Post on 04-Jun-2018
transcript
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Clinical Pathological
Conference2004-12-29
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Case Presentation
Present Illness
This one-year-six-month-old boy came to our
pediatric emergency department with thechief compliant of bilious vomitingand
intermittent irritable cryingsince 4hours
ago.
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Case Presentation
Personal and Family History
Past history:
Before this presentation,the child was ingood condition without any compliant of
abdominal symptoms.
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Case Presentation
Radiologic & Lab Findings
Plain film of abdomen : showed a nonspecificlocal ileuspattern over right upper quadrant.
Laboratory data:
white blood count:25300/nl (6000-17500/nl)
with 75% segment(54-62%) and
18% lymphocyte(25-33%).
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Case Presentation
Radiologic & Lab FindingsSerum 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.
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Case Presentation
Radiologic & Lab Findings
Abdomen sonography :revealed a soft
tissue mass over right lower quadrant,but noevidence of sign oftarget
appearance; besides, the relationship of
superior mesentery artery and superiormesentery vein was in rightposition.
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Case Presentation
Hospital Course-IITwelve hours later, heart rate increased to
150-180 per minutes.
Meanwhile, decreased urine output anddownhilled blood pressurehappened to him
despite of intravenous fluid supplement.
Under the impression of intestinal obstruction
complicated with shock, our pediatric surgeon
arranged emergency laparotomy.
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Case Presentation
Hospital Course-II
Post-operative course was relative
smooth,and started feeding on the4th
dayof lapatotomy smoothly.
His condition was stable during the
follow-up period at our out patientclinics.
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Major Problems Minor Problems
Bilious vomiting
A soft tissue mass
over right lowerquadrant
Downhilled blood
pressure(shock)
Intermittent irritablecrying
Decreased urine
output
Leukocytosis
Hyperchloremia
Local ileus pattern
over right upperquadrant
Tachycardia
Hypertension
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Questionsabout 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?
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Questions- about Physical
Examination and laboratory dataAnemic conjunctiva? Lymphoadenopathy?
RLQ soft tissue mass movable or non-
movable?Bowel sound? Hyperactive to be replacedwith hypoactive bowel sounds?
Stool rontine examination? occult blood?WBC? pattern?
Blood smear? blast cell?
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Questions-about radiologic finding
Plain film of abdomen :further finding?Foreign body/Bezoars?
Abdomen Sonography: further finding?Appendix? Ascites?Kidney? Any findingabout tumor?
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Bilious vomiting
Vomitus or nasogastric aspirate containing
bile which in children almost alwaysindicates bowel obstruction distal to the
sphincter of Oddi.
By contrast, infants with pyloric stenosishave non-bile-stained vomiting.
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Intestinal obstruction
Intraluminal:polyp, mass, parasites,
and tumor.Intramural:stricture, tumor,
hematoma.
Extrinsic:postoperative adhesion,adhesion from peritonitis, hernia,volvulus,and tumor.
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Clinical Classification of ShockSeptic shock:bacterial,Viral,Fugal..
Cardiogenic shock : ischemia,cardiomyopathy ,congestive heart failure
Distributive shock:toxins,anaphylaxis
Hypovolemic shock:enteritis,hemorrhage,
Obstructive shock :tension pneumothroax
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HyperchloremiaPathophysiology
Metabolic Acidosis with a normal Anion Gap
Causes
Artifact (low Anion Gap)
Metabolic and Endocrine
Hyperparathyroidism, Renal Tubular Acidosis,Hypernatremia.
Bromide intoxication
Nervine, Sominex
AcetazolamideCarbonic anhydrase inhibition
Boric acid , Triamterene,Ammonium Chloride
Excess IV Normal Saline
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HyperchloremiaGastrointestinal
Dehydration
Prolonged DiarrheaLoss of pancreatic secretion
Ileal loops
Ureteral colonic anastomosis
(From: Pediatric
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Vomiting
Chronic
Acute
History andphysical exam
Sign or
symptoms
suggestive
of increased ICP?
