林杰樑(林口長庚 醫院臨床毒物科主任)】 《透視食品添加物》硼砂 增加食品彈性口感 新聞來源: 硼砂主要是在食品品質改良的應用。它增加食品的韌性、 彈性、保水性以及保存性。防止蝦頭的黑變,使蝦有好 的賣相;魚丸、年糕、油條、鹼粽 途,已被禁止使用。 … 等,較常見的則是 在油麵的製程中添加,使食品的口感、脆感、保鮮等用 硼砂進入體 內後,經胃酸作用,轉變 為硼酸( Boric acid ),會影響消化酵素作用。 可能引起食慾減退,消化不良,抑制營養素之吸收。 硼酸中毒症狀為嘔吐、腹瀉、紅斑、循環係統障礙、休 克及昏迷等硼酸症徵狀,而且有致死量,大人約 20 公克、 小孩約為 5 公克。
Leiomyoma of the
small
bowel with hypercalcaemia: presence of a substance with parathormone activity Nouvelle Presse Medicale. 8(40):3245-6, 1979 Oct 22.
A leiomyoma of the
small
laboratory features of bowel produced hyperparathyroidism which disappeared promptly after tumour resection. Hypercalcaemia, hypophosphatemia,
hyperchloremia
, elevated chloride/phosphorus ratio, increased urinary cyclic AMP, and blood levels of immunoreactive parathormone were present.
Retroperitoneal hematoma
In the majority of cases there is an associated pathological condition of a viscus or vessel due to trauma, aneurysm, atherosclerosis, eroding primary or secondary tumors, or pancreatitis . Furthermore, some have stated that hemophilia and anticoagulant therapy may be the cause in some cases.
Retroperitoneal hematoma
These patients usually present with mild to severe abdominal pain, nausea and vomiting . Physical examination reveals signs of shock, ileus and flank mass .
CT scans
are used usually to establish the diagnosis of retroperitoneal hematoma.
Bilious vomiting intermittent irritable crying one-year-six month-old boy Dehydration Hypertension Leukocytosis Hyperchloremia Soft tissue mass over RLQ by Abdomen sonography Decreased urine output and downhill BP in 16 hours
Wilms tumor
It may be associated with
hemihypertrophy, aniridia,
and other
congenital anomalies
, usually of the genitourinary tract. Sign of Wilms tumor
:palpable mass in abdomen
(60% ),
hypertension
hematuria(15%) ,abdomen mass (25%), is the most common presenting symptom and sign ,occasionally there is abdomen pain,especially when
hemorrhage
occurs in the tumor following trauma.
Wilms tumor
Some patients may present with
abdominal pain and vomiting
and, infrequently, hematuria. Occasionally,
rapid abdominal enlargement
and anemia may occur owing to bleeding into the renal parenchyma or pelvis.
Wilms tumor
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed., On ultrasound examination the tumour appears as a well-defined, solid mass of mixed echogenicity .Areas of haemorrhage and necrosis can produce focal hypoechoic lesions within the mass.
Ultrasound may be used for periodic surveillance of the opposite kidney.
Superior mesenteric artery syndrome The classic example is an
adolescent
who starts vomiting after application of a
body cast for orthopedic surgery
. Other associated factors include
anorexia, prolonged bed rest, weight loss,
abdominal surgery, and exaggerated lumbar lordosis.
The diagnosis is established radiologically with the demonstration of a
cutoff of the duodenum
just to the right of the midline.
Superior mesenteric artery syndrome An
extrinsic compression of the duodenum
in children after
rapid weight loss
and
in a supine position
. The compression is thought to occur as the
mesentery loses its fat
and allows the superior mesenteric artery to
collapse on the duodenum
, compressing it between the superior mesenteric artery anteriorly and the aorta posteriorly.
