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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


Meckels diverticulum with bleeding


Meconium ileus

Intussusception



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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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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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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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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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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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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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
http://www.infotimes.com.tw/http://www.infotimes.com.tw/

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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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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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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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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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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


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


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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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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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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.

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