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 hematomaTesticular or ovarian torsion
Sign or symptoms suggestive
of increased ICP
Signs or
symptoms
suggestive
of an
acute
abdomen
No
Yes(From: PediatricDecision-makingStrategiesaccompanied byNelson)
No
Yes
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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
Ab l
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Abdomen
mass
Yes
No
History and
physical exam
Abdomen
US
Perform
abdomen USNeonate?
Perform
Abdomen CT
Yes(From: Pediatric Decision-makingStrategies accompanied by Nelson)
Lower
abdomen
mass in
female Normal result
Abnormal
result
No
Yes
NoHepatomegalyor
splenomegalypresent
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Not neonate ,
Not female with lower abdomen mass
Splenomegaly Wilms tumorAdrenal cortical neoplasms
Pancreatic masses/cysts
Neuroblastoma Hydronephrosis
RhabdomyosarcomaUrinary retention Hepatic lesion
Teratoma Bezoar
Appendiceal abscess Intestinal tumor
Mesenteric cyst Omental cystLymphangioma Lymphoma
Choledochal cyst Constipation
Inflammatory bowel disease
Retroperitoneal hematoma
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Foreign body/Bezoars
Meckels diverticulum
Hirschsprungs disease
AppendicitisIntestinal tumor
Neuroblastoma
Rhabdomyosarcoma
LymphomaCongenital structural abnormalities
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Foreign body/Bezoars (bezr)
An accumulation of exogenous matter inthe stomach or intestine.
peak incidence between the ages of 6 moand 3 yr
90% of foreign bodies are opaque.
vomiting, anorexia, and weight loss.
An abdominal plain film may suggestthe presence of a bezoar, which can beconfirmed on ultrasound or CTexamination.
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Gastric trichobezoarPediatric Emergency Care. 19(5):343-7, 2003 Oct.
On plain abdominal radiographs, thebezoar will appear as a mottled
heterogenous massthat may be mistakenfor a food-filled stomach.
The classic sonographic appearance is
described as a band of increasedechogenicityin the region of the stomachwith complete loss of posterior echoes.
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Small bowel obstruction and covered
perforationin childhood caused by bizarre
bezoars and foreign bodies.
Small bowel obstruction with
perforationis an unusual and rarecomplication of bezoars.
Israel Medical Association Journal: Imaj. 2(2):129-31, 2000 Feb.
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Hirschsprungs disease
Abnormal innervation of the bowel .
Most common cause of lower intestinalobstructionin neonates .
Usually begin at birthwith the delayed passageof meconium.
Some infants pass meconium normallybutsubsequently present with a history of chronicconstipation.
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Hirschsprungs disease
Failure to thrive, with hypoproteinemia
from a protein-losing enteropathy, is a
less common presentation.
Rectal examinationdemonstrates normal
anal tone and is usually followed by anexplosive dischargeof foul-smelling
feces and gas.
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Hirschsprungs disease
Rectal manometryand rectal suction biopsyare the easiest and most reliable indicators ofHirschsprung disease.
Barium enemaexamination is useful indetermining the extent of aganglionosis.
Sonography may also help in determining thedynamic or adynamic state of fluid-filled orsolid-filled bowel loops.
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Meckels diverticulum
Remnant of the embryonic yolk sac
Arise within the 1st 2 yr of life .
Intermittentpainless rectal
bleedingby ulcerationof the
adjacent normal ileal mucosa.
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Meckels diverticulum
Brick colored or currant jelly colored.
Obstructionoccurs when the diverticulumacts as the lead point of an intussusception.
A Meckel diverticulum may occasionallybecome inflamed(diverticulitis) and present
similarly to acute appendicitis.The most sensitive study is a Meckelradionuclide scan
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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
diverticulumor an internal hernia.
Clinical Nuclear Medicine. 21(12):938-40, 1996 Dec.
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Meckel's diverticulummimicking infantile colic:
sonographic detection.
