An unusual cause of colic

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An unusual cause of colic

• Dr Yasser Negm
• SpR of Paediatric Gastroenterology
• Great Ormond Street Hospital

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E L

• Female
• DOB 22.11.02
• Ethnic origin White British
• Healthy parents
• Born - At full term
• - Normal delivery
• - No antenatal events
• - Birth weight 3.9 Kg
• - Passed meconium within 24 hours

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Symptoms

• Started since birth.
• Persistent discomfort during feeding.
• Frequent vomiting.
• Frequent foul smelling loose stools.
• Breast feeding stopped at the age of 1 week.
• Cows milk formula
• Soya milk
• No improvement

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• Paediatrician at the age of 3 months.
• Pepti junior
• Neocate
• Normal stools, no vomiting
• Night only 4 20 times
• Screaming
• Arching

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• Normal examination
• Normal development
• Normal growth

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• At 5 months Started on Ranitidine, Domperidone
  Omeprazole
• No
  improvement
• PH study couldnt be completed
• Barium study Normal
• 
  
  

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• Admitted for assessment Continues to scream at
  night only, behaving like breath-holding
• ENT Normal
  
• 
  
• Midazolam
  Referrral

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Any further investigations/ Treatment at DGH
level
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Differential diagnosis
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GOSH11/20031 year old

• Still satisfactory growth
• Normal examination
• Initial management
• - Dietary
  changes
• - Dose timing
  changes
• -
  Immunoglobulins and subclasses
• - SIgE for food
  screen

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Tissue transglutaminase antibodies NEGATIVE
Total IgE 23.4
kU/L 0 - 32
EGG WHITE
lt0.35 COW'S MILK
lt0.35 WHEAT
lt0.35 SOYA BEAN
lt0.35
IgG 10.80
G/L 4.9 - 16.1 IgA 1.32
G/L 0.4 - 2.0 IgM 1.15
G/L 0.5 - 2.0
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Investigations

• Endoscopy Mild chronic gastritis, duodenitis
• Upper GI series Gastro-oesophageal reflux
  (GORD), no malrotation
• PH study GORD
• EGG (Electrogastrogram)
• Suggestive of atopy

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11/20042 years old

• Still no improvement (Even worse during daytime)
  in spite of
• Dietary exclusions
• Increasing doses of Domperidone, Ranitidine
  Omeprazole/Lansoprazole to maximum.
• Trials of Sulphasalazine, Cromoglycate,
  Cetirizine, Ketotifen even steroids (Possible
  colitis)
• Described as picky eater, but still excellent
  growth
• ( 91st centile for both wt. ht.)
• Dry cough for 3 days/4-6 weeks (Reflux??)

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11/20053 years old

• Parents completely exhausted Waking up 10-20
  times/night
• Tried on Cisipride, Dicyclomine
• New PH study, milk scan, abdominal U/S Normal
• Repeat endoscopy Inactive mild gastritis
• Allergy clinic Supported diagnosis of allergic
  enterocolitis, exclusion of wheat/dairy/egg/soya
  and same medications

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Any ideas????!!!!
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11/20064 years old

• Another PH study Normal
• Mebeverine, peppermint oil
• Barium follow-through
• - Position of the caecum?
• Discussed in x-ray meeting Probably
  mobile

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11/20075 years old

• Symptoms get worse when eats wheat moaning,
  tossing turning in bed
• Montelukast added
• A trial of Metronidazole
• Urine for Bacterial overgrowth

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Urine test for bacterial overgrowth

• D-lactic acid levels differentiate bacterial
  overgrowth syndrome from other metabolic causes.
• The D isomer of arabinitol is elevated in
  patients with invasive candidiasis
• P-Hydroxybenzoate, p-Hydroxyphenylacetate and
  Tricarballylate are produced by microbial action
  on tyrosine and phenylalanine and are markers of
  bacterial growth in the gut.
• Pizzorno and Murray, Organic Compounds in Urine -
  Natural Medicine (1998), Churchill Livingstone,
  London

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Surgical referral

• Surgical cause of abdominal pain??
• Differential diagnosis of volvulus
• hernia
• 
  Meckels
• 
  ovarian
• 
  gallbladder
• 
  appendix

27/09/2019
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Laparoscopy
27/09/2019
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Laparoscopic Caecopexy
27/09/2019
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11/20086 years old

• 3 months post-op
• Pain disappeared completely
• Good energy levels
• Regular school attendance
• Still wakes once or twice/night
• Funny taste in her mouth

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SL

• Female
• DOB 11.10.06
• First week of life - Screaming
• - Agitation
• - Abdominal
  distension
• - Vomiting
• - Loose stools
• Growing well
• Treated as GORD, food allergy

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Investigations

• PH study 5 GORD
• Barium follow-through
• - No delay in gastric emptying
• - DJ flexure in midline
• - Small bowel predominantly on the right
• Normal endoscopy

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Surgical referral

• Sibling
• Upper GI contrast DJ flexure in midline
• Caecum in right iliac fossa
• Proceeded to laparoscopy

27/09/2019
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Laparoscopic Caecopexy
27/09/2019
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• The caecum is a section of the intestinal tract.
  It lies at the junction of the small and the
  large intestines and is the origin of the
  appendix.

