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Pediatric Gastrointestinal/ Geniturinary Emergencies

Pediatric Gastrointestinal/ Geniturinary Emergencies. Leybie Ang PEM Fellow Aug 6 2009. Pediatric Gastrointestinal Emergencies. Objectives. Approach to GI Bleed DDx Common Causes Life threatening Causes Approach to Abdominal Pain Case Presentations. Approach to GI Bleed. A B C

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Pediatric Gastrointestinal/ Geniturinary Emergencies

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  1. Pediatric Gastrointestinal/Geniturinary Emergencies Leybie Ang PEM Fellow Aug 6 2009

  2. Pediatric Gastrointestinal Emergencies

  3. Objectives • Approach to GI Bleed • DDx • Common Causes • Life threatening Causes • Approach to Abdominal Pain • Case Presentations

  4. Approach to GI Bleed • A B C • Severity of the bleeding • Site of the bleed

  5. Common cause of UGI in neonatal period? • Common cause of UGI in preschool age?

  6. Common cause of LGI during neonatal period? • Common cause of LGI during infancy?

  7. Approach to Abdominal Pain

  8. Causes of Acute Abdomen Pain

  9. Causes of Acute Abdomen Pain

  10. Life-Threatening Cause

  11. Life Threatening Cause

  12. Case Presentation #1 • 2 week old male presented with abdominal distension • At triage, noted to have bilious vomiting • Former 37 weeker SVD • SCN stay x 48hr for ?TTN • No sick contact • Afebrile HR 200 RR 65 O2 sat 98% RA • Fussy but consolable • GI exam revealed distended abdomen

  13. Case Presentation #1 (con’t) • Management priorities? • Likely diagnosis?

  14. Malrotation With Midgut Volvulus • Congenital malrotation of the midgut • During 5th-8th embryonic week, intestine projects out of cavity, rotates 270 degree and then returns • If incomplete rotation, intestine does not anchor at the mesentry • Volvulus is twisting of a loop of bowel about the mesentric attachment

  15. Malrotation with Volvulus • Incidence 1 in 500 • Male-to-female ratio 2:1 • Usually presents in the first year of life • Bilious vomiting • Abdominal distension • Hematochezia

  16. Imaging • Abdominal films – Classic double bubble sign • Upper GI (GOLD STD) – “cork-screwing”, spiraling of SB around SMA • US – distended, fluid filled duodenum, with dilated loops of bowel to the right of the spinal column

  17. Treatment • SURGICAL CONSULT!!! • IV hydration • Correction of electrolytes • NG tube

  18. Case Presentation 2 • 1 yo female presents with vomiting, and intermittent abdominal cramping • Noted to be lethargic • PE revealed palpable mass in RUQ • Heme positive stools

  19. Most likely diagnosis??? • Management???

  20. Intussusception • Telescoping of a segment of bowel into an adjacent segment • Mesentery and venous supply obstruct  mucosal edema and increased pressure  arterial flow obstruction • Incidence: 6mo to 2 yo

  21. Intussusception • Most common location ??? • Most common reported symptoms ???

  22. Intussuception • Idiopathic • Meckel’s Diverticulum • HSP • Polyps • Tumors • Lymphoma

  23. Intussusception • Intermittent, colickly abdominal pain • Currant jelly stools => late finding • +/- RUQ mass • Emesis -> bilious • Heme positive stools

  24. Intussusception - Dx • AXR – may normal initially, but then may see signs of obstruction, paucity of air and dilated loops of bowel • US – “target” or “donut” sign = single hypoechoic ring with hyperechoic center • “pseudokidney” sign = superimposed hypo- and hyperechoic rings of edematous bowel and compressed mucosal layers

  25. What is crescent sign? • Please show it in the imaging below….

  26. Air Enema vs Contrast Enema • PROS • Inert • Rapid • Less radiation • Air perforation better than contrast perforation • Easier to administer • CONS • May miss the lead point • Poorer visualisation

  27. Absolute contraindication???

  28. Case Presentation 3 • 6 yo male presents with diffuse abdo pain, decreased appetite, fever, vomiting, increased pain with motion • T38 HR 120 bp 108/58 RR22 • In moderate discomfort • Abdo exam revealed tenderness over periumbilical pain with rebound tenderness • Differential diagnosis?

  29. Appendicitis • Most common etiology for surgical abdomen in children • Third leading cause of pediatric hospitalisation • Incidence 4 cases per 1000 children • Male to female ratio 2:1

  30. Appendicitis • Mortality in children 0.1-1% • False positive rate 15-20% • Perforation rate 15-40% in younger children due to delayed in diagnosis • In younger children <5 yo, ,perforation rate 50-85% • Morbidity in children treated with appendicitis results either from late diagnosis or negative appendectomy

  31. Pathophysiology • Blockage of lumen with stool, barium, food or parasites • Swollen lymph glands • Hyperplastic lymphoid tissue • Edematous appendical mucosa • Increase intraluminal pressure • Persistence inflammation • Exudate drainage

  32. Pathophysiology (con’t) • Exudate touches parietal peritoneum • Pain (diffuse) • Fecal bacteria grown within the obstructing material • Worsening inflammation response • Further increase intraluminal pressure • perforation

  33. Pathophysiology (con’t) • Peritonitis develops • In adult, the omentum can wall off inflamed or perforated appendix • In child, less well developed omentum, hence decrease the ability to wall off perforation • More likely to have peritonitis • Severe blunt abdo trauma

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