Abdominal sonography at 6 months of agedemonstrated an abdominal masswith an
anechoic center and a double-layered wall,surrounded by bowel loops.
Histologic examination of the resected massrevealed a Meckel's diverticulumwith a
perforationsealed off by the neighboring boweland mesenteryto form an inflammatory mass.
Journal of Clinical Ultrasound. 28(6):314-6, 2000 Jul-Aug
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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
duplications may cause
gastrointestinalbleedingin almostany age group and require a high
index of suspicion for diagnosis.
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AppendicitisThe risk ofperforationis greatest in1- to 4-
yr-old children (7075%) and is lowest in
the adolescent age group (3040%) .
The classic triad consists of pain, nausea
with vomiting, and fever.
The progression from onset of symptoms to
perforation usually occurs over 3648hr.
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Appendicitis
History included onset of pain beforevomiting or diarrhea, loss of appetite,
migration of painfrom periumbilical toright lower quadrant.
Auscultation may reveal normal or
hyperactivebowel soundsin earlyappendicitis, to be replaced withhypoactivebowel soundsas it progressesto perforation.
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Appendicitis
Findings of appendicitis on abdominal filmsinclude calcified appendicolith, small boweldistention or obstruction, and soft tissue mass
effect.Graded compression ultrasonographyis anoninvasive study with false-negative and false-
positive rates of 810% .
CT is more sensitive and specificthanultrasonographyand more likely to changepatient management.
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Pediatric appendicitisin "real-time": the value of
sonographyin diagnosis and treatment.
Pediatric Emergency Care. 17(5):334-40, 2001 Oct.
The natural progression in appendicitis
from initial symptoms to perforation isabout 36 to 48hours . However,perforation may occur more rapidly in theyounger child, sometimes within 6 to 12hours .
Extensive necrosisof the appendix mayrender it difficult to visualize .
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Pediatric appendicitisin "real-time": the value of
sonographyin diagnosis and treatment.Pediatric Emergency Care. 17(5):334-40, 2001 Oct.
We may have to rely on the otherultrasound features of peri-appendiceal
inflammation.
Studies have shown that the presence ofloculated pericecal fluid,prominent
pericecal fat, atonic bowel loops, thickenedbowel walls,and the circumferential lossof the appendiceal submucosal layer onultrasound were the significant predictivefactors forperforation.
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Distal Intestinal Obstruction Syndrome
In the older child or young adultwith CF,
the distal small bowel may by obstructedby thick stool. This condition was called"meconium ileus equivalent" by Jensen in1962 .
Palpable mass in the right lowerabdominalquadrant. Bilious vomitingas a result ofthe intestinal obstruction
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Distal Intestinal Obstruction Syndrome
Radiographs of the abdomendemonstrate dilated small bowel
loops and abubbly ileocecal soft-
tissue mass .
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Carcinoid tumor
About 85% of carcinoid tumors develop in thegastrointestinal tract, usually theappendix.
Carcinoid syndrome:flushing,diarrhea,wheezing.
Carcinoid crisis:generalized flush, tachycardia,severe diarrhea with abdominal pain,hypotension converting to hypertension, andcentral nervous system changes leading tocoma and then death.
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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, frequentlycausingpartial small bowel obstruction.
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Carcinoid tumor
On CT, the mesenteric extension from
carcinoid will usually appear as a soft
tissue-densitymesenteric mass .
Calcificationcan be seen in up to 70% of
cases .
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Lymphoma
from manual of pediatric hematology and oncology ,3rd
edition
Non-Hodgkins lymphoma:
peak age 5-15years,rick factor includinggenetic and poettransplantationimmunosuppression.
Clinical feature:Head and neck(13%),
medicatinum(26%),abdomen(35%).
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Non-Hodgkins lymphoma
The ileumis mostly involved due to ahigher number of lymphocytes in the distal
gut, accounting for about 50% of smallbowel lymphomas
Present with abdomen pain, vomitingand
diarrhea, abdominal distension, palpablemass, intussusception,peritonitis, ascites,GI bleeding, hepatosplenomegaly.
