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3. PEDIATRICS > PEDIATRIC Section 7: Luminal GI (Bowel Obstruction in Neonate) > Flashcards

PEDIATRIC Section 7: Luminal GI (Bowel Obstruction in Neonate) Flashcards

1
Q

Think of bowel obstruction in the nonate as __ or ___.

A

High or Low

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2
Q

When you say high bowel obstruction, think about these

A
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3
Q

When you say LOW bowel obstruction, think about these

A
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4
Q

Why might you think the question is leading you toward obstruction?

A

Anytime you are dealing with a neonate, and the history mentions
“vomiting,”
“belly pain,” or
“hasn’t passed a stool yet.”

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5
Q

Think of this algorithm when dealing with Bowel Obstruction:

A
  1. Bubbles
  2. Upper GI patterns
  3. Low Obstruction in Neonate
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6
Q

What are the 9 possible pattern when you think of Bubbles in Neonatal Obstruction?

A
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7
Q

Single Bubble =

A

Gastric (Antral or Pyloric) atresia

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8
Q

Double bubble =

A

Duodenal Atresia (Highly Specific)

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9
Q

Associated conditions in Duodenal Atresia?

A
  • 30% have Downs
  • 40% have polyhydramnios and are premature
  • The“single atresia” - cannulation error
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10
Q

In Duodenal Atresia, Double bubble can be shown on what trimester? in what modality?

A

On multiple choice test the “double bubble” can be shown on 3rd trimester OB ultrasound, plain film, or on MRI.

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11
Q

Triple Bubble =

A

Jenunal Atresia

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12
Q

When you call jejunal atresia, you often prompt search for additional atresias - what are they?

A

Colonic Atresia

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13
Q

What casuses Jejunal atresia?

A

Vascular insult during development

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14
Q

“Mulliptle Atresia” =

A

Vascular error

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15
Q
  1. Single bubble + distal gas?
  2. Single bubble + distal gas + bilious vomiting?
  3. Next step?
A
  1. Can mean nothing
  2. Can be midgut volvulus
  3. Upper GI
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16
Q
  1. Double bubble + distal gas?
  2. Next step?
A
  1. Exclude duodenal atresia.
    DDx:
    a. Duodenal web
    b. Duodenal stenosis
    c. midgut vovlulus
  2. Next step UPPER GI
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17
Q
  1. Multiple diffusely dilated loops =
  2. Next step?
A
  1. Low obstruction (ileum or colon)
  2. Contrast enema - if normal –> Upper GI to exclude atypical look for midgut volvulus
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18
Q

Mildly Dilated, Scattered Loops =

A
  1. “Sick Belly” - can be seen in proximal or distal obstruction
  2. UPPER GI and contrast enma
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19
Q

What are the UPPER GI patterns in Neonates?

A
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20
Q

Normally, the developmental rotation of the gut places the ligament of Trietz to the LEFT? or to the RIGHT?

A

Normally, the developmental rotation of the gut places the ligament of Trietz to the LEFT of the spine at the level of duodenal bulb

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21
Q

If mother nature fucks up and this normal rotation doesnt happen, you end up with the duodenum to the right of the midline (spine), you end up with this

A

Malrotation

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22
Q

Malrotation increase the risk of these conditions:

A

Midgut volvulus
Internal hernias

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23
Q

Malrotation + bilious vomiting =

A

Midgut volvulus

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24
Q

Malrotation is associated with these condetions:

A

Heterotaxy syndromes
Omphaloceles

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25
Q

Diagnosis

A

Malrotation

Classic Malrotation:
* Small bowel follow through shows all the bowel on one side
* The duodenum does not cross the midline

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26
Q

Diagnosis?

A

SMA at the right of SMV

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27
Q

What makes UGI fals positive on UGI?

A

Distal Bowel obstruction displaceing the duodenum (ligamentous laxity)

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28
Q

When I say “Non-bilious voming” - you say?

next step?

A

Hypertrophic Pyloric Stenosis

Ultrasound

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29
Q

When I say “Bilious vomiting”, - you say?

Next step?

A

Mid Gut Volvulus (Til proven otherwise)

Upper GI

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30
Q

Diagnosis?

A

Corkscrew Duodenum

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31
Q

this is diagnostic of midgut volvulus (surgical emergency)

A

Corckscrew Duodenum

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32
Q

In older children (or even adults) obstruction in the setting of malrotation will present as? what is the caus?

