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Clinical Pathological
Conference
2004-12-29
三軍總醫院 小兒科部
劉家宏/華一鳴
Case Presentation
Present Illness
This one-year-six-month-old boy came to our
pediatric emergency department with the
chief compliant of bilious vomiting and
intermittent irritable crying since 4 hours
ago.
Case Presentation
Personal and Family History
Past history:
Before this presentation,the child was in
good condition without any compliant of
abdominal symptoms.
Case Presentation
Physical Examination
Vital sign: PR: ↑ 136 /min (70-110),
RR: 20 /min(20-30), BT: 35.7 ºC
BP: ↑ 112/70(90-105,50-70),
decreased urine output.
HEENT: dehydration with dry lip.
Abdomen : soft, neither sign of peritonitis
nor hepatosplenomegaly .
Case Presentation
Radiologic & Lab Findings
Plain film of abdomen : showed a nonspecific
local ileus pattern over right upper quadrant.
Laboratory data:
white blood count: ↑ 25300/nl (6000-17500/nl)
with 75% segment(54-62%) and
18% lymphocyte(25-33%).
Case Presentation
Radiologic & Lab Findings
Serum 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.
Case Presentation
Radiologic & Lab Findings
Abdomen sonography :revealed a soft
tissue mass over right lower quadrant,
but no evidence of sign of target
appearance; besides, the relationship of
superior mesentery artery and superior
mesentery vein was in right position.
Case Presentation
Hospital Course-I
Under the impression of intestinal
obstruction, he was admitted to our
pediatric department for further
evaluation and management.
After admission, this patient had
persistent bilious vomiting.
Case Presentation
Hospital Course-II
Twelve hours later, heart rate increased to
150-180 per minutes.
Meanwhile, decreased urine output and
downhilled blood pressure happened to him
despite of intravenous fluid supplement.
Under the impression of intestinal obstruction
complicated with shock, our pediatric surgeon
arranged emergency laparotomy.
Case Presentation
Hospital Course-II
Post-operative course was relative
smooth,and started feeding on the 4th
day of lapatotomy smoothly.
His condition was stable during the
follow-up period at our out patient
clinics.
Major Problems
Bilious vomiting
A soft tissue mass
over right lower
quadrant
Downhilled blood
pressure(shock)
Minor Problems
Intermittent irritable
crying
Decreased urine
output
Leukocytosis
Hyperchloremia
Local ileus pattern
over right upper
quadrant
Tachycardia
Hypertension
Questions –about 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?
Questions- about Physical
Examination and laboratory data
Anemic conjunctiva? Lymphoadenopathy?
RLQ soft tissue mass movable or nonmovable?
Bowel sound? Hyperactive to be replaced
with hypoactive bowel sounds?
Stool rontine examination? occult blood?
WBC? pattern?
Blood smear? blast cell?
Questions-about radiologic finding
Plain film of abdomen :further finding?
Foreign body/Bezoars?
Abdomen Sonography: further finding?
Appendix? Ascites?Kidney? Any finding
about tumor?
Bilious vomiting
Vomitus or nasogastric aspirate containing
bile which in children almost always
indicates bowel obstruction distal to the
sphincter of Oddi.
By contrast, infants with pyloric stenosis
have non-bile-stained vomiting.
Intestinal obstruction
Intraluminal :polyp, mass, parasites,
and tumor.
Intramural :stricture, tumor,
hematoma.
Extrinsic:postoperative adhesion,
adhesion from peritonitis, hernia,
volvulus,and tumor.
Clinical Classification of Shock
Septic shock :bacterial,Viral,Fugal..
Cardiogenic shock : ischemia,
cardiomyopathy ,congestive heart failure
Distributive shock:toxins,anaphylaxis…
Hypovolemic shock :enteritis,hemorrhage,
Obstructive shock :tension pneumothroax
Hyperchloremia
Pathophysiology
Metabolic Acidosis with a normal Anion Gap
Causes
Artifact (low Anion Gap)
Metabolic and Endocrine
Hyperparathyroidism, Renal Tubular Acidosis,
Hypernatremia.
