Clinical Pathological Conference 2004-12-29

1
Clinical Pathological Conference2004-12-29

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2
Case PresentationPresent 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.

3
Case PresentationPersonal and Family History

• Past history
• Before this presentation,the child was in good
  condition without any compliant of abdominal
  symptoms.

4
Case PresentationPhysical 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 .

5
Case PresentationRadiologic 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).

6
Case PresentationRadiologic 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.

7
Case PresentationRadiologic 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.

8
Case PresentationHospital 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.

9
Case PresentationHospital 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.

10
Case PresentationHospital 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.

11
Major Problems Minor Problems

• Bilious vomiting
• A soft tissue mass over right lower quadrant
• Downhilled blood pressure(shock)

• Intermittent irritable crying
• Decreased urine output
• Leukocytosis
• Hyperchloremia
• Local ileus pattern over right upper quadrant
• Tachycardia
• Hypertension

12
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?

13
Questions- about Physical Examination and
laboratory data

• Anemic conjunctiva? Lymphoadenopathy?
• RLQ soft tissue mass movable or non-movable?
• Bowel sound? Hyperactive to be replaced with
  hypoactive bowel sounds?
• Stool rontine examination? occult blood? WBC?
  pattern?
• Blood smear? blast cell?

14
Questions-about radiologic finding

• Plain film of abdomen further finding? Foreign
  body/Bezoars?
• Abdomen Sonography further finding? Appendix?
  Ascites?Kidney? Any finding about tumor?

15
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.

16
Intestinal obstruction

• Intraluminal polyp, mass, parasites,
• and tumor.
• Intramural stricture, tumor,
• hematoma.
• Extrinsicpostoperative adhesion, adhesion from
  peritonitis, hernia, volvulus,and tumor.

17
Clinical Classification of Shock

• Septic shock bacterial,Viral,Fugal..
• Cardiogenic shock ischemia, cardiomyopathy
  ,congestive heart failure
• Distributive shocktoxins,anaphylaxis
• Hypovolemic shock enteritis,hemorrhage,
• Obstructive shock tension pneumothroax

18
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

19
Hyperchloremia

• Gastrointestinal
• Dehydration
• Prolonged Diarrhea
• Loss of pancreatic secretion
• Ileal loops
• Ureteral colonic anastomosis

20
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 Hirschsprung
s disease Superior mesenteric artery
syndrome Duodenal hematoma Testicular or ovarian
torsion
(From Pediatric Decision-making Strategies
accompanied by Nelson)
Surgery Consult
Yes
Signs or symptoms suggestive of an acute
abdomen
Acute
History and physical exam
Vomiting
Sign or symptoms suggestive of increased ICP?
Yes
No
No
Sign or symptoms suggestive of increased ICP
Chronic
21
Malrotation with volvulus Appendicitis Congenit
al structural abnormalities Postsurgical
adhesions Foreign body/Bezoars Meckels
diverticulum with bleeding Incarcerated inguinal
hernia Meconium ileus Intussusception Hirschsprung
s disease Superior mesenteric artery
syndrome Duodenal hematoma Testicular or ovarian
torsion
22
Abdomen US
(From Pediatric Decision-making Strategies
accompanied by Nelson)
Abnormal result
Yes
Yes
Perform abdomen US
Neonate?
No
Lower abdomen mass in female
History and physical exam
No
Normal result
Abdomen mass
No
Hepatomegaly or splenomegaly present
Perform Abdomen CT
Yes
23
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
24
Foreign body/Bezoars Meckels diverticulum Hirschs
prungs disease Appendicitis Intestinal
tumor Neuroblastoma Rhabdomyosarcoma Lymphoma C
ongenital structural abnormalities
25
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.

26
Gastric trichobezoarPediatric 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.

27
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.

28
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.

29
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.

30
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.

31
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.

32
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

33
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.

34
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

35
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.

36
Appendicitis

• The risk of perforation is greatest in 1- to
  4-yr-old children (7075) and is lowest in the
  adolescent age group (3040) .
• The classic triad consists of pain, nausea with
  vomiting, and fever.
• The progression from onset of symptoms to
  perforation usually occurs over 3648hr.

37
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.

38
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
  false-positive rates of 810 .
• CT is more sensitive and specific than
  ultrasonography and more likely to change patient
  management.

