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Intestinal Obstruction in Children

Objectives
Presentation of obstruction To know different causes A brief about each cause

Duodenal Hematoma
Causes: Blunt trauma RTA Associated injuries include ----laceration to the left lobe of liver and to the pancreases Bleeding Disorders(Henoch-schonlein purpura) It can cause complete or partial obstruction

IMAGING Ba Meal ( Thickened mucosal folds, localized filling defects due to intramural hematoma) CT Abdomen (for assessment of acute trauma and hematoma directly, or for abnormal duodenal enhancement)

Enhanced CT Intramural duodenal hematoma almost completely obscuring the lumen

An abnormal portion of intestine which is attached to or intrinsic with normal bowel Incomplete recanalization at around 8wks Any where in the GIT 1/3 involve distal small bowel Types Tubular Spherical communication

DUPLICATION CYST

Presentation depends on the size and site Esp. those assoc. with stomach or \duodenum present with Abd. Pain Vomiting May act as a lead point for Intussusception GI Bleeding ( From ectopic mucosa)

Imaging
Radiography (mass effect with displacement of adjacent bowel loops) Ultrasound (simple hypoechoic cyst, Gut wall signature)

Hypoechoic cyst with double gut wall signature(inner echogenic mucosa & outer hypoechoic smooth muscle layer

Differentials -mesenteric -omental -choledochal -renal -ovarian

Mesenteric/Omental cyst(lymphangiomas)
Developmental anomalies of lymphatic system (mesentry/ omentum) Presentation -similar to duplication cyst On U/S multiloculated cyst with thin septation Tx surgical resection

Mesenteric Cyst

Meckel s Diverticulum
Persistence of prox. Vitelline duct True diverticulum From anti mesenteric border Rule of twos Complication -acute inflammation (mimicking appendicitis) -GI bleed -lead point for intussusception

Supine & prone radiographs of the upper GI barium series

Appendicitis
Peak incidence 12-15 years Presention -ill defined abd. Pain in RIF -fever and vomiting

IMAGING
Radiography May be normal or localized dilated bowel loops 5-10% radiodense appendicolith identified

Ultrasound Non compressible blind ending tubular structure approx 6mm or more Increased echogenicity of mesenteric fat Hyperemia on color Doppler Free fluid / mesenteric lymph nodes

Right iliac fossa mixed echogenicity inflammatory mass and echogenic focus with acoustic shadowing

Hypoechoic tubular structure 7mm in diameter adjacent to iliac vessels

CT findings are --localized or multi-focal abscess

Complication
Appendicolith Pelvic abcess Generalized peritonitis Portal vein thrombosis Multiple hepatic abcess ( rare)

Differential -- mesenteric adenitis --Crohns disease --Infection --ovarian torsion/cyst

HENOCH SCHONLEIN PURPERA


Small bowel vasculitis Jejunum most frequently involved Unknown etiology/postinfectious/post drug therapy Presentations with Purpuric rash over the buttocks & legs Abdominal pain glomerulonephritis

Henoch schonlein pupura Ultrasound & barium follow through

Jejunal bowel wall thickening

Complications Transient small bowel intussusception(rare) Echogenic kidney suggest renal involvement

OTHER
INFECTIONS (giardia,compylobacter,yersinia,salmonella etc) GRAFT VERSUS HOST REACTION (mostly effecting small bowel) CROHNS DISEASE (mostly effecting terminal ilium & cecum)

Polyps and polyposis syndromes


Isolated juvenile polyps Single or multiple Under 10 years of age Found in sigmoid colon and rectum Unlike adults they are hamartomas Present with painless rectal bleeding leading to iron deficiency anemia Not premalignant

Double contrast barium enema Endoscopy A pedunculated polyp with a long stalk is seen

Barium enema showing a pedunculated polyp in the descending colon

Juvenile polyposis
Positive family hx (most cases) Five or more polyps Associated with higher long term risk of colonic carcinoma

Peutz jeghers syndrome


Autosomal dominant Occur anywhere from stomach to rectum (mostly small intestine) Associated with mucocutaneous pigmentation and GI hamartomas Small bowl follow through -multiple filling defects

Complications Intussusception around polyps(usually transient) Small bowel obstruction Gastrointestinal adenocarcinoma & non GI neoplasm involving pancreas, breast or reproductive organs

Familial polyposis coli Gardner syndrome Both are dominanly inherited Multiple adenomatous polyps are found (numerous in colon) High malignant potential Prophylactic proctocolectomy usually recommended