Bromide intoxication
Nervine, Sominex
Acetazolamide
Carbonic anhydrase inhibition
Boric acid , Triamterene ,Ammonium Chloride
Excess IV Normal Saline
Hyperchloremia
Gastrointestinal
Dehydration
Prolonged Diarrhea
Loss of pancreatic secretion
Ileal loops
Ureteral colonic anastomosis
(From: Pediatric
Decision-making
Strategies
accompanied by
Nelson)
Acute
Yes
Surgery
Consult
Signs or
symptoms
suggestive
of an
acute
abdomen
History and
physical exam
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 hematoma
Testicular or ovarian torsion
Vomiting
No
Chronic
Sign or
symptoms
suggestive
of increased ICP?
Sign or symptoms suggestive
of increased ICP
Yes
No
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
(From: Pediatric Decision-making
Strategies accompanied by Nelson)
Yes
Abdomen
US
Yes
No
History and
physical exam
Neonate?
No
Abdomen
mass
Hepatomegaly
or
splenomegaly
present
Lower
abdomen
mass in
female
Abnormal
result
Perform
abdomen US
Normal result
No
Yes
Perform
Abdomen CT
Not neonate ,
Not female with lower abdomen mass
Splenomegaly Wilms tumor
Adrenal cortical neoplasms
Pancreatic masses/cysts
Neuroblastoma Hydronephrosis
Rhabdomyosarcoma
Urinary retention Hepatic lesion
Teratoma Bezoar
Appendiceal abscess Intestinal tumor
Mesenteric cyst Omental cyst
Lymphangioma Lymphoma
Choledochal cyst Constipation
Inflammatory bowel disease
Retroperitoneal hematoma
Foreign body/Bezoars
Meckels diverticulum
Hirschsprungs disease
Appendicitis
Intestinal tumor
Neuroblastoma
Rhabdomyosarcoma
Lymphoma
Congenital structural abnormalities
Foreign body/Bezoars (bezôr)
An accumulation of exogenous matter in
the stomach or intestine.
peak incidence between the ages of 6 mo
and 3 yr
90% of foreign bodies are opaque.
vomiting, anorexia, and weight loss.
An abdominal plain film may suggest
the presence of a bezoar, which can be
confirmed on ultrasound or CT
examination.
Gastric trichobezoar
Pediatric Emergency Care. 19(5):343-7, 2003 Oct.
On plain abdominal radiographs, the
bezoar will appear as a mottled
heterogenous mass that may be mistaken
for a food-filled stomach.
The classic sonographic appearance is
described as a band of increased
echogenicity in the region of the stomach
with complete loss of posterior echoes.
Small bowel obstruction and covered
perforation in childhood caused by bizarre
bezoars and foreign bodies.
Small bowel obstruction with
perforation is an unusual and rare
complication of bezoars.
Israel Medical Association Journal: Imaj. 2(2):129-31, 2000 Feb.
Hirschsprungs disease
Abnormal innervation of the bowel .
Most common cause of lower intestinal
obstruction in neonates .
Usually begin at birth with the delayed passage
of meconium.
Some infants pass meconium normally but
subsequently present with a history of chronic
constipation.
Hirschsprungs disease
Failure to thrive, with hypoproteinemia
from a protein-losing enteropathy, is a less
common presentation.
Rectal examination demonstrates normal
anal tone and is usually followed by an
explosive discharge of foul-smelling
feces and gas.
Hirschsprungs disease
Rectal manometry and rectal suction biopsy
are the easiest and most reliable indicators of
Hirschsprung disease.
Barium enema examination is useful in
determining the extent of aganglionosis.
Sonography may also help in determining the
dynamic or adynamic state of fluid-filled or
solid-filled bowel loops.
Meckels diverticulum
Remnant of the embryonic yolk sac
Arise within the 1st 2 yr of life .
Intermittent painless rectal
bleeding by ulceration of the
adjacent normal ileal mucosa.
Meckels diverticulum
Brick colored or currant jelly colored.
Obstruction occurs when the diverticulum
acts as the lead point of an intussusception.
A Meckel diverticulum may occasionally
become inflamed (diverticulitis) and present
similarly to acute appendicitis.
The most sensitive study is a Meckel
radionuclide scan
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
diverticulum or an internal hernia.
Clinical Nuclear Medicine. 21(12):938-40, 1996 Dec.
Meckel's diverticulum mimicking infantile colic:
sonographic detection.
Abdominal sonography at 6 months of age
demonstrated an abdominal mass with an
anechoic center and a double-layered wall,
surrounded by bowel loops.