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Congenital abnormalities of caecal fixation

• Adhesions
• Mobile caecum syndrome

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Congenital caecal adhesions/peritoneal bands

• May cause chronic intermittent abdominal pain,
  especially if associated with mobile caecum
• Many authors have described this association
  
• A nodal point
• Twist
• Volvulus

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ELBarium follow-through
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SLBarium follow-through
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Mobile Caecum Syndrome (MCS)

• Abdominal pain due to improper attachment/detachme
  nt of the caecum to the rest of the bowel.
• It is not clear what degree of detachment is
  enough to cause symptoms.
• Can cause volvulus of the caecum which is
  uncommon but serious and is distinct from MCS.

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Embryological origin of mobile caecum

• An anatomic variation due to failure of right
  colon fusion with lateral peritoneum at 12 weeks
  of gestation.
• It affords the opportunity for free partial
  rotation of the caecum or folding upon itself.
• As a result intermittent intestinal
  sub
• obstruction
• or volvulus
  (complete torsion)
• Tirol FT. Recurrent cecocolic torsion Phantom
  Tumor. Abdm Surg 1999, Fall20-24

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Epidemiology of mobile caecum

• More commonly found in children
• (Incidentally during appendicectomy)
• More commonly found in females
• (Especially during pregnancy)
• 10-15 of population in one study
• More common in African and Asian ethnic groups
• (Mcgraw JP et al. The Roentgen diagnosis of
  volvulus of the cecum. Surgery 194824 793-804

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Presentation

• Chronic abdominal pain (Right lower quadrant,
  commonly postprandial)
• Constipation/diarrhea
• Very similar to irritable bowel syndrome (IBS).
• Usually in an adult multipara female from a
  tropical ethnic background

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Caecal volvulus

• Axial twist of the bowel upon its mesentery.
• Misnomer as the terminal ileum and ascending
  colon are usually involved.
• (Frimann-Dahl J. Volvulus of the right colon Acta
  Radiol (Stockh), 195441141- 155)
• Results in acute intestinal obstruction.
• May or may not be complicated by occlusion of the
  mesenteric vessels
• Ischaemia
• First described by Rokitansky in 1837

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Baron Carl von Rokitansky

• 19 February 1804 23 July 1878
• A Bohemian physician, pathologist,
• humanist philosopher and liberal politician
• First to describe Superior mesenteric artery
  syndrome
• Warned against the abuse of "natural science
  liberties". Scientists should first regard humans
  as "conscious and free-willing subjects" and only
  then follow their urge toward knowledge.

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Caecal volvulus

• Extremely rare in children, more common in adults
  
• Sex predilection variable in literature, but most
  report male predominance
• Overall 3-7 cases/million/year
• Geographical distribution variable
• (More common in Eastern Europe and Scandinavia)
• Clinical picture of acute intestinal obstruction
• Up to 40 mortality in children
• (Ballantyne, GH et al. Volvulus of the colon.
  Incidence and mortality. Ann Surg 1985 20283)

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Association with other GI abnormalities

• Reported association with GORD (More with
  malrotation)
• Reported association with food intolerances
• (Firor HV, Steiger E. Morbidity of rotational
  abnormalities of the gut beyond infancy. Cleve
  Clin Q 198350303-309)
• Definite aetiological correlation with all causes
  of intestinal distension and dysmotility
• (Constipation, malabsorption, etc)
• (T Consorti, T H Liu. Diagnosis and treatment of
  caecal volvulus. Postgrad med j. 2005 December
  81(962) 772776)

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Learning points

• The 6 do nots
• - Do not turn down the parents voice.
• - Do not under appreciate the significance of
  persistence.
• - Do not rely fully on apparent well being.
• - Do not give up finding clues in the history.
• - Do not stop talking to other specialties.
• - Do not think that invasive procedures have to
  be at the bottom of the work-up.

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I do thank

• The mentor of this lecture Dr Susan Hill,
  Consultant of Paediatric Gastroenterology
• Mr David Drake, Consultant of Paediatric Surgery
• Miss Kate Cross, Consultant of Paediatric Surgery
• Miss Nishat Rahman, Specialist Registrar of
  Paediatric Surgery
• Dr Katy Wessely, Clinical fellow of Radiology
• The dynamo of the PGME summer lecture series
  Jack Fairhall, Education Officer

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And I do thank you all for your kind attention
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