Inflammatory bowel disease
The most common time of onset of IBD is during
adolescence and young adulthood
. A bimodal distribution has been shown with an early onset at
15–25 yr
of age and a
second smaller peak at 50–80 yr
of age. Nonetheless, IBD may begin as early as the
1st yr of life
. In developed countries, these disorders are the major causes of chronic
intestinal inflammation
yr of life.
in children beyond the 1st few
Ulcerative colitis
Bloody stool and diarrhea
are the typical presentation of ulcerative colitis. Constipation may be observed in those with proctitis. Fever, severe anemia, hypoalbuminemia, leukocytosis, and greater than five bloody stools per day for 5 days is what defines
fulminant colitis
.
Ulcerative colitis
Extraintestinal manifestations
that tend to occur more commonly with ulcerative colitis than with Crohn disease include pyoderma gangrenosum, sclerosing cholangitis, chronic active hepatitis, and ankylosing spondylitis .
Crohns disease
Crohn colitis may be associated with
bloody diarrhea, tenesmus, and urgency.
Children with Crohn disease often appear
chronically ill
,
weight loss linear growth retardation.
Crohns disease
The initial presentation most commonly involves
ileum and colon (ileocolitis )
may involve the small bowel alone in but about 30% or colon alone in 10%–15%.
Children with ileocolitis typically have
cramping, abdominal pain, and diarrhea,
sometimes with blood. Ileitis may present as
right lower quadrant abdominal pain
alone.
Crohns disease
There may be abdominal tenderness that is either diffuse or localized to the
right lower quadrant
.
The diagnosis of Crohn disease depends on finding
typical clinical features of the disorder ( history, physical examination , laboratory studies, and endoscopic or radiologic findings
).
Crohns disease
Plain films of the abdomen may be normal or may demonstrate findings of
partial small bowel obstruction or thumbprinting
of the colon wall. An upper gastrointestinal contrast study with small bowel follow-through may show
aphthous ulceration and thickened, nodular folds
as well as narrowing of the lumen anywhere in the gastrointestinal tract.
Duplication
Duplications can be classified into three categories:
localized duplications
duplications of the colon.
, duplications associated with spinal cord defects and vertebral malformations, and Duplications may cause
bowel obstruction intestinal lumen
lead point of an intussusception or a site for a by
volvulus
.
compressing the adjacent
, or they may act as the
If they are lined by
acid-secreting mucosa
, they may cause
ulceration, perforation, and hemorrhage of the adjacent bowel
.
Patients may present with
abdominal pain, vomiting, palpable mass, or acute gastrointestinal hemorrhage .
Radiologic studies such as barium studies, ultrasonography, CT, and MRI are helpful but usually nonspecific, demonstrating
cystic structures or mass effects .
Radioisotope technetium
ectopic gastric mucosa
. scanning may localize The treatment of duplications is
surgical resection
and management of associated defects.
Atypical presentation of an
intestinal duplication
in a three month old child Journal de Radiologie. 85(6 Pt 1):773-5, 2004 Jun.
Intestinal duplication
is an uncommon congenital anomaly that often is diagnosed during childhood . Ultrasound diagnosis is based on the presence of a characteristic double-walled cystic mass. We report a case of
duplication
old child in a three Month presenting with small bowel obstruction.
Intestinal duplication
presenting as spontaneous hemoperitoneum .
Journal of Pediatric Gastroenterology & Nutrition. 31(2):181-2, 2000 Aug.
In approximately 60% of the cases, the condition appears during the
first year of life
as a
palpable abdominal mass
or as complications such as intestinal obstruction due to extrinsic compression, volvulus , or intussusception.
Intestinal duplication
presenting as spontaneous hemoperitoneum .
Journal of Pediatric Gastroenterology & Nutrition. 31(2):181-2, 2000 Aug.
It was probably caused by erosion of a blood vessel adjacent to the perforation that had been sealed off at laparotomy.
Sudden infant death, large
intestinal
volvulus, and a
duplication
cyst of the terminal ileum.
American Journal of Forensic Medicine & Pathology. 21(1):62-4, 2000 Mar.