Histologic examination of the resected mass
revealed a Meckel's diverticulum with a
perforation sealed off by the neighboring bowel
and mesentery to form an inflammatory mass.
Journal of Clinical Ultrasound. 28(6):314-6, 2000 Jul-Aug
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
gastrointestinal bleeding in almost
any age group and require a high
index of suspicion for diagnosis.
Appendicitis
The risk of perforation is greatest in 1- to 4yr-old children (70–75%) and is lowest in
the adolescent age group (30–40%) .
The classic triad consists of pain, nausea
with vomiting, and fever.
The progression from onset of symptoms to
perforation usually occurs over 36–48hr.
Appendicitis
History included onset of pain before
vomiting or diarrhea, loss of appetite,
migration of pain from periumbilical to
right lower quadrant.
Auscultation may reveal normal or
hyperactive bowel sounds in early
appendicitis, to be replaced with
hypoactive bowel sounds as it progresses
to perforation.
Appendicitis
Findings of appendicitis on abdominal films
include calcified appendicolith, small bowel
distention or obstruction, and soft tissue mass
effect.
Graded compression ultrasonography is a
noninvasive study with false-negative and falsepositive rates of 8–10% .
CT is more sensitive and specific than
ultrasonography and more likely to change
patient management.
Pediatric appendicitis in "real-time": the value of
sonography in diagnosis and treatment.
Pediatric Emergency Care. 17(5):334-40, 2001 Oct.
The natural progression in appendicitis
from initial symptoms to perforation is
about 36 to 48 hours . However,
perforation may occur more rapidly in the
younger child, sometimes within 6 to 12
hours .
Extensive necrosis of the appendix may
render it difficult to visualize .
Pediatric appendicitis in "real-time": the value of
sonography in diagnosis and treatment.
Pediatric Emergency Care. 17(5):334-40, 2001 Oct.
We may have to rely on the other
ultrasound features of “peri-appendiceal
inflammation.”
Studies have shown that the presence of
loculated pericecal fluid, prominent
pericecal fat, atonic bowel loops, thickened
bowel walls, and the circumferential loss
of the appendiceal submucosal layer on
ultrasound were the significant predictive
factors for perforation .
Distal Intestinal Obstruction Syndrome
In the older child or young adult with CF,
the distal small bowel may by obstructed
by thick stool. This condition was called
"meconium ileus equivalent" by Jensen in
1962 .
Palpable mass in the right lower abdominal
quadrant. Bilious vomiting as a result of
the intestinal obstruction
Distal Intestinal Obstruction Syndrome
Radiographs of the abdomen
demonstrate dilated small bowel
loops and a bubbly ileocecal softtissue mass .
Carcinoid tumor
About 85% of carcinoid tumors develop in the
gastrointestinal tract, usually the appendix.
Carcinoid syndrome:flushing,diarrhea,
wheezing.
Carcinoid crisis:generalized flush, tachycardia,
severe diarrhea with abdominal pain,
hypotension converting to hypertension, and
central nervous system changes leading to
coma and then death.
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, frequently
causing partial small bowel obstruction.
Carcinoid tumor
On CT, the mesenteric extension from
carcinoid will usually appear as a soft
tissue-density mesenteric mass .
Calcification can be seen in up to 70% of
cases .
Lymphoma
from manual of pediatric hematology and oncology ,3rd edition
Non-Hodgkins lymphoma:
peak age 5-15 years ,rick factor including
genetic and poettransplantation
immunosuppression.
Clinical feature:Head and neck(13%),
medicatinum(26%),abdomen(35%).
Non-Hodgkins lymphoma
The ileum is mostly involved due to a
higher number of lymphocytes in the distal
gut, accounting for about 50% of small
bowel lymphomas
Present with abdomen pain, vomiting and
diarrhea, abdominal distension, palpable
mass, intussusception,peritonitis, ascites,
GI bleeding, hepatosplenomegaly.
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 to
intussusception, but rarely will result in
obstruction because the masses are typically
pliable and soft.
Again, because the masses are characteristically
soft, it is rare that the mesenteric vasculature is
compromised.
Journal of Computer Assisted Tomography. 28(1):106-16, 2004 Jan-Feb.
Neuroblastoma
from manual of pediatric hematology and oncology,3rd edition
Give rise to adrenal medulla and the
sympathetic ganglia.
