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Intestinal obstruction in children
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- 2. ObjectivesObjectives • Presentation ofobstruction • To know different causes • A brief about each cause
- 3. Duodenal HematomaDuodenal 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
- 4. IMAGING •Ba Meal •( Thickenedmucosal folds, localized filling defects due to intramural hematoma) •CT Abdomen •(for assessment of acute trauma and hematoma directly, or for abnormal duodenal enhancement)
- 5. Enhanced CTEnhanced CT Intramuralduodenal hematoma almost completelyIntramural duodenal hematoma almost completely obscuring the lumenobscuring the lumen
- 6. DUPLICATION CYSTDUPLICATION CYST •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
- 7. • Presentation depends onthe 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)
- 8. ImagingImaging • Radiography (mass effectwith displacement of adjacent bowel loops) • Ultrasound (simple hypoechoic cyst, Gut wall signature)
- 9. Hypoechoic cyst withdouble ‘gut wallHypoechoic cyst with double ‘gut wall signature’(inner echogenic mucosa & outersignature’(inner echogenic mucosa & outer hypoechoic smooth muscle layerhypoechoic smooth muscle layer
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- 12. Mesenteric/OmentalMesenteric/Omental cyst(lymphangiomas)cyst(lymphangiomas) • Developmental anomaliesof lymphatic system (mesentry/ omentum) Presentation • -similar to duplication cyst • On U/S multiloculated cyst with thin septation • Tx– surgical resection
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- 14. Meckel ‘s DiverticulumMeckel‘s Diverticulum Persistence of prox. Vitelline duct • True diverticulum • From anti mesenteric border • Rule of two’s Complication • -acute inflammation (mimicking appendicitis) • -GI bleed • -lead point for intussusception
- 15. Supine & proneradiographs of the upper GI barium seriesSupine & prone radiographs of the upper GI barium series
- 16. AppendicitisAppendicitis • Peak incidence12-15 years Presention • -ill defined abd. Pain in RIF • -fever and vomiting
- 17. IMAGINGIMAGING Radiography •May be normalor 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
- 18. Right iliac fossamixed echogenicity inflammatoryRight iliac fossa mixed echogenicity inflammatory mass and echogenic focus with acousticmass and echogenic focus with acoustic shadowingshadowing
- 19. Hypoechoic tubular structure7mm in diameterHypoechoic tubular structure 7mm in diameter adjacent to iliac vesselsadjacent to iliac vessels
- 20. CT findings are •--localizedor multi-focal abscess
- 21. ComplicationComplication • Appendicolith • Pelvicabcess • Generalized peritonitis • Portal vein thrombosis • Multiple hepatic abcess ( rare)
- 22. Differential •-- mesenteric adenitis •--Crohn’sdisease •--Infection •--ovarian torsion/cyst
- 23. HENOCH SCHONLEINHENOCH SCHONLEIN PURPERAPURPERA Smallbowel vasculitis •Jejunum most frequently involved •Unknown etiology/postinfectious/post drug therapy Presentations with •Purpuric rash over the buttocks & legs •Abdominal pain •glomerulonephritis
- 24. Henoch schonlein pupuraHenochschonlein pupura Ultrasound & barium follow throughUltrasound & barium follow through
- 25. JejunalJejunal bowel wallthickeningbowel wall thickening
- 26. Complications •Transient small bowelintussusception(rare) •Echogenic kidney suggest renal involvement
- 27. OTHEROTHER INFECTIONS •(giardia,compylobacter,yersinia,salmonella etc) GRAFT VERSUSHOST REACTION •(mostly effecting small bowel) CROHN’S DISEASE •(mostly effecting terminal ilium & cecum)
- 28. Polyps and polyposisPolypsand polyposis syndromessyndromes 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
- 29. • Double contrastbarium enema • Endoscopy • A pedunculated polyp with a long stalk is seen
- 30. Barium enema showinga pedunculated polyp in theBarium enema showing a pedunculated polyp in the descending colondescending colon
- 31. Juvenile polyposisJuvenile polyposis •Positive family hx (most cases) • Five or more polyps • Associated with higher long term risk of colonic carcinoma
- 32. Peutz jeghers syndromePeutzjeghers 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
- 33. Complications •Intussusception around polyps(usuallytransient) •Small bowel obstruction •Gastrointestinal adenocarcinoma & non GI neoplasm involving pancreas, breast or reproductive organs