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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 tointussusception, but rarely will result inobstructionbecause the masses are typically
pliable and soft.
Again, because the masses are characteristicallysoft, it is rare that the mesenteric vasculature iscompromised.
Journal of Computer Assisted Tomography. 28(1):106-16, 2004 Jan-Feb.
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Neuroblastoma
from manual of pediatric hematology and oncology,3rdeditionGive rise to adrenal medulla and thesympathetic ganglia.
Most common tumor in infancy ,peakincidence is 2 yearsof age
Clinical finding related to anatomic site ofabdomen :anorexia ,vomiting,abdomenpain,massive involvement of theliverwithmetastasis (especially in the newborn)
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Neuroblastoma
Paraneoplastic manifestations :
excessive catecholamine secretion
(sweating,flushing, paller,palpitation,hypertension),VIP secretion (watery
diarrhea,abdomen distension,
hypokalemia) ,and acute myoclonicencephalopathy.
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NeuroblastomaGrainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging,
4th ed.,
A neuroblastoma is usually solid with aheterogeneous echotexture.Calcificationis
evident by the presence of echogenic fociwith posterior acoustic shadowing.
Anterior displacement and encasement ofthe aorta and inferior vena cava(IVC) bythis retroperitoneal tumour is characteristic.
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Rhabdomyosarcomafrom manual of pediatric hematology and
oncology,3rdeditionTwo age peaks:2-6 yearsand 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 bileductand may extend into both lobes of the
liver.
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Final diagnosis
1.Meckels diverticulum with
diverticulitis or congenital structuralabnormalities
2.Ruptured Appendicitis
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THANK YOU!!
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Mesenteric cyst / Omental cyst
They ranged in age from 1 month to 14years;75% were younger than 5 years.
The main presenting symptom is abdominalpain, followed by nausea and vomiting.
Some mesentericcysts may present as anacute abdomen due to a possiblecomplication, such as hemorrhage, rupture,or torsionof the cyst.
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Mesenteric cyst / Omental cyst
Mesenteric cysts in children Surgery 1994;115:571-7
Acute symptoms are related to compression
of intra-abdominal organsor stretching of
the mesentery by rapid expansion.
Among these categories, the cystic
lymphangiomais differentiated from theothers because it is far more common in
children.
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Lymphangioma
Five pathologic patterns account for mostmesenteric cysts, namely,lymphangioma,enteric duplication cysts, enteric cysts,
mesothelial, and nonpancreaticpseudocysts.
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50 mg/dl(6.3 mEq/l)
164 mgdl (50 mgdl)2004; 54: 189-93
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2003.12.27
Boricacid
205
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Leiomyoma of the smallbowel with hypercalcaemia:presence of a substance withparathormoneactivity
Nouvelle Presse Medicale. 8(40):3245-6, 1979 Oct 22.
A leiomyoma of the smallbowel producedlaboratory features ofhyperparathyroidism which
disappeared promptly after tumour resection.
Hypercalcaemia, hypophosphatemia,hyperchloremia, elevated chloride/phosphorusratio, increased urinary cyclic AMP, and blood
levels of immunoreactive parathormone werepresent.
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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 thathemophilia and anticoagulanttherapy may
be the cause in some cases.
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Retroperitoneal hematoma
These patients usually present with mild tosevere abdominal pain, nausea and
vomiting.Physical examination reveals signs ofshock, ileus and flank mass.
CT scansare used usually to establish thediagnosis of retroperitoneal hematoma.
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Bilious vomitingintermittent irritable
crying
Dehydration
Hypertension
Leukocytosis
Hyperchloremia
Soft tissue massover RLQ by
Abdomen sonography
Decreased urine outputand downhill BP
in 16 hours
one-year-six
month-old boy
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Wilms tumor
It may be associated with hemihypertrophy,aniridia,and other congenital anomalies,usually of the genitourinary tract.