If an intussusception or volvulus is identified, careful search for predisposing lesions or conditions such as duplication cysts , mesenteric cysts, mesenteric defects, Meckel's diverticula, mesenteric lymph nodes, polyps, neoplasms, mural hematomas, or cystic fibrosis should also be undertaken.
Jejunal and Ileal Atresia and Obstruction
Jejunoileal atresias have been attributed to
intrauterine vascular accidents
leading to
ischemic necrosis of the sterile bowel
and resorption of the affected segments.
Most infants become symptomatic
during the 1st day of life
with
abdominal distention and bile stained emesis
or gastric aspirate .
Plain radiographs demonstrate many
air fluid levels or peritoneal calcification
associated with meconium peritonitis. In
meconium ileus
, plain films of the abdomen show a typical
hazy or ground glass
appearance in the
right lower quadrant
.
Pneumoperitoneum
is most readily seen as free air between the liver and the diaphragm on an upright radiograph of the abdomen; if there is a large amount of free air, the entire abdomen may look like a
football
from distention with air; the ligamentum teres is sometimes clearly visible in the midline.
Malrotation
Incomplete rotation of the intestine during fetal development The majority of patients present within the
1st yr of life
with symptoms of acute or chronic obstruction. Infants often present within the 1st wk of life with
bilious emesis and acute bowel obstruction.
An acute presentation of usually a result of
small bowel obstruction
in a patient without previous bowel surgery is
volvulus
associated with malrotation.
The abdominal plain film is usually nonspecific but may demonstrate evidence of
duodenal obstruction with a double-bubble sign
. Barium enema usually demonstrates
malposition of the cecum
patients.
but may be normal in 10% of Upper gastrointestinal series demonstrates
malposition of the ligament of Treitz.
Ultrasonography
demonstrates
inversion
of the
superior mesenteric artery and vein
.
A superior mesenteric vein located to the left of the superior mesenteric artery is suggestive of malrotation. Surgical intervention is recommended for any patient with a significant rotational abnormality, regardless of age.
Intussception
A portion of the alimentary tract is
telescoped
an adjacent segment. into The
most common cause of intestinal obstruction
between
3 mo and 6 yr of age.
Sixty per cent of patients are
younger than 1 yr
, and 80% of the cases occur before 24 mo; it is rare in neonates. The
male:female ratio is 4:1.
Most intussusceptions
do not strangulate the bowel within the first 24hr
but may later eventuate in intestinal
gangrene and shock.
Sudden onset, severe
paroxysmal colicky pain Vomiting
occurs in most cases and is usually more frequent early.
60%
of infants pass a stool containing
red blood and mucus
, the
currant jelly stool
.
Tender sausage-shaped mass,
increase in size and firmness during a paroxysm of pain and is most often in the which may
right upper abdomen,
with its long axis cephalocaudal. Plain abdominal radiographs may show a
density
in the area of the intussusception.
Neonate with abdomen mass
Neuroblastoma Congenital Hydronephrosis Multiple cystic kidney Infantile polycystic kindey disease Neurogenic bladder Renal vein thrombosis Collecting system duplication Intestinal duplication Sacrococcygeal teratoma Adrenal hemarrhage Mesoblastic nephroma Pancreatic cyst Hepatoblastoma Meconium ileus Hematoma(hepatic,splenic) Magacolon(obstruction) Anterior myelomenihgocele Appendiceal abscess Intestinal tumor Mesenteric / Omental cyst Choledochal cyst
Neuroblastoma Congenital Hydronephrosis Multiple cystic kidney Infantile polycystic kindey disease Neurogenic bladder Renal vein thrombosis Collecting system duplication Intestinal duplication Sacrococcygeal teratoma Adrenal hemarrhage Mesoblastic nephroma Pancreatic cyst Hepatoblastoma Meconium ileus Hematoma(hepatic,splenic) Magacolon(obstruction) Anterior myelomenihgocele Appendiceal abscess Intestinal tumor Mesenteric / Omental cyst
Renal Vein Thrombosis
In newborns and infants, RVT is commonly associated with
asphyxia, dehydration, shock, sepsis,
and infants born to mothers with
diabetes
mellitus. Sudden onset of gross hematuria and
unilateral or bilateral flank masses
, microscopic hematuria,
flank pain, hypertension
, or
oliguria
.