- 35. • Familial polyposiscoli • Gardner syndrome • Both are dominanly inherited • Multiple adenomatous polyps are found (numerous in colon) • High malignant potential • Prophylactic proctocolectomy usually recommended
- 36. TURCOT’S SYNDROMETURCOT’S SYNDROME •Autosomal recessive condition • Colonic adenomas associated with CNS glioma
- 37. Small bowel malignanciesSmallbowel 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
- 38. ULTRASOUND •Thickened hypoechoic bowelloops are seen often forming adherent masses with infiltration of adjacent omentum & mesentery •Hepatospenomegaly •Retroperitoneal lymphadenopathy
- 39. CAUSES OF COLITISINCAUSES OF COLITIS IN CHILDHOODCHILDHOOD • INFECTIOUS • (compylobacter,E.coli,salmonella,shigella etc) • INFLAMMATORY BOWEL DISEASE • TYPHILITIS • HEAMOLYTIC URAEMIC SYNDROME • PSEUDOMEMBRANOUS COLITIS • GRAFT VERSUS HOST REACTIONS • ISCHAEMIC COLITS • IRRADIATION COLITIS
- 40. CROHN’S DISEASECROHN’S 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
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- 42. IMAGINGIMAGING • ENDOSCOPY • BARIUMENEMA(largely replaced by endoscopy) • aphthoid ulceration • mucosal ulceration is deep, discontinuous & asymmetrical • generally have thicker colon than ulcerative colitis • LEUCOCYTE SCINTOGRAPHY(extent of disease)
- 43. CT SCAN •transmural bowelwall thickening •creeping fat within the mesentery •strictures •fistulas •localised collection MRI •assessment of disease extent
- 44. Innumerable aphthoid ulcerin crohn’s diseaseInnumerable aphthoid ulcer in crohn’s disease
- 45. Enema in crohn’sdisease showing extensiveEnema in crohn’s disease showing extensive cobblestoning due to linear ulceration &mucosalcobblestoning due to linear ulceration &mucosal edema. Rectum is sparededema. Rectum is spared
- 46. ULCERATIVE COLITISULCERATIVE COLITIS •Relapsing and remitting proctits • Rectum is always effected • Effects young adults(15-25yrs) with second smaller peak at approx 60yrs
- 47. CLINICAL FINDING •bloody diarrhoea •abdominalpain •failure to thrive
- 48. IMAGINGIMAGING Double contrast bariumenema Proctosigmoidoscopy •loss of normal mucosal vascular pattern (earliest detectable change) •ulceration is continuous & superficial •(deep ulceration does occur) •haustral blunting
- 49. • Luminal narrowing •Colonic shortening(due to muscular abnormality rather than fibrosis) CT SCAN not for primary diagnosis once toxic megacolon is established
- 50. Double contrast bariumenema shows granularDouble contrast barium enema shows granular mucosa (changes of early disease)mucosa (changes of early disease)
- 51. Complication •Risk of colonicca is high approx 20% per decade •toxic megacolon
- 52. TYPHILITISTYPHILITIS • 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
- 53. Bowel wall thickening& fat strandingBowel wall thickening & fat stranding
- 54. HAEMOLYTIC URAEMICHAEMOLYTIC URAEMIC SYNDROMESYNDROME •Commonest cause of acute renal failure in children • Diarrheal illness caused by E.coli leading to • Microangiopathic anemia • Thrombocytopenia and acute renal failure
- 55. IMAGINGIMAGING Ultrasound •Association of colonicthickening &echogenic kidneys is highly suggestive of diagnosis •Doppler flow within the bowel wall is reduced (atleast in prodromal phase)
- 56. INTUSSUSCEPTIONINTUSSUSCEPTION • Invagination ofa 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
- 57. Classic presentation •Episodic abdominalpain •Screaming episodes associated with passage of blood & mucus(current jelly) •Haemodynamic instability due to considerable fluid shift
- 58. IMAGINGIMAGING Abdominal radiograph •Absence ofbowel 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
- 59. Paucity of bowelgas in the right iliac fossa andPaucity of bowel gas in the right iliac fossa and soft tissue masssoft tissue mass
- 60. Transverse ultrasound showingmultipleTransverse ultrasound showing multiple hypoechoic concentric rings, central echogenichypoechoic concentric rings, central echogenic mesentery and few small echogenic lymph nodesmesentery and few small echogenic lymph nodes
- 61. • Small crescentsof 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
- 62. TREATMENTTREATMENT RADILOLOGICAL REDUCTION •Absolute contraindicationsare peritonitis and perforation PNEUMATIC REDUCTION(air enema) •Replaced the barium in most paediatric centres(70- 90% success rate)
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