Most common tumor in infancy ,peak
incidence is 2 years of age
Clinical finding related to anatomic site of
abdomen :anorexia ,vomiting,abdomen
pain,massive involvement of the liver with
metastasis (especially in the newborn)
Neuroblastoma
Paraneoplastic manifestations :
excessive catecholamine secretion
(sweating,flushing, paller,palpitation,
hypertension) ,VIP secretion (watery
diarrhea,abdomen distension,
hypokalemia) ,and acute myoclonic
encephalopathy.
Neuroblastoma
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging,
4th ed.,
A neuroblastoma is usually solid with a
heterogeneous echotexture. Calcification is
evident by the presence of echogenic foci
with posterior acoustic shadowing.
Anterior displacement and encasement of
the aorta and inferior vena cava (IVC) by
this retroperitoneal tumour is characteristic.
Rhabdomyosarcoma
from manual of pediatric hematology and
oncology,3rdedition
Two age peaks:2-6 years and 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 bile
duct and may extend into both lobes of the
liver.
Final diagnosis
1.Meckels diverticulum with
diverticulitis or congenital structural
abnormalities
2.Ruptured Appendicitis
THANK YOU!!
Mesenteric cyst / Omental cyst
They ranged in age from 1 month to 14
years; 75% were younger than 5 years.
The main presenting symptom is abdominal
pain, followed by nausea and vomiting.
Some mesenteric cysts may present as an
acute abdomen due to a possible
complication, such as hemorrhage, rupture,
or torsion of the cyst.
Mesenteric cyst / Omental cyst
Mesenteric cysts in children Surgery 1994;115:571-7
Acute symptoms are related to compression
of intra-abdominal organs or stretching of
the mesentery by rapid expansion.
Among these categories, the cystic
lymphangioma is differentiated from the
others because it is far more common in
children.
Lymphangioma
Five pathologic patterns account for most
mesenteric cysts, namely, lymphangioma,
enteric duplication cysts, enteric cysts,
mesothelial, and nonpancreatic
pseudocysts.
溴化物中毒之神經精神異常表現
陳建良、劉義聰、蔡瑞安、林自強
溴化物離子在各種膜性傳導系統上,可取代氯離子,特別是在
神經系統,高濃度的溴化物,膜性抑制作用會逐漸損害神經元
的傳導。
長期服用含有溴化物藥劑,可能造成慢性溴化物中毒,而表現
出各式各樣神經精神異狀如意識混亂、躁動、頭暈、步態不穩、
運動失調、視力模糊、視野缺損、嗅覺障礙、短期記憶力障礙、
幻想、幻覺、麻木等週邊神經病變。
一般認為血中溴化物濃度超過50 mg/dl(6.3 mEq/l)將產生一些
神經和精神症狀,實驗室檢查發現除了溴化物濃度過高以外亦
可發現血氯偏高及負陰離子間隙。
我們報告一病例因長期服用感冒糖漿造成溴化物中毒,臨床表
現出胸痛,呼吸急促與焦躁不安等症狀,起初血液檢查顯示出
高血氯,負陰離子間隙,因而聯想到溴化物中毒,經測血中溴
化物濃度高達164 mg/dl (正常值<50 mg/dl) 。住院後給予
靜脈輸液利尿治療,一週後胸悶、胸痛、焦躁不安等症狀完全
改善。(臨床醫學 2004; 54: 189-93)
2003.12.27 【林杰樑(林口長庚
醫院臨床毒物科主任)】
《透視食品添加物》硼砂 增加食品彈性口感 新聞來源:
硼砂主要是在食品品質改良的應用。它增加食品的韌性、
彈性、保水性以及保存性。防止蝦頭的黑變,使蝦有好
的賣相;魚丸、年糕、油條、鹼粽…等,較常見的則是
在油麵的製程中添加,使食品的口感、脆感、保鮮等用
途,已被禁止使用。
硼砂進入體內後,經胃酸作用,轉變為硼酸(Boric
acid),會影響消化酵素作用。
可能引起食慾減退,消化不良,抑制營養素之吸收。
硼酸中毒症狀為嘔吐、腹瀉、紅斑、循環係統障礙、休
克及昏迷等硼酸症徵狀,而且有致死量,大人約20公克、
小孩約為5公克。
Leiomyoma of the small bowel with hypercalcaemia:
presence of a substance with parathormone activity
Nouvelle Presse Medicale. 8(40):3245-6, 1979 Oct 22.
