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GASTROINTESTINAL EMERGENCIES
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GASTROINTESTINAL EMERGENCIES

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  • 1. GASTROINTESTINAL EMERGENCIES
    PEDIATRIC GASTROINTESTNAL EMERGENCIES
  • 2. GASTROINTESTINAL EMERGENCIES
    Gastrointestinal emergencies are serious conditions that often develop suddenly and requires prompt and immediate treatment.
    Gastrointestinal emergencies can develop throughout the digestive system
  • 3. GI TRACT EMERGENCIES
    Esophagus
    Stomach
    Small Intestines
    Large intestines
    Biliary system
    ( liver, pancreas, gallbladder, bile duct )
  • 4. GASTROINTESTINAL EMERGENCIES IN Adults and Infants/Children
    Acute Abdominal Pain
    Gastrointestinal Hemorrhage
    Biliary Tract Obstruction
    Hepatic Failure
    Hepatic Encephalopathy
  • 5. GI TRACT EMERGENCIES UNIQUE TO THE PEDIATRIC PATIENT
    Two major categories
    Intestinal obstruction
    Neonatal cholestasis
  • 6. INTESTINAL OBSTRUCTION
    Antral and Duodenal stenosis and webs
    Infantile hypertrophic pyloric stenosis
    Extrinsic Duodenal obstruction
    Duplications
    Malrotation with and without volvulus
    Hirschsprung’s disease
    Anorectal malformations or Imperforate anus
    Abdominal Wall Defect
    Hernias
    Thick Meconium syndromes
    Intussception
    Volvulus
    Other
    -Appendicitis
    - Meckel’s Diverticulum
  • 7.
  • 8. GI EMERGENCIES
    1. 15 year old male presents with severe abdominal pain, and vomiting.
    There is no history of fever, weight loss , diarrhea , jaundice or joint pain.
    Based on above information, what additional history ,
    physical finding ,labs and/or radio imaging are needed to
    make a diagnosis of :
    • Pancreatitis
    • 9. Appendicitis
    • 10. Malrotationwith volvulus
    • 11. Incarcerated hernia
    • 12. Intussception
  • APPENDICITIS
    Most common condition leading to emergency abdominal surgery in children/adults
    Incidence : 140 in 100,000 people of all ages
    Most frequent between 15 and 24 years of age ( rare in preschool children and rarer in < 1 year of age
    Presentation : periumbilical abdominal pain, vomiting, fever
    1/3 of all presentation is with perforation of the appendix or lower abdominal mass
    Note : 11 – 32 % false positive rate pre operatively
    > 50 % have nonsurgical abdominal
  • 13. GI EMERGENCIES
    Pancreatitis
    Diagnosis:
    Key Points
    Symptoms :( age dependant )
    + pancreatic isoenzymes
    ( amylase and / or lipase) 2 to 3 times
    elevated over normal reference level.
    Hydration very important especially in the early stages.
    Studies in animals indicate the CT contrast given early in the course of acute pancreatitis may further diminish blood flow to ischemic areas of the pancreas and increase the likelihood of necrosis------CT contrast should avoided in earlystages
    Rx : NPO, IV FLUIDS, PAIN MEDS
  • 14.
  • 15. GI EMERGENCIES
    A 12 month old infant presents with the history of increased irritability and inconsolable. Growth and development are normal . The physical examination was remarkable for abdominal distension, tenderness and bloody stools ( guiac positive for blood).
    Based on your working diagnosis, what labs or test would you request?
