Good morning! July 24, 2014
Prep #1 A 2-year-old boy presents to your office with a 2-day history of swelling of the right eye. He has been otherwise well. There are scattered insect bites on his body, including one about 2cm lateral to the affected eye. There is no discharge, and the bite appears to be healing. The boy s right eyelids are swollen and seem tender to palpation. Of the following, the MOST concerning additional ophthalmologic finding for this boy is: A. Decreased extraocular movements B. Hyperemia of the palpebral conjunctiva C. Photophobia D. Purulent exudates E. Subconjunctival hemorrhage
Chief Complaint: Emesis What do you want to know?
Let s go to the dictionary! Refers to oral expulsion of gastric contents with contraction of abdominal and chest wall muscles NORMAL-Slight yellow tinge -Small amounts of bile into stomach ABNORMAL- Green or bright yellow Bilious -Often associated with intestinal obstruction No standard approach to workup
Why is he vomiting?
Back to our patient Let s take a look at him. What do you want to do next?
What if I had shown you this?
Is there another imaging study you might want? What is that?!?!?
Intussusception Everyone divide into your groups Content Spec: Recognize the presence of intussusception
Definition and Epidemiology Invagination or telescoping of proximal intestine and its mesentery into an adjacent distal segment Intussusceptum is the portion of bowel that invaginates into the enveloping portion, which is the intussuscipiens. Most common cause of intestinal obstruction in children 6-36 mos Rare before 3 months or after 6 yrs Male:Female 3:2 Peaks in winter and summer
Causes and Pathogenesis As telescoping occurs, the associated mesentery is brought with it. This leads to venous lymphatic congestion with resulting intestinal edema Ischemia results, leading to bleeding into the mucosa ( current jelly stools ) Sites involved: Ileocecal junction* Small bowel involvement with HSP Jejunal-ileal, and colic-colic may also occur
Causes and Pathogenesis 75% of cases are idiopathic Remainder of cases involve: Meckel diverticulum Intestinal polyps B cell lymphoma Appendiceal stumps Parasites Foreign bodies Hemangiomas Tumors Lymphatic hypertrophy of the Peyer patches from recent viral infections May be seen in children with HSP, CF, Celiac, Crohn s, HUS
Clinical presentation Classic Triad (<15% of presentations!) Sudden onset of colicky abdominal pain Periumbilical or RLQ pain Crying and drawing of legs toward abdomen Palpable abdominal mass Currant jelly stools Vomiting Typically non-bilious becomes bilious as obstruction progresses Lethargy or encephalopathy can be presenting sign in infants Often confused with sepsis
Clinical exam Usually unrevealing Sausage-shaped mass in the in the RLQ or midabdomen Signs of intestinal obstruction- distension, high-pitched bowel sounds or normal Stools mixed with blood and mucus >70% of cases present with occult blood
Diagnose with pictures Abdominal x-rays (Less sensitive AND specific!) 1. Signs of intestinal obstruction (massively distended loops with absence of colonic gas) 2. Crescent sign LUQ Occurs when the intussusceptum projects into a gasfilled colonic pocket 3. Target sign RUQ Doughnut or bull s eye appearance Occurs when 2 layers of peritoneal fat surrounding the intussusceptum and the invaginating intestine come together
Diagnose with pictures US Demonstrates bowel within bowel (target sign) Considered test of choice* Approaches 100% sensitivity and specificity Can diagnose ileo-ileal intussusception and indentify lead point in ~2/3 of cases with an underlying pathology
How do I treat? Those with typical presentation or radiologic findings: Straight to non-operative reduction!
Imaging ANNND Treatment?!? Barium contrast or air enema Air enema usually preferred (safer and cleaner) Coiled spring on barium enema The outline of the leadpoint of the intussusception
Will the patient need surgery? He/She will if acutely ill or has evidence of perforation If the contrast enema is unsuccessful, surgical reduction may be warranted 15% of patients require surgical intervention
Prognosis May have low grade fever afterwards 2/2 bacterial translocation or the release of endotoxin/cytokines Observe in hospital 12-24 hours Reductions successful in 80-95% with ileocolic intussusception 10% of intussusceptions treated by non-operative reduction may recur Advance feedings as tolerated Better success: Infants younger than 12 months or children older than 5 yrs, when plain films show signs of intestinal obstruction
A note on Pyloric Stenosis Enlarged pylorus with increased muscular thickness, generally leading to gastric outlet obstruction Epidemiology Male:Female 4:1, most commonly first-born, white infants Etiology Use of erythromycin during first 2 weeks of life Increased incidence with B and O blood types Abnormal muscle innervation Underlying defect is redundant pyloric muscosa-> edema, obstruction, secondary muscle hypertrophy
Pyloric Stenosis continued Clinical manifestations Typically 3- to 6-week-old infant Progressive or intermittent nonbilous vomiting after feeding Infant is often hungry after vomiting, wants to feed again Weight loss and dehydration Palpable small olive-shaped mass in mid-epigastric area, visible gastric peristaltic wave after feeding
Pyloric Stenosis continued Diagnostics Clinical dx possible in 60-80% Hypochloremic hypokalemic metabolic alkalosis Abdominal US (90% sensitivity) Upper GI- has risk for aspiration Management Correct dehydration and electrolyte abnormalities Laproscopic pyloromyotomy
A note on Malrotation/Volvulus Abnormal midgut development resulting in anomalous positioning of the small intestine, cecum, ascending colon. This results in volvulus when the malrotated intestine twists on the axis of the SMA, comprising blood flow Epidemiology 30% detected by 1 week of age, 90% by 1 year Majority have associated anomalies Pathophysiology In 5 th -6 th week, intestinal size exceeds abdominal cavity space and rotates 270 degrees Malrotation occurs when this normal counterclockwise rotation of the midgut is incomplete
Malrotation/Volvulus continued Clinical Manifestations Ranges from acute intestinal obstruction to chronic, intermittent abdominal pain Delayed presentation usually includes shock with hematochezia or melena Midgut obstruction- should have flat or scaphoid abdomen Distal small bowel or colonic obstruction- abdominal distension
Malrotation/Volvulus continued Diagnostics Abdominal xray- gastric and duodenal dilation Upper GI* Stomach lies left of the midline and the duodenum makes a C shape crossing left-right-left, joining jejunum at ligament of Treitz In malrotation, C-loop and ligament of Treitz lie on right and do not cross midline Management Ladd Procedure- counterclockwise reduction with repositioning of small intestine to RLQ and cecum to LLQ, necrotic bowel resection, appendix removal
Have a great day! Noon Conference: Class Housestaff (Interns-2Center, Upper Levels-Auditorium)