TURCOTS SYNDROME
Autosomal recessive condition Colonic adenomas associated with CNS glioma

Small bowel malignancies


Burkit type non Hodgkin lymphoma Mostly involve Ileocecal region Male predominance Peak incidence 5-8yrs Presenting symptoms are Abdominal pain Palpable mass Failure to thrive

ULTRASOUND Thickened hypoechoic bowel loops are seen often forming adherent masses with infiltration of adjacent omentum & mesentery Hepatospenomegaly Retroperitoneal lymphadenopathy

CAUSES OF COLITIS IN CHILDHOOD


INFECTIOUS
(compylobacter,E.coli,salmonella,shigella etc)

INFLAMMATORY BOWEL DISEASE TYPHILITIS HEAMOLYTIC URAEMIC SYNDROME PSEUDOMEMBRANOUS COLITIS GRAFT VERSUS HOST REACTIONS ISCHAEMIC COLITS IRRADIATION COLITIS

CROHNS DISEASE
Involve any part of GIT from mouth to anus (usually sparing the rectum) Prepubertal child or adolescent are effected Extraintestinal features more prominent weight loss anorexia short stature Delayed puberty

GI SYMPTOMS Diarrhoea Abdominal pain

IMAGING
ENDOSCOPY BARIUM ENEMA(largely replaced by endoscopy) aphthoid ulceration mucosal ulceration is deep, discontinuous & asymmetrical generally have thicker colon than ulcerative colitis LEUCOCYTE SCINTOGRAPHY(extent of disease)

CT SCAN transmural bowel wall thickening creeping fat within the mesentery strictures fistulas localised collection MRI assessment of disease extent

Innumerable aphthoid ulcer in crohns disease

Enema in crohns disease showing extensive cobblestoning due to linear ulceration &mucosal edema. Rectum is spared

ULCERATIVE COLITIS
Relapsing and remitting proctits Rectum is always effected Effects young adults(15-25yrs) with second smaller peak at approx 60yrs

CLINICAL FINDING bloody diarrhoea abdominal pain failure to thrive

IMAGING
Double contrast barium enema Proctosigmoidoscopy loss of normal mucosal vascular pattern (earliest detectable change) ulceration is continuous & superficial (deep ulceration does occur) haustral blunting

Luminal narrowing Colonic shortening(due to muscular abnormality rather than fibrosis) CT SCAN not for primary diagnosis once toxic megacolon is established

Double contrast barium enema shows granular mucosa (changes of early disease)

Complication Risk of colonic ca is high approx 20% per decade toxic megacolon

TYPHILITIS
Inflammatory condition Predominantly effects right colon in neutropenic patients ON ULTRASOUND Thickened hypoechoic cecum and ascending colon Echogenic mucosa and hyperaemia

CT SCAN -shows bowel wall thickening

Bowel wall thickening & fat stranding

HAEMOLYTIC URAEMIC SYNDROME


Commonest cause of acute renal failure in children Diarrheal illness caused by E.coli leading to Microangiopathic anemia Thrombocytopenia and acute renal failure

IMAGING
Ultrasound Association of colonic thickening &echogenic kidneys is highly suggestive of diagnosis Doppler flow within the bowel wall is reduced (atleast in prodromal phase)

INTUSSUSCEPTION
Invagination of a segment of bowel(the intussusceptum) into the contiguous segment(the intussuscipiens) Site Ileocolic(approx 90% cases) Ileoileocolic,colocolic,ileoileal

Peak age incidence 6 months to 2yrs

Classic presentation Episodic abdominal pain Screaming episodes associated with passage of blood & mucus(current jelly) Haemodynamic instability due to considerable fluid shift

IMAGING
Abdominal radiograph Absence of bowel gas in the right iliac fossa with rounded soft tissue mass A crescent of air at the apex of intussusception Or small bowl obstruction Ultrasound(highly sensitive) a mass with multiple hyperechoic concentric rings

Paucity of bowel gas in the right iliac fossa and soft tissue mass

Transverse ultrasound showing multiple hypoechoic concentric rings, central echogenic mesentery and few small echogenic lymph nodes

Small crescents of peritoneal fluid may be trapped b/w the layers of intussusception Colour flow with in the mass suggests bowel viability Small lymph nodes are frequently found within the intussusception

TREATMENT
RADILOLOGICAL REDUCTION Absolute contraindications are peritonitis and perforation PNEUMATIC REDUCTION(air enema) Replaced the barium in most paediatric centres(7090% success rate)

THANKS

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