A leiomyoma of the small bowel produced
laboratory features of hyperparathyroidism which
disappeared promptly after tumour resection.
Hypercalcaemia, hypophosphatemia,
hyperchloremia, elevated chloride/phosphorus
ratio, increased urinary cyclic AMP, and blood
levels of immunoreactive parathormone were
present.
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 that
hemophilia and anticoagulant therapy may
be the cause in some cases.
Retroperitoneal hematoma
These patients usually present with mild to
severe abdominal pain, nausea and
vomiting.
Physical examination reveals signs of
shock, ileus and flank mass.
CT scans are used usually to establish the
diagnosis of retroperitoneal hematoma.
Dehydration
Hypertension
Leukocytosis
Hyperchloremia
Bilious vomiting
intermittent irritable
crying
one-year-six
month-old boy
Soft tissue mass
over RLQ by
Abdomen sonography
Decreased urine output
and downhill BP
in 16 hours
Wilms tumor
It may be associated with hemihypertrophy,
aniridia, and other congenital anomalies,
usually of the genitourinary tract.
Sign of Wilms tumor:palpable mass in
abdomen (60%),hypertension (25%),
hematuria(15%),abdomen mass is the most
common presenting symptom and
sign ,occasionally there is abdomen
pain,especially when hemorrhage occurs in
the tumor following trauma.
Wilms tumor
Some patients may present with
abdominal pain and vomiting and,
infrequently, hematuria.
Occasionally, rapid abdominal
enlargement and anemia may occur
owing to bleeding into the renal
parenchyma or pelvis.
Wilms tumor
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging,
4th ed.,
On ultrasound examination the tumour
appears as a well-defined, solid mass of
mixed echogenicity.Areas of haemorrhage
and necrosis can produce focal hypoechoic
lesions within the mass.
Ultrasound may be used for periodic
surveillance of the opposite kidney.
Superior mesenteric artery syndrome
The classic example is an adolescent who
starts vomiting after application of a body cast
for orthopedic surgery. Other associated
factors include anorexia, prolonged bed rest,
weight loss, abdominal surgery, and
exaggerated lumbar lordosis.
The diagnosis is established radiologically
with the demonstration of a cutoff of the
duodenum just to the right of the midline.
Superior mesenteric artery syndrome
An extrinsic compression of the duodenum
in children after rapid weight loss and in a
supine position.
The compression is thought to occur as the
mesentery loses its fat and allows the
superior mesenteric artery to collapse on the
duodenum, compressing it between the
superior mesenteric artery anteriorly and the
aorta posteriorly.
Inflammatory bowel disease
The most common time of onset of IBD is
during adolescence and young adulthood. A
bimodal distribution has been shown with an
early onset at 15–25 yr of age and a second
smaller peak at 50–80 yr of age.
Nonetheless, IBD may begin as early as the
1st yr of life.
In developed countries, these disorders are the
major causes of chronic intestinal
inflammation in children beyond the 1st few
yr of life.
Ulcerative colitis
Bloody stool and diarrhea are 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.
Ulcerative colitis
Extraintestinal manifestations that
tend to occur more commonly with
ulcerative colitis than with Crohn
disease include pyoderma gangrenosum,
sclerosing cholangitis, chronic active
hepatitis, and ankylosing spondylitis.
Crohns disease
Crohn colitis may be associated with
bloody diarrhea, tenesmus, and urgency.
Children with Crohn disease often appear
chronically ill, weight loss linear growth
retardation.
Crohns disease
The initial presentation most commonly
involves ileum and colon (ileocolitis) but
may involve the small bowel alone in
about 30% or colon alone in 10%–15%.
Children with ileocolitis typically have
cramping, abdominal pain, and
diarrhea, sometimes with blood. Ileitis
may present as right lower quadrant
abdominal pain alone.
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).
Crohns disease
Plain films of the abdomen may be normal
or may demonstrate findings of partial
small bowel obstruction or
thumbprinting of the colon wall.
An upper gastrointestinal contrast study
with small bowel follow-through may
show aphthous ulceration and thickened,
nodular folds as well as narrowing of the
lumen anywhere in the gastrointestinal
tract.
Duplication
Duplications can be classified into three
categories: localized duplications,
duplications associated with spinal cord
defects and vertebral malformations, and
duplications of the colon.