  • 16. INTUSSCEPTION
    COMMON CAUSE OF INTESTINAL OBSTRUCTION IN CHILDREN
    Peak incidence is infancy
    • 50% < 1year of age
    • 17. Male to female ratio is 3:2
    • 18. No lead point/ usually idiopathatic
    • 19. 90 % proximal to the ileocecal valve –ileocolonic, ileoileal,colocolonic
    • 20. > 2 years of age associated with a lead point
    Dx/Rx : KUB features the target sign ( a mass in the RUQ ), cresent sign
    • ( intussceptum, intusscepting lead point, protruding into air filled pocket ), absent liver edge sign/absence of the subhepatic angle, and signsof obstruction ( smooth intestinal wall/dilation- hose or sausage- like due to loss of plication/haustration, air –fluid level –candy cane or upside down J, gas distribution, and orderliness)
    • 21. air or barium contrast enema
    Surgery if lead point or > 48 hours
    • 10% recurrence
    Complication – perforation ( greater in infants, < 6 months of age, and /or symptoms >3 days
    • 9
  • INTUSSCEPTION
  • 22. MALROTATION WITH OR WITHOUT VOLVULUS
    Malrotation occurs during normal
    formation of the bowel
    Its presence predisposes to volvulus
    Its incidence is 1 in 6,000
    Male to female 3:1
    Presentation : bilious vomiting, abdominal pain,
    blood in stool etc., but older children may have vague
    symptoms ( chronic abdominal pain and/or intermittent vomiting)
    Diff Dx :
    neonates – duodenal atresia and stenosis, annular pancreas, antral or duodenal web, small bowel atresia
    Older infant/children – pyloric stenosis, GER, formula intolerance, colic, lactose intolerance
    Associated anomalies : congenital diaphragmatic hernia, abdominal wall defect (30-60%), duodenal atresia (50%), CHD, Hirschsprung’s disease, mesenteric cysts
    Dx: Barium enema – cecum localized to the right or left quadrant
    UGI series – duodenum does not cross midline and the remainder of small bowel lies to the right of the midline
    U/S – clockwise rotation of the superior mesenteric vein around the mesenteric artery
    ( “ whirlpool” sign )
    Rx : surgery
  • 23.
  • 24. INFANTILE HYPERTROPHIC PYLORIC STENOSIS
    Hyper trophy and hyperplasia of the smooth muscle in the antral and pyloric regions
    Proposed etiology - ? Hypergastrinemia, ?increased prostaglandins E2 and F2alpha, ? Decreased NADPH diaphorase activity ( a lack of nitric oxide synthase in pyloric tissue
    Sx : nonbilious vomiting < 5 months ( usually by 3 weeks )
    PE : visible gastric peristalic wave
    Hypochloremic alkalosis
    ( water loss and hydrochloric acid )
    Elevated unconjugated bilirubin
    Dx : pathognomomic “ pyloric olive”
    + clinical history + labs
    No imaging is required
    Plain film “ caterpillar “shape ( hyperperistalsis and paucity of small and large bowel gas )
    Radio imaging with contrast – elongated , double channel ( railroad tract )-enlarged distal antrum muscle and duodenal bulb
    U/S : hypertrophied pyloric muscle ( anechoic mass )
    Rx : medical/surgery
  • 25. DUPLICATIONS
    Esophageal – rare
    Gastric – incidence 10%
    -greater curvature
    -palpable abdominal mass
    +/- GI bleeding
    +/- chronic abdominal pain
    +/- pancreatitis
    Duodenal – incidence 10-15 %
    -located in the mesenteric border
    Presentation – abdominal mass , abdominal pain, jaundice ,GI bleeding , pancreatitis
    Associated anomalies : Duplication cysts, vertebral anomalies, ectopic pancreas
    Dx : UGI with contrast –beaklike projection from the duodenal
    • CT scan or U/S – mass next to the duodenum
    • 26. Endoscopy – mass or extrinsic compression
    • 27. ERCP – duplication seen if the biliary or pancreatic duct is involved
    • 28. Rx : surgery
  • EXTRINSIC DUODENAL OBSTRUCTION
    Two most common causes
    Annular pancreas
    Congenital bands
    Associated anomalies : duodenal atresia or stenosis, cardiovascular defect, malrotation, Down’s , TEF
    Dx : plain film – double bubble
  • 29. GI EMERGENCIES
    As you are leaving the newborn nursery, your favorite nurse ask if you would see this 5 hour term infant because of feeding intolerance and mild abdominal distension.