39
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 .

40
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 .

41
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

42
Distal Intestinal Obstruction Syndrome

• Radiographs of the abdomen demonstrate dilated
  small bowel loops and a bubbly ileocecal
  soft-tissue mass .

43
Carcinoid tumor

• About 85 of carcinoid tumors develop in the
  gastrointestinal tract, usually the appendix.
• Carcinoid syndromeflushing,diarrhea,
• wheezing.
• Carcinoid crisisgeneralized flush,
  tachycardia, severe diarrhea with abdominal pain,
  hypotension converting to hypertension, and
  central nervous system changes leading to coma
  and then death.

44
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.

45
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 .
  

46
Lymphomafrom manual of pediatric hematology and
oncology ,3rd edition

• Non-Hodgkins lymphoma
• peak age 5-15 years ,rick factor including
  genetic and poettransplantation
  immunosuppression.
• Clinical featureHead and neck(13),
  medicatinum(26),abdomen(35).

47
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.

48
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.

49
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)

50
Neuroblastoma

• Paraneoplastic manifestations
• excessive catecholamine secretion
  (sweating,flushing, paller,palpitation,
  hypertension) ,VIP secretion (watery
  diarrhea,abdomen distension, hypokalemia) ,and
  acute myoclonic encephalopathy.

51
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.

52
Rhabdomyosarcomafrom manual of pediatric
hematology and oncology,3rdedition

• Two age peaks2-6 years and 15-19 years.
• Rare primary sites for rhabdomyosarcomainclude
  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.

53
Final diagnosis

• 1.Meckels diverticulum with diverticulitis or
  congenital structural abnormalities
• 2.Ruptured Appendicitis

54

• THANK YOU!!

55
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.

56
Mesenteric cyst / Omental cyst Mesenteric cysts
in children Surgery 1994115571-7

• 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.

57
Lymphangioma

• Five pathologic patterns account for most
  mesenteric cysts, namely, lymphangioma, enteric
  duplication cysts, enteric cysts, mesothelial,
  and nonpancreatic pseudocysts.

58
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59
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60
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.

61
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.

62
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.

63
Bilious vomiting intermittent irritable crying
Dehydration Hypertension Leukocytosis Hyperchlorem
ia

one-year-six month-old boy
Decreased urine output and downhill BP in 16
hours
Soft tissue mass over RLQ by Abdomen sonography
64
Wilms tumor

• It may be associated with hemihypertrophy,
  aniridia, and other congenital anomalies, usually
  of the genitourinary tract.
• Sign of Wilms tumorpalpable 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.

65
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.

66
Wilms tumorGrainger 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.

67
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.

68
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.

69
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 1525 yr of age and a second smaller peak at
  5080 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.

70
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.

71
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.

72
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.

73
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
  1015.
• Children with ileocolitis typically have
  cramping, abdominal pain, and diarrhea, sometimes
  with blood. Ileitis may present as right lower
  quadrant abdominal pain alone.

74
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).

75
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.

76
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.

77

• 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.

78

• 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.

79
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.

80
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.

81
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.

82
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.

83
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.

84

• Most infants become symptomatic during the 1st
  day of life with abdominal distention and
  bile-stained emesis or gastric aspirate.

85

• Plain radiographs demonstrate many air-fluid
  levels or peritoneal calcification associated
  with meconium peritonitis.
• In meconium ileus, plain films of the abdomen
  show a typical hazy or ground-glass appearance in
  the right lower quadrant.

86

• 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.

87
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.

88

• 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.

89

• 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.

90
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 malefemale ratio is 41.
• Most intussusceptions do not strangulate the
  bowel within the first 24hr but may later
  eventuate in intestinal gangrene and shock.

91

• 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.

92

• 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

93

• 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

94
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.

95
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.

96

• 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.

97

• 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.

98

• 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 .

99
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.

100
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102
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.

103
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.

104
Wilms tumor

• The incidence is approximately 8 cases/million
  children younger than 15 yr of age.
• It usually occurs in children between 25 yr of
  age, although it has also been encountered in
  neonates, adolescents, and adults.

105
Neonatal intestinal perforation caused by
congenital defect of the small intestinal
musculature report of one case.Acta Paediatrica
Taiwanica. 40(4)271-3, 1999 Jul-Aug.

• 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.