A

intermittent episodes of spontaneous duodenal obstruction.

The cause is not midgut volvulus (a surgical emergency) but rather kinking from Ladd’s Bands.

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33
Q

What is a Ladd’s Band?

A

a fibrous stalk o f peritoneal tissues that fixes the cecum to the abdominal wall, and can obstruct the duodenum.

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34
Q

What’s the procedure to prevent midgut volvulus? How is it done?

A

Ladd’s procedure

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35
Q

Absent distal air

A

Complete duodenal Atressia

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36
Q

Complete duodenal atresia is strongly associated with what condition?

A

Midgut volvulus

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37
Q

If the kid is vomiting this might be from extrinsic narrowing (Ladd band, annular pancreas), or intrinsic (duodenal web, duodenal stenosis). You can’t tell.

A

Partial Duodenal Obstruction

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38
Q

An anatomic variant where the portal vein sits anterior the 2nd part of the duodenum.

A

Preduodenal Portal Vein

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39
Q

Associated with duodenal obstruction 50% of the time.

A

Preduodenal Portal Vein (It isn’t the cause, it just happens to be present with other things (Ladds Bands, Annular Pancreas, etc..).

40
Q

Thickening of the gastric pyloric musculature, which results in progressive obstruction.

A

Hypertrophic Pyloric Stenosis

41
Q

Non-bilius vomiting that does NOT occur at birth or after 3 months

A

Hypertrophic Pyloric Stenosis

42
Q

DIagnosis? Describe the criteria?

A

Thickening of the gastric pyloric musculature

4 and 14 mm
4mm in thickness (single wall)
14 mm in length

43
Q

Specific age range of Hypertrophic Pyloric Stenosis?

A

2-12 weeks (peak at 3-6 weeks).

44
Q

What is the primary differential of Hypertrophic Pyloric Stenosis?

A

pylorospasm (wich will relax during the exam.

45
Q

What is the common pitfall in Hypertrophic Pyloric Stenosis during US?

A

gastric over distention, which can lead to displacement of the antrum and pylorus - leading to false negative.

False positive can result from off axis measurement.

46
Q

Paradoxic aciduria occurs in what condition?

A

Paradoxic aciduria occurs in hypertrophic pyloric stenosis and in adults with gastric outlet obstruction.

47
Q

Diagnosis? Sign?

A

Hypertrophic Pyloric Stenosis

“Caterpillar sign” - Multiple areas of peristalsis in the stomach

NExt step? - USD

48
Q

Treatment of Hypertrophic Pyloric Stenosis

A

Pyloromyotomy

49
Q

What are the two (2) types of Gastric Volvulus?

A

Organoaxial and Mesenteroaxial

50
Q

what is Organoaxial Gastric Volvulus?

A

greater curvature flips over the lesser curvature (rotation along the long axis).

51
Q

Diagnosis?

A

Organoaxial Gastric Volvulus?

52
Q

What is Mesenteroaxial Gastric Volvulus?

A

Twisting over the mesentery (rotation along short axis). The antrumflips near the GE junction.

53
Q

What is seen in old ladies with paraesophageal hernias?

A

Organoaxial Gastric Volvulus?

“O” for older

54
Q

Mesenteroaxial Gastric volvulus can cause?

A

Ischemia and needs to be fixed

55
Q

This type of Gastric volulus is more common in kids

A

Mesenteroaxial

56
Q

WHat is the clinical picture of gastric volvulus?

A

Think of Borchardt Triad:
Inability to pass NGT
Severe epigastric pain
Retching without vomiting

57
Q

This is best thought o f as “almost duodenal atresia. ”

A

Duodenal Web

58
Q

Where is the duodenal web located?

A

Distal to ampulla of vater - Bile stained emesis

59
Q

Duodenal web is associated with what condition?

A

Downs syndrome

60
Q

Diagnosis?

A

Duodenal web

61
Q

Essentially an embryologic screw up (failure of ventral bud to rotate with the duodenum), = encasement of the duodenum

A

Annular pancreas

62
Q

Diagnosis?

A

Annular pancreas

Look for pancreatic tissue (same enhancement as the nearby normal pancreas) encircling the descending duodenum.

63
Q

When you see annular pancreas in:

Kids = think of?
Adults = think of?

A

Kids = Duodenal obstruction
Adults = Pancreatitis

64
Q

Diagnosis?