    What two things performed that would aid in making a diagnosis?
    What was your differential diagnosis ?
    Give at least 3 associated anomalies .
  • 30. INTESTINAL OBSTRUCTION
    Atresia – congenital absence or obstruction of the intestinal lumen
    Types
    Esophageal - incidence 1 in 3000/4500
    Duodenal - incidence 1 in 2000/40,00
    Jejunal and ileal -incidence 1 in 330/1500
    Colonic - incidence 1 in 20,000
  • 31. JEJUNAL AND ILEAL ATRESIA
    It is 30% of all neonatal intestinal obstruction
    Male = female
    30 % proximal jejunum
    70 % distal jejunum
    10 – 15 % proximal ileum
    Presentation – less than 24 hours of age – bilious vomiting, progressive abdominal distension ( ileal > jejunum ), failure to pass meconium
    Associated anomalies common – gastroschisis, meconium ileus, malrotation with and without volvulus, Hirschsprung’ disease
    *Microcolon is seen with all ileal atresia
    Diff Dx : colonic atresia, Hirschsprung’s disease, meconium plug, meconium ileus, malrotation with volvulus, and bowel duplication
    Dx : Plain film –multiple dilated loops of bowel with air – fluid levels
    Rx : medical / surgery
  • 32. DUODENAL ATRESIA
    Presentation : symptoms within hours of birth,
    abdominal distension, > 30 ml bilious gastric fluid
    Nonbilious if obstruction is proximal to
    the ampulla of vater
    Diff Dx : webs, stenosis, duplication,
    • annular pancreas, congenital bands
    Associated anomalies are common :
    • esophageal atresia, malrotation,
    • 33. annular pancreas, imperforate anus,
    • 34. CHD, IUGR
    Dx : plain film – “double bubble” sign
    UGI with contrast ---confirms diagnosis
    BE with contrast –determine the presence
    of malrotation and/or midgut volvulus
    Rx : medical/surgery
    ** 30 % Down’s syndrome
  • 35. ESOPHAGEAL ATRESIA
    Five types
    1. Proximal atresia with distal fistula ( 85 % )
    2. Proximal and distal blind pouch and no fistula (8 to 10 %)
    3. H type , T E fistula and no atresia ( 3 to 4 % )
    4 and 5. variation of proximal fistula, etc.
    Presentation depends on the type
    Dx : Inability to pass NG tube into the stomach
    Plain film ----coiled NG tube
    Contrast study only to diagnose H type
    Diff Dx : choanal atresia, diaphragmatic hernia,
    CHD
    Associated anomalies : esophageal atresia (40-70%),
    cardiovascular(40%) VSD, TOF, COA,PDA,vascular rings
    10% VACTERL ( vertebral defects, anal atresia, TEF,
    renal defect, radial limb dysplasia )
    10 – 15 % imperforated anus
    GI anomalies – malrotation, duodenal atresia
  • 36. HERNIAS
    Location is along intestines
    diaphragm
    umbilical
    inguinal
    internal – rare/ seen at autopsy ( most common type mesocolon /paraduodenum )
  • 37. INGUINAL HERNIA
    Its incidence is 0.88 to 4.44 in children ( it is higher in premature infants )
    Male to female ratio is 6:1
    Right sided occurrence is 60 %
    Left sided occurrence is 30 %
    Bilateral occurrence is 10 %
    Associated anomalies : bladder exstrophy, Ehlers-Danlo’s syndrome, ascites, VPS, peritoneal dialysis, CF, congenital dislocation of the hip, undescended testicles,ambiguuous genitalia, congenital wall defect
    Presentation : bulge in the groin, scrotum, testicles
    Dx : clinical
    Transillumination,
    Ultrasound
    Diff Dx : Testicle torsion, epididymis-orchitis, torsion of the appendix testis, hydrocele, inguinal or femoral lymph adenitis