Sign of Wilms tumor:palpable mass inabdomen(60%),hypertension(25%),hematuria(15%),abdomen mass is the mostcommon presenting symptom and
sign ,occasionally there is abdomenpain,especially whenhemorrhageoccurs inthe tumor following trauma.
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Wilms tumor
Some patients may present withabdominal pain and vomitingand,infrequently, hematuria.
Occasionally, rapid abdominalenlargementand anemia may occurowing tobleeding into the renalparenchymaor pelvis.
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Wilms tumorGrainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging,
4th ed.,
On ultrasound examination the tumourappears as a well-defined, solid massofmixed echogenicity.Areas of haemorrhageand necrosis can produce focal hypoechoic
lesions within the mass.
Ultrasound may be used for periodicsurveillance of the opposite kidney.
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Superior mesenteric artery syndrome
The classic example is anadolescentwhostarts vomiting after application of a body castfor orthopedic surgery. Other associated
factors include anorexia, prolonged bed rest,weight loss, abdominal surgery, andexaggerated lumbar lordosis.
The diagnosis is established radiologicallywith the demonstration of a cutoff of theduodenumjust to the right of the midline.
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Superior mesenteric artery syndrome
An extrinsic compression of the duodenumin children after rapid weight lossand in a
supine position.
The compression is thought to occur as themesentery loses its fatand allows the
superior mesenteric artery to collapse on theduodenum, compressing it between thesuperior mesenteric artery anteriorly and theaorta posteriorly.
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Inflammatory bowel disease
The most common time of onset of IBD isduring adolescence and young adulthood. A
bimodaldistribution has been shown with an
early onset at 1525 yrof age and a secondsmaller peak at 5080 yrof age.
Nonetheless, IBD may begin as early as the1st yr of life.
In developed countries, these disorders are themajor causes of chronic intestinalinflammationin children beyond the 1st fewyr of life.
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Ulcerative colitis
Bloody stool and diarrheaare 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.
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Ulcerative colitis
Extraintestinal manifestationsthat
tend to occur more commonly with
ulcerative colitis than with Crohn
disease includepyoderma gangrenosum,
sclerosing cholangitis, chronic active
hepatitis, and ankylosing spondylitis.
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Crohns disease
Crohn colitis may be associated with
bloody diarrhea, tenesmus, and urgency.
Children with Crohn disease often appear
chronically ill, weight losslinear growthretardation.
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Crohns disease
The initial presentation most commonlyinvolves ileum and colon (ileocolitis)but
may involve the small bowel alone inabout 30% or colon alone in 10%15%.
Children with ileocolitis typically havecramping, abdominal pain, anddiarrhea,sometimes with blood. Ileitismay present as right lower quadrantabdominal painalone.
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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).
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Crohns disease
Plain films of the abdomen may be normalor may demonstrate findings of partial
small bowel obstructionorthumbprintingof the colon wall.
An upper gastrointestinal contrast studywith small bowel follow-through may
show aphthous ulceration and thickened,nodular foldsas well as narrowing of thelumen anywhere in the gastrointestinaltract.
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Duplication
Duplications can be classified into threecategories: localized duplications,
duplications associated with spinal corddefects and vertebral malformations, andduplications of the colon.
Duplications may cause bowelobstructionby compressing the adjacent
intestinal lumen, or they may act as thelead point of an intussusception or a sitefor a volvulus.
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If they are lined by acid-secreting mucosa,
they may cause ulceration, perforation,
and hemorrhageof the adjacent bowel.
Patients may present with abdominal pain,
vomiting, palpable mass, or acutegastrointestinal hemorrhage.
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Radiologic studies such as barium studies,ultrasonography, CT, and MRI are helpful but
usually nonspecific, demonstrating cysticstructuresor mass effects.
Radioisotope technetiumscanning may localizeectopic gastric mucosa.
The treatment of duplications is surgicalresectionand management of associated defects.