Duplications may cause bowel
obstruction by compressing the adjacent
intestinal lumen, or they may act as the
lead point of an intussusception or a site
for a volvulus.
If they are lined by acid-secreting mucosa,
they may cause ulceration, perforation,
and hemorrhage of the adjacent bowel.
Patients may present with abdominal pain,
vomiting, palpable mass, or acute
gastrointestinal hemorrhage.
Radiologic studies such as barium studies,
ultrasonography, CT, and MRI are helpful but
usually nonspecific, demonstrating cystic
structures or mass effects.
Radioisotope technetium scanning may localize
ectopic gastric mucosa.
The treatment of duplications is surgical
resection and management of associated defects.
Atypical presentation of an intestinal
duplication in a three month old child
Journal de Radiologie. 85(6 Pt 1):773-5, 2004 Jun.
Intestinal duplication is an uncommon
congenital anomaly that often is diagnosed during
childhood.
Ultrasound diagnosis is based on the presence of a
characteristic double-walled cystic mass.
We report a case of duplication in a three Month
old child presenting with small bowel obstruction.
Intestinal duplication presenting 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 first
year of life as a palpable abdominal
mass or as complications such as
intestinal obstruction due to extrinsic
compression, volvulus, or
intussusception.
Intestinal duplication presenting as
spontaneous hemoperitoneum.
Journal of Pediatric Gastroenterology & Nutrition.
31(2):181-2, 2000 Aug.
It was probably caused by erosion of
a blood vessel adjacent to the
perforation that had been sealed off at
laparotomy.
Sudden infant death, large intestinal
volvulus, and a duplication cyst 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.
Jejunal and Ileal Atresia and
Obstruction
Jejunoileal atresias have been
attributed to intrauterine vascular
accidents leading to ischemic
necrosis of the sterile bowel and
resorption of the affected segments.
Most infants become symptomatic
during the 1st day of life with
abdominal distention and bilestained emesis or gastric aspirate.
Plain radiographs demonstrate many airfluid levels or peritoneal calcification
associated with meconium peritonitis.
In meconium ileus, plain films of the
abdomen show a typical hazy or groundglass appearance in the right lower
quadrant.
Pneumoperitoneum is most readily seen
as free air between the liver and the
diaphragm on an upright radiograph of the
abdomen; 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.
Malrotation
Incomplete rotation of the intestine during fetal
development
The majority of patients present within the 1st yr
of life with symptoms of acute or chronic
obstruction. Infants often present within the 1st
wk of life with bilious emesis and acute bowel
obstruction.
An acute presentation of small bowel obstruction
in a patient without previous bowel surgery is
usually a result of volvulus associated with
malrotation.
The abdominal plain film is usually nonspecific
but may demonstrate evidence of duodenal
obstruction with a double-bubble sign.
Barium enema usually demonstrates malposition
of the cecum but may be normal in 10% of
patients.
Upper gastrointestinal series demonstrates
malposition of the ligament of Treitz.
Ultrasonography demonstrates inversion
of the superior mesenteric artery and
vein. A superior mesenteric vein located to
the left of the superior mesenteric artery is
suggestive of malrotation.
Surgical intervention is recommended for
any patient with a significant rotational
abnormality, regardless of age.
Intussception
A portion of the alimentary tract is telescoped into
an adjacent segment.
The most common cause of intestinal
obstruction between 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 is
rare in neonates. The male:female ratio is 4:1.
Most intussusceptions do not strangulate the
bowel within the first 24hr but may later
eventuate in intestinal gangrene and shock.
Sudden onset, severe paroxysmal colicky pain
Vomiting occurs in most cases and is usually
more frequent early.
60% of infants pass a stool containing red blood
and mucus, the currant jelly stool.
Tender sausage-shaped mass, which may
increase in size and firmness during a paroxysm
of pain and is most often in the right upper
abdomen, with its long axis cephalocaudal.
Plain abdominal radiographs may show a density
in the area of the intussusception.