A

Look for an extrinsic narrowing of the duodenum. Obviously this is non-specific (typical barium - voodoo), use the location and clinical history to bias yourself.

65
Q

How do you approach lower obstruction?

A

Pattern-based method

66
Q

What are the “Low obstuction” patterns in Neonate?

A

Normal
Short Microcolon
Long Microcolon
Caliber change

67
Q

Low Obstruction pattern

A

Normal:
* This is what normal looks like:

68
Q

Low Obstruction pattern

A

Short Microcolon (think of colonic atresia)

69
Q

Low Obstruction pattern

A

Long microcolon
- Meconium ileus
- distal ileal atresia

70
Q

Low Obstruction pattern

A

Caliber change

71
Q

Diagnosis?

A

Colonic Atresia

72
Q

Meconium ileus can only be seen in patients with? why?

A

ONLY in patients with Cystic Fibrosis

result of thick sticky meconium
causing obstruction of the distal ileum.

73
Q

Diagnosis? Describe

A

Meconium Ileus

Contrast will reach ileal loops, and demonstrate multiple filling defects (meconium).

74
Q

Treatment of meconium ileus?

A

This can be treated with an enema -enema is both diagnostic and therapeutic.

75
Q

Diagnosis? Describe

A

Distal ileal Atresia

Contrast will NOT reach ileal loops.

76
Q

Distal ileal atresia is a result of?

What is the treatment?

A

This is the resuh of intrauterine vascular insult.

This needs surgery.

77
Q

Caliber change in distal obstruction is seen in what conditions?

A

Small left colon syndrome or
Hirshprungs

78
Q

This is a transient functional colonic obstruction, that is self limited and relieved by contrast enema.

A

Small Left Colon (Meconium Plug) Syndrome

79
Q

What is the difference between a meconium plug and meconium ileus?

A

Meconium plug is NOT associated with Cystic Fibrosis

80
Q

Small Left Colon (Meconium Plug) Syndrome is seen in?

A
  1. Infants of Diabetic mothers
  2. Mom received magnesium sulfate for Eclampsia
81
Q

Failure o f the V ganglion cells to migrate and innervate the distal
colon.

A

Hirschsprung Disease

82
Q

Hirschsprung Disease is:
Common in what gender?
Associated with what condition?
Diagnosis is made by?

A

Hirschsprung Disease is:
Common in boyes 4:1
Associated with Downs
Diagnosis is made by rectal biopsy

83
Q

Diagnosis?

A

Hirshprung

-Enema - Rectum smaller than the Sigmoid “Recto-sigmoid ratio < 1”

-Enema - Rectum with “sawtooth pattern” Represents bowel spasm

84
Q

Diagnosis?

A

Small Left Colon (Meconium Plug) Syndrome

85
Q

Presentation of Hirshsprung?

A

(1) Newborn who fails to have BM > 48 hours (or classically > 72 hours)

(2) “Forceful passage of meconium after rectal exam”

(3) One month old who shows up “sick as stink” with NEC (Necrotizing Enterocolitis) bowel

86
Q

This is a super rare variant of Hirschsprungs, and can mimic microcolon.

A

Total Colonic Aganglionosis

The piece of commonly asked trivia is that it can also involve the terminal ileum.

87
Q

This is a potential complication of bowel atresia or meconium ileus.

A

Meconium Peritonitis:

88
Q

Characteristic look of Meconium Peritonitis? explain

A

It’s a calcified mass in the mid
abdomen - result of a sterile peritoneal reaction to an in-utero bowel perforation.
Usually, the perforation seals off prior to birth and there is no leak.

89
Q

Diagnosis?

A

Meconium Peritonitis

90
Q

imperforate or Ectopic Anus range

A

This can range from simple membranous anal atresia to an arrest of the colon as it descends through the puborectalis sling.

91
Q

what is the thing to know when you talk about Imperforate or Ectopic anus?

A

fistula to genitourinary tract

92
Q

Imperforate anus is also associated with What condition?

A

Imperforate anus is also associated with a tethered cord (probably need a screening ultrasound).

93
Q

When I say “Baby with no asshole” you say?

A

VACTERL

94
Q

Why do you screen a Baby with no asshole in US?

A

Screen for tethered cord.

95
Q

Opinions are like Assholes Everyone has One
Unless you have an Imperforate Anus

Then you probably have?

A

VACTERL and a Tethered Cord

3. PEDIATRICS (32 decks)

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