    Rx : surgery
  • 38. INGUINAL HERNIA
    It’s a sac containing abdominal contents and protrude into a patent processes virginals testis through the inguinal canal
    IT IS THE LEADING CAUSE OF INTESTINAL OBSTRUCTION IN INFANTS
    *Herniorraphies are the most
    common surgical procedures
    performed in children
    Two types
    • Indirect ( sac passes through
    the internal ring lateral to
    the inferior epigastric vessels )
    • Direct ( sac enters the canal
    through the posterior wall
    medial to the inferior epigastric vessels )
  • 39. GI EMERGENCIES
    KEY POINTS :
    Abdominal pain
    Clinical history
    Chronology – time of onset
    Location – epigastric, peri-umbilical, or hypogastric
    Intensity and characterization – type of pain : sharp dull, crampy
    PE
    LABS/RADIOLOGY
  • 40. MECKEL’S DIVERTICULUM
    Remnant of the embryonic proximal portion of the yolk stalk ( omphalomesenteric or vitelline duct in utero ) It usually disappears 5 the and 7th week of life
    It is located in the antimesenteric aspect of the ileum
    It is 40 to 100 cm from the ileocecal valve
    THE MOST COMMON congenital GI ANOMALY
    THE MOST COMMON CLINICAL PRESENTATION IS LOWER GASTROINTESTINAL HEMORRHAGE
    – “ currant jelly like “(painless )
    Dx : Meckel’s (technetium 99m pertechnetate) scan
    Sensitivity can be increased by administration of cimetidine, glucagon or pentagastrin
    +/- angiography
    +/- Tagged RBC
  • 41.
  • 42.
  • 43. GI EMERGENCIES
    Hemorrhage
    KEY POINTS :
    Bleeding from the gastrointestinal tract may be determined
    by :
    Magnitude ( acute vs. chronic )
    Location of the bleeding site ( upper vs. lower )
    Pathogenesis mechanisms ( inflammatory vs. vascular)
    Mode of presentation (hematemesis vs. hematochezia)
    2. Management in GI Hemorrhage
    FOUR SUCCESSIVE STEPS APPROACH
    • Assessment of the severity of the bleed
    • 44. ( HR, BP, and postural changes )
    • 45. Resuscitation and Empiric Therapy
    • 46. Locate the bleed
    • 47. Diagnostic tests
    BE ABLE TO DIFFERENTIATE BETWEEN UPPER AND LOWER BLEEDS
    DETERMINE IF PAINLESS VS. PAINFUL
  • 48. GI EMERGENCIES
    A 28 day old infant has a history of jaundice in the first of life that resolved but has icteric sclera of recent onset. Growth and development are normal. On examination, the liver was enlarged ( span by percussion is 8 cm) but the spleen is nonpalpable. On rectal examination, soft pale yellow stool ( quaiac negative ) was obtained.
    Based on your working diagnosis, what test and / or treatment would you order ?
  • 49. GI EMERGENCIES
    Cholestasis – impairment of bile flow
    Causes – intrahepatic vs. extrahepatic
    Biliary atresia
    Choledocal cyst
    Alagille ‘s
    Neonatal hepatitis
    Metabolic causes
  • 50. BILIARY ATRESIA
    INCIDENCE 1 IN 10,000 OR 25,000
    FEMALE TO MALE RATIO IS 1.4:1
    PRESENTATION : JAUNDICE
    ( CONJUGATED/DIRECT HYPERBILIRUBINEMIA) ONSET 2 TO 3 MONTHS OF AGE )
    ASSOCIATED ANOMALIES : ABSENT INFERIOR VENA CAVA, PREDUODENAL PORTAL VEIN, INTESTINAL MALROTATION, POLYSPENIA
    • Surgical intervention success is highly weighted on the time of surgery
    ( greater success performed < 3months of age )
  • 51. BILIARY SYSTEM
  • 52. GI EMERGENCIES
    You are asked to see a patient in the ER for elevated liver enzymes of unclear etiology. What tests/labs should be ordered to determine liver function?