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 teratoma
Adrenal hemarrhage Mesoblastic nephroma
Pancreatic cyst Hepatoblastoma
Meconium ileus Hematoma(hepatic,splenic)
Magacolon(obstruction)
Anterior myelomenihgocele
Appendiceal abscess Intestinal tumor
Mesenteric / Omental cyst Choledochal cyst
Neuroblastoma
Congenital Hydronephrosis
Multiple cystic kidney
Infantile polycystic kindey disease
Neurogenic bladder
Renal vein thrombosis
Collecting system duplication
Intestinal duplication
Sacrococcygeal teratoma
Adrenal hemarrhage
Mesoblastic nephroma
Pancreatic cyst
Hepatoblastoma
Meconium ileus
Hematoma(hepatic,splenic)
Magacolon(obstruction)
Anterior myelomenihgocele
Appendiceal abscess Intestinal tumor
Renal Vein Thrombosis
In newborns and infants, RVT is commonly
associated with asphyxia, dehydration,
shock, sepsis, and infants born to mothers
with diabetes mellitus.
Sudden onset of gross hematuria and
unilateral or bilateral flank masses,
microscopic hematuria, flank pain,
hypertension, or oliguria.
Renal Vein Thrombosis
RVT is usually unilateral. Bilateral RVT
results in acute renal failure. Most patients
also have a microangiopathic hemolytic
anemia and thrombocytopenia.
Ultrasonography shows marked
enlargement, whereas radionuclide studies
reveal little or no renal function in the
affected kidney(s).
Doppler flow studies of the inferior vena
cava and renal vein confirm the diagnosis.
The advent of technetium (Tc) 99m
pertechnetate radionuclide scanning has
greatly facilitated the diagnosis of
Meckel's diverticula and may also be
useful for intestinal duplications. A
positive scan requires the presence of
ectopic gastric mucosa, which may be
identified in both Meckel's diverticula and
intestinal duplications.
The significance of ectopic gastric mucosa
is that it contains acid-secreting parietal
cells, which may cause ulceration and
bleeding. Only rarely are intestinal
duplications diagnosed preoperatively.
After initial fluid resuscitation, bleeding
from Meckel's diverticula and intestinal
duplications require surgical intervention.
Resection is the treatment of choice.
A barium enema shows a filling defect or cupping
in the head of barium where its advance is
obstructed by the intussusceptum (coiled-spring
sign) .
Ultrasonography is a sensitive diagnostic tool
in the diagnosis of intussusception.
The diagnostic findings of intussusception
include a tubular mass in longitudinal views and
a doughnut or target appearance in transverse
images .
Posttraumatic retroperitoneal rupture of the right
colon simulating a retroperitoneal hematoma.
Journal of Trauma-Injury Infection & Critical Care. 42(4):741-2, 1997 Apr.
This case illustrates the diagnostic
problems encountered in a patient with
posttraumatic retroperitoneal abscess
caused by perforation of the posterior
wall of the cecum, simulating a
retroperitoneal hematoma.
Blunt colonic injuries are rare and difficult
to diagnose. Septic signs are unexpected in
case of posttraumatic retroperitoneal
hematoma and should suggest the
diagnosis of retroperitoneal colonic
perforation.
Incarcerated inguinal hernia
An inguinal hernia appears as a bulge in the
inguinal region that extends toward and possibly
into the scrotum.
The hallmark signs of an inguinal hernia on
physical examination are a smooth, firm mass
that emerges through the external inguinal ring
lateral to the pubic tubercle and enlarges with
increased intra-abdominal pressure.
A quiet infant can be made to strain the
abdominal muscles by stretching out supine on
the bed with legs extended and arms held straight
above the head. Most infants struggle to get free,
thus increasing the intra-abdominal pressure and
pushing out the hernia.
Incarcerated inguinal hernia
The infant or child with an
incarcerated inguinal hernia is
likely to have associated findings
suggestive of intestinal obstruction
such as abdominal distention,
vomiting, and multiple air-fluid
levels evident on plain radiographs.
Wilms tumor
The incidence is approximately 8
cases/million children younger than
15 yr of age.
It usually occurs in children between
2–5 yr of age, although it has also been
encountered in neonates, adolescents,
and adults.
Neonatal intestinal perforation caused by congenital
defect of the small intestinal musculature: report
of one case.
Acta Paediatrica Taiwanica. 40(4):271-3, 1999 JulAug.
Congenital defect of the small intestinal musculature is a
rare cause of neonatal spontaneous intestinal obstruction or
perforation.
Histology examination demonstrates multifocal deficiency
of the inner circular muscle layer three cm around the
perforation site. The clinical and histological characteristics
are reviewed and discussed. We propose that the muscle
defect of small intestine, especially ileum, is secondary to
ischemic injury rather than an embryological malformation.
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