Renal Vein Thrombosis
RVT is usually
unilateral
. Bilateral RVT results in acute renal failure. Most patients also have a
microangiopathic hemolytic anemia
and thrombocytopenia.
Ultrasonography
shows
marked enlargement
, whereas radionuclide studies reveal little or no renal function in the
affected kidney
(s). Doppler flow studies of the
inferior vena cava and renal vein
confirm the diagnosis.
The advent of technetium (Tc) 99m pertechnetate radionuclide scanning has greatly facilitated the diagnosis of Meckel's diverticula and may also be useful for
intestinal duplication
s. A positive scan requires the presence of ectopic gastric mucosa, which may be identified in both Meckel's diverticula and
intestinal duplication
s.
The significance of ectopic gastric mucosa is that it contains acid-secreting parietal cells, which may cause ulceration and bleeding. Only rarely are
intestinal duplication
s diagnosed preoperatively. After initial fluid resuscitation, bleeding from Meckel's diverticula and
intestinal duplication
s require surgical intervention. Resection is the treatment of choice.
A barium enema shows a
filling defect
or cupping in the head of barium where its advance is obstructed by the intussusceptum (coiled-spring sign) .
Ultrasonography is a sensitive diagnostic tool
in the diagnosis of intussusception.
The diagnostic findings of intussusception include a
tubular mass
in longitudinal views and a
doughnut or target
images .
appearance in transverse
Posttraumatic
retroperitoneal
rupture of the right colon simulating a
retroperitoneal hematoma
.
Journal of Trauma-Injury Infection & Critical Care. 42(4):741-2, 1997 Apr.
This case illustrates the diagnostic problems encountered in a patient with posttraumatic
retroperitoneal
abscess caused by
perforation of the posterior wall of the cecum,
simulating a
retroperitoneal hematoma
. Blunt colonic injuries are rare and difficult to diagnose. Septic signs are unexpected in case of posttraumatic
retroperitoneal hematoma
and should suggest the diagnosis of
retroperitoneal colonic perforation
.
Incarcerated inguinal hernia
An inguinal hernia appears as a
bulge in the inguinal region
into the scrotum. that extends toward and possibly The hallmark signs of an inguinal hernia on physical examination are a
smooth, firm mass that emerges through the external inguinal ring lateral to the pubic tubercle
and enlarges with increased intra-abdominal pressure. A quiet infant can be made to
the bed
pushing out the hernia.
strain the abdominal muscles by stretching out supine on
with legs extended and arms held straight above the head. Most infants struggle to get free, thus increasing the intra-abdominal pressure and
Incarcerated inguinal hernia
The infant or child with an
incarcerated inguinal hernia
is likely to have associated findings suggestive of
intestinal obstruction
such as
abdominal distention, vomiting, and multiple air-fluid levels evident
on plain radiographs.
Wilms tumor The incidence is approximately 8 cases/million children
younger than 15 yr of age
. It usually occurs in children
between 2–5 yr of age
, encountered in although it has also been
neonates
, adolescents, and adults.
Neonatal
intestinal
perforation caused by
congenital defect of the small intestinal musculature: report of one case
.
Acta Paediatrica Taiwanica. 40(4):271-3, 1999 Jul Aug.
Congenital defect of the small
intestinal
musculature is a rare cause of neonatal spontaneous
intestinal obstruction
perforation. or Histology examination demonstrates multifocal deficiency of the inner circular muscle layer three cm around the perforation site. The clinical and histological characteristics are reviewed and discussed. We propose that the muscle defect of small intestine, especially ileum, is secondary to ischemic injury rather than an embryological malformation.