    The clotting function tests were prolonged. What should be done next? What is the time above the normal PT level that is suggestive of the risk for bleeding.
    If mother describes her child as becoming more restless with wide mood changes, and confusion, what would the above suggest in regard to his present clinical status?
  • 53. GI EMERGENCIES
    Hepatic failure is defined as impairment/ loss of the liver to perform vital ( synthetic and biliary ) functions.
    Failure may be classified as acute, subacute /late – onset failure. It is time frame from the onset of hepatic failure to encephalopathy development
    • Fulminant hepatic failure: < 8 weeks after the beginning of acute hepatitis
    • 54. Subacute hepatic failure : encephalopathy develops 8 to 24 weeks after the onset of liver disease
    *Note : 1. The lack of preexisting liver disease is KEY to making this diagnosis.
    2. This strict definition may not be as applicable to all pediatrics disorders –Reye’s syndrome, several inborn errors and Wilson’s disease.
  • 55. COAGULATION
    The liver has a role in the control of coagulation
    Almost exclusively all coagulation factors are produced in the liver except von Willbrand factor
    The liver produces and breakdown factors integral to fibrinolysis
    It clears activated clotting factors from the circulation
    Vitamin K dependant factors : Factors ll, Vll, lX, and X
    Note : Vitamin K ( fat soluble vitamin) is stored in the liver in limited amounts
    Factor Vlll is made extensively in nonhepatic sites
    ( vascular endothelium)
  • 56. COAGULATION
    Clotting study
    PT – measures time to take factor ll, prothrombin, to be converted to thrombin then fibrinogen into fibrin.
    Factors activated are V, Vll, and X. This is the extrinsic pathway of coagulation. Normal 11.5 to 12.5
    Prolongation > 2 seconds is pathologic
    Prolongation > 3 seconds is associated with risk for bleeding
    PTT – also measures the generation of thrombin. This is the intrinsic pathway of coagulation.
    All factors are involved except Factor Vll.
    Since all factors are exclusively made by the liver except Factor Vll, the clotting study can reasonably assess the live synthetic function. HOWEVER, Vitamin K deficiency must be ruled out as the cause for the prolonged coagulation.
    Give 1mg/year of age slowly IM OR IV with a minimum of 1 mg given to full term infant
    Can check PT 4 TO 6 HOURS AFTER Vit K administration.
    Other prognostic tests : Factor Vll levels > 8%
    Be cautious with interpreting prolonged PT or PTT ----? DIC ? ( Factor Vll level may be helpful, normal in liver disease but decreased in DIC )
  • 57. GI EMERGENCIES
    HEPATIC ENCEPHALOPATHY
    (neuropsychiatric/ brain dysfunction resulting from acute hepatic dysfunction )
  • 58.
  • 59. GI EMERGENCIES
    A term infant fails to pass meconium . If the exam is unremarkable , what is the possible etiology and evaluation to perform ?
  • 60. THICK MECONIUM SYNDROMES
    Two types
    Meconium ileus
    Meconium plug syndrome
    Presentation :
    Simple 24 – 48 hours after birth
    Complicated - less than 24 hours of age
    Note : initial presentation for CF
    Dx :
    Contrast study of the colon
    Rx : contrast study of the colon
    Sugery for the complicated
    Note : polyhydraminious especially complicated
    “ soap bubbles” ( Neuhauser sign )
  • 62.