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Atypical presentation of an intestinal
duplicationin a three month old childJournal de Radiologie. 85(6 Pt 1):773-5, 2004 Jun.
Intestinalduplicationis an uncommoncongenital anomaly that often is diagnosed during
childhood.Ultrasound diagnosis is based on the presence of acharacteristic double-walled cystic mass.
We report a case of duplicationin a three Monthold childpresenting with small bowel obstruction.
I t ti l d li ti ti
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Intestinalduplicationpresenting 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 firstyear of lifeas a palpable abdominal
massor as complications such as
intestinal obstruction due to extrinsic
compression, volvulus, or
intussusception.
I t ti l d li ti ti
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Intestinalduplicationpresenting as
spontaneous hemoperitoneum.
Journal of Pediatric Gastroenterology & Nutrition.31(2):181-2, 2000 Aug.
It was probably caused by erosion of
a blood vessel adjacentto theperforation that had been sealed off at
laparotomy.
Sudden infant death, large intestinal
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, g
volvulus, and a duplicationcyst 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.
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Jejunal and Ileal Atresia and
Obstruction
Jejunoileal atresias have been
attributed to intrauterine vascularaccidentsleading to ischemic
necrosis of the sterile boweland
resorption of the affected segments.
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Most infants become symptomatic
during the 1st day of lifewith
abdominal distention and bile-
stained emesisor gastric aspirate.
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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-
glassappearancein the right lowerquadrant.
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Pneumoperitoneum is most readily seen
as free air between the liver and the
diaphragmon an upright radiograph of theabdomen; 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.
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Malrotation
Incomplete rotation of the intestine during fetaldevelopment
The majority of patients present within the 1st yrof lifewith symptoms of acute or chronicobstruction. Infants often present within the 1stwk of life with bilious emesis and acute bowelobstruction.
An acute presentation of small bowel obstruction
in a patient without previous bowel surgery isusually a result of volvulusassociated withmalrotation.
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The abdominal plain film is usually nonspecific
but may demonstrate evidence of duodenalobstruction with a double-bubble sign.
Barium enema usually demonstrates malpositionof the cecumbut may be normal in 10% of
patients.
Upper gastrointestinal series demonstratesmalposition of the ligament of Treitz.
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Ultrasonographydemonstratesinversion
of the superior mesenteric artery and
vein.A superior mesenteric vein located tothe left of the superior mesenteric artery is
suggestive of malrotation.
Surgical intervention is recommended forany patient with a significant rotational
abnormality, regardless of age.
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Intussception
A portion of the alimentary tract is telescopedinto an adjacent segment.
The most common cause of intestinalobstructionbetween 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 israre in neonates. The male:female ratio is 4:1.
Most intussusceptions do not strangulate thebowel within the first 24hrbut may latereventuate in intestinal gangrene and shock.
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Sudden onset, severe paroxysmal colicky pain
Vomiting occurs in most cases and is usuallymore frequent early.
60%of infants pass a stool containing red bloodand mucus, the currant jelly stool.
Tender sausage-shaped mass,which mayincrease in size and firmness during a paroxysmof pain and is most often in the right upperabdomen,with its long axis cephalocaudal.Plain abdominal radiographs may show a densityin the area of the intussusception.
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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 teratomaAdrenal hemarrhage Mesoblastic nephroma
Pancreatic cyst Hepatoblastoma
Meconium ileus Hematoma(hepatic,splenic)
Magacolon(obstruction)
Anterior myelomenihgocele
Appendiceal abscess Intestinal tumor
Mesenteric / Omental cyst Choledochal cyst
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Neuroblastoma
Congenital Hydronephrosis
Multiple cystic kidney
Infantile polycystic kindey disease
Neurogenic bladderRenal vein thrombosis
Collecting system duplication
Intestinal duplication
Sacrococcygeal teratoma
Adrenal hemarrhage
Mesoblastic nephromaPancreatic cyst
Hepatoblastoma
Meconium ileus
Hematoma(hepatic,splenic)
Magacolon(obstruction)
Anterior myelomenihgocele
Appendiceal abscess Intestinal tumor
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Renal Vein Thrombosis
In newborns and infants, RVT is commonlyassociated with asphyxia, dehydration,
shock, sepsis,and infants born to motherswith diabetesmellitus.
