Feedback: Q6 A 4 week old child is brought to your emergency
department with a distended abdomen. Marking What six (6) questions
would you ask to aide you with your diagnosis? (6 marks) passage
meconium first 48 hours; vomiting history ? bilious; bowel opening
history; tolerating feeds/ passing urine; distressed/ unwell;
premature; significant PMH eg bowel surgery Needed to ask about
passage meconium to get 6/6 question Not about Dx but about
approach One point for Dx Marking State two (2) positive and two
(2) relevant negative findings on the AXR. (4 marks) XR +ve:
dilated bowel loops (large and small) paucity of air in rectum
XR-ve: No free air (football sign, riglers/ double wall sign) No
pneumatosis intestinalis No double bubble sign Marking What is the
most likely diagnosis? (1 mark)
Hirschsprungs Name two (2) differential diagnosis.(2 marks) causes
bowel obstruction malrotation, imperforate anus, constipation,
meconium plug/ ileus, incarcerated hernia, NEC Marking State three
management steps. (3 marks)
Surgery referral, NBM, NGT on free drainage, iv access and fluids,
analgesia if distressed Hirschsprung Disease Absence of ganglion
cells in bowel wall from anus proximally Delayed passage meconium
(99% full term infants pass meconium in 48 hours) Chronic
constipation Risk of enterocolitis if not Dx early AXR- obstruction
and paucity gass rectum Rectal suction biopsy for Dx then
definitive surgery Malrotation Incomplete rotation of intestine as
foetus
Mesentery (including SMA) tethered by narrow stalk which can twist
producing midgut volvulus Can also cause duodenal obstruction (Ladd
bands) Present 1st year of life with about 40% presenting first
week and 50% by first month Bilious emesis, bowel obstruction and
significant abdominal pain (especially with volvulus) Necrotizing
Enterocolitis
Newborn emergency- disease of the NICU Multifactorial Mucosal/
transmural necrosis of intestine Incidence and mortality increase
with decreasing BW and GA 90% in premature infant Can be secondary
disease- including Hirschsprung! Usually 2nd-3rd week of life but
can be as late as 3 months in VLBW infants AXR- pneumatosis
intestinalis Hirschsprungs with pneumatosis intestinalis
Intussusception 2 months to 2 years (can occur any age)
Peak incidence 5 to 9 months (weaning) Intermittent severe colicky
abdo pain Typically 2-3/ hour and at least 1/hour Usually assoc
with vomiting, pallor, lethargy Blood in stool is late sign Mass
hard to feel Intussusception: Imaging
diagnostic investigation of choice Air enema: diagnostic and
therapeutic AXR: only if concerned perforated or obstructed Target
sign- 2 concentric circular radiolucent lines usually in RUQ
Crescent sign- a crescent shaped lucency usually LUQ with a soft
tissue mass Perforation If suspected consider left lateral
decubitus film Rigglers sign/ double wall sign Football sign Small
Bowel vs Large Bowel Obstruction
Small bowel tends to be central Normal large bowel distribution
with haustral folds