  • 63. HIRSCHSPRUNG’S DISEASE
    * Most common cause of lower intestinal obstruction
    in the neonate
    Incidence is 1 in 5,000
    Male to female - 3.8:1 ( 2.2:1 for total aganglionosis)
    Rectum and sigmond colon are the most common sites
    Positive family history – 3 to 7 %
    Etiology ? Ret proto-oncogene mapped to chromosome 10q11,2 ( gene has a critical role in oncgenesis and in the development of mammalian enteric neuron system
    • MEN 11a and MEN 11b syndrome
    Associated anomalies : Down’s syndrome, Waardenburg’s syndrome, cerebral palsy, mental retardation or developmental delay, meconium plug syndrome, MEN 11a, MEN11b
    Presentation : failure to pass meconium < 24-48 hours, or infrequent defecation from birth
    Diff Dx : meconium plug syndrome, microcolon, hypothyroidism, drugs that decrease intestinal transit, sepsis, neuronal intestinal dysplasia, functional constipation, anterior anus displacement, pseudo-obstruction
    Dx :
    • BE without prep- transition zone * negative after daily enemas in infants less than 2 weeks old and presence of total aganglionosis
    • 64. Rectal suction biopsy (RSB) or full thickness
    • 65. Anorectal manometry (ARM)
    RX : medical and surgery
  • 66.
  • 67.
  • 68.
  • 69. CLINICAL STAGES OF HEPATIC ENCEPHALOPATHY
    Stage
    1 ( Prodrome ) altered mental alertness
    2 ( Impending coma) drowsiness, altered sleep pattern, confusion, mood swing, inappropriate behavior
    3 (Stupor) sleepy but arousable, unresponsive to verbal commands , hyperreflexia
    4( Coma) unconscious, decerebrate, decorticate
    Response to pain present (4A) or absent (4B)
    Electroencephalographic
    Asterixis /changes
    1 slight/minimal
    2 easily elicited/usually generalized slowing of rhythm
    3 present if patient cooperates / grossly abnormal slowing
    4 usually absent/appearance of delta waves, decreased amplitude
  • 70. ABDOMINAL WALL DEFECTGastroschisis
    Its incidence is 1 in 12,00
    Its greater in prematurity or LBW INFANTS
    It results from mechanical insult ( early tear of the cord before the ring is complete. The abdominal wall is well developed
    It is associated with lower mortality than omphalocele as well as congenital anomalies
    NOTE : There is no change in mortality or morbidity with vaginal vs. C section. Also, there is no advantage to early delivery unless volvulus is highly suspected
    Dx : prenatal ultrasound
    Increased alpha fetoprotein (100 % )
    Rx : medical/surgery
  • 71. OMPHALOCELE
    Its incidence is 1 in 10,00
    Associated anomalies are determined by the site of fusion failure ---cephalic, lateral, or cardiac
    Pentalogy of Cantrell – combination of distal sternal, an omphalocele, an anterior diaphragmatic defect, and pericardial and intracardiac defect
    Associated anomalies : cardiovascular, chromosomal abnormalities (trisomy D and E ), Beckwith- Wiedman syndrome, gigantism
    Dx : prenatal ultrasound
    Increased alpha fetoprotein
  • 72. UMBILICAL
    Its an out pouching of the intestine through a defect of the fascia at the umbilical ring
    Common in newborns
    Five to ten times more common in Afro-American infants
    It’s a cosmetic problem
  • 73. ANORECTAL MALFORMATION OR IMPERFORATION
    This results from abnormal development of the urorectal septum leading to an absent or abnormal anus
    Classification based on relationship of the rectal pouch to the pelvic musculature
    -high : rectal pouch lies above the levator muscles (male > female)
    • Intermediate : rectum partially passes the levator muscles
    • 74. - Low : rectum tranverses the levator muscles completely ( male = female )
    Associated anomalies is common (50-70%)
    -genitourinary tract, skeletal, CNS, CVS, GI tract and esophageal atresia
    Dx : clinical/PE
    MRI AND / OR CT SCAN TO DISTINGUISH BETWEEN HIGH AND LOW
  • 75. GI TRACT EMERGENCIES : Intestinal Obstruction
    Give an example of intestinal obstruction emergency include clinical presentation, differential diagnosis, diagnostic approach, associated anomalies and treatment approach.
    What is the most common cause of intestinal obstruction in the infant ?
    What is the most common cause in children?
  • 76. GI TRACT EMERGENCIES
    What are the GI tract emergencies that are seen in both infants/children and adults ?
    What are the two categories that are seen in infants and children because of its unique presentation and/or more frequently seen in early in life ?