Sudden onset of gross hematuria and
unilateral or bilateral flank masses,microscopic hematuria, flank pain,hypertension, or oliguria.
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Renal Vein Thrombosis
RVT is usually unilateral. Bilateral RVTresults in acute renal failure.Most patients
also have a microangiopathic hemolyticanemiaand thrombocytopenia.
Ultrasonographyshows markedenlargement, whereas radionuclide studies
reveal little or no renal function in theaffected kidney(s).
Doppler flow studies of the inferior venacava and renal veinconfirm the diagnosis.
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The advent of technetium (Tc) 99mpertechnetate radionuclide scanning has
greatly facilitated the diagnosis ofMeckel's diverticula and may also beuseful for intestinalduplications. A
positive scan requires the presence of
ectopic gastric mucosa, which may beidentified in both Meckel's diverticula andintestinalduplications.
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The significance of ectopic gastric mucosais that it contains acid-secreting parietal
cells, which may cause ulceration andbleeding. Only rarely are intestinalduplications diagnosed preoperatively.After initial fluid resuscitation, bleeding
from Meckel's diverticula and intestinalduplications require surgical intervention.Resection is the treatment of choice.
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A barium enema shows a filling defector cuppingin the head of barium where its advance isobstructed by the intussusceptum (coiled-springsign) .
Ultrasonographyis a sensitive diagnostic toolin the diagnosis of intussusception.
The diagnostic findings of intussusception
include a tubular massin longitudinal views anda doughnut or targetappearance in transverseimages .
P i i l f h i h
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Posttraumatic retroperitonealrupture of the right
colon simulating a retroperitonealhematoma.
Journal of Trauma-Injury Infection & Critical Care. 42(4):741-2, 1997 Apr.This case illustrates the diagnostic
problems encountered in a patient withposttraumatic retroperitonealabscess
caused by perforation of the posteriorwall of the cecum,simulating aretroperitonealhematoma.
Blunt colonic injuries are rare and difficult
to diagnose. Septic signs are unexpected incase of posttraumatic retroperitonealhematomaand should suggest thediagnosis of retroperitonealcolonic
perforation.
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Incarcerated inguinal hernia
An inguinal hernia appears as a bulge in theinguinal regionthat extends toward and possiblyinto the scrotum.
The hallmark signs of an inguinal hernia onphysical examination are a smooth, firm massthat emerges through the external inguinal ringlateral to the pubic tubercleand enlarges withincreased intra-abdominal pressure.
A quiet infant can be made to strain theabdominal muscles by stretching out supine onthe bedwith legs extended and arms held straightabove the head. Most infants struggle to get free,thus increasing the intra-abdominal pressure and
pushing out the hernia.
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Incarcerated inguinal hernia
The infant or child with an
incarcerated inguinal herniais
likely to have associated findings
suggestive of intestinal obstruction
such as abdominal distention,
vomiting, and multiple air-fluidlevels evidenton plain radiographs.
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Wilms tumor
The incidence is approximately 8cases/million children younger than15 yr of age.
It usually occurs in children between25 yr of age,although it has also been
encountered inneonates, adolescents,and adults.
Neonatal intestinalperforation caused by congenital
d f t f th ll i t ti l l t t
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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 intestinalmusculature is arare cause of neonatal spontaneous intestinalobstructionor
perforation.
Histology examination demonstrates multifocal deficiencyof the inner circular muscle layer three cm around the
perforation site. The clinical and histological characteristicsare reviewed and discussed. We propose that the muscledefect of small intestine, especially ileum, is secondary toischemic injury rather than an embryological malformation.