Intestinal obstruction in children


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Intestinal obstruction in children

  1. 1. IntestinalIntestinal Obstruction inObstruction in ChildrenChildren
  2. 2. ObjectivesObjectives • Presentation of obstruction • To know different causes • A brief about each cause
  3. 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. 4. IMAGING •Ba Meal •( Thickened mucosal folds, localized filling defects due to intramural hematoma) •CT Abdomen •(for assessment of acute trauma and hematoma directly, or for abnormal duodenal enhancement)
  5. 5. Enhanced CTEnhanced CT Intramural duodenal hematoma almost completelyIntramural duodenal hematoma almost completely obscuring the lumenobscuring the lumen
  6. 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. 7. • Presentation depends on the 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. 8. ImagingImaging • Radiography (mass effect with displacement of adjacent bowel loops) • Ultrasound (simple hypoechoic cyst, Gut wall signature)
  9. 9. Hypoechoic cyst with double ‘gut wallHypoechoic cyst with double ‘gut wall signature’(inner echogenic mucosa & outersignature’(inner echogenic mucosa & outer hypoechoic smooth muscle layerhypoechoic smooth muscle layer
  10. 10. Differentials •-mesenteric •-omental •-choledochal •-renal •-ovarian
  11. 11. Mesenteric/OmentalMesenteric/Omental cyst(lymphangiomas)cyst(lymphangiomas) • Developmental anomalies of lymphatic system (mesentry/ omentum) Presentation • -similar to duplication cyst • On U/S multiloculated cyst with thin septation • Tx– surgical resection
  12. 12. Mesenteric Cyst
  13. 13. 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
  14. 14. Supine & prone radiographs of the upper GI barium seriesSupine & prone radiographs of the upper GI barium series
  15. 15. AppendicitisAppendicitis • Peak incidence 12-15 years Presention • -ill defined abd. Pain in RIF • -fever and vomiting
  16. 16. IMAGINGIMAGING Radiography •May be normal or 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
  17. 17. Right iliac fossa mixed echogenicity inflammatoryRight iliac fossa mixed echogenicity inflammatory mass and echogenic focus with acousticmass and echogenic focus with acoustic shadowingshadowing
  18. 18. Hypoechoic tubular structure 7mm in diameterHypoechoic tubular structure 7mm in diameter adjacent to iliac vesselsadjacent to iliac vessels
  19. 19. CT findings are •--localized or multi-focal abscess
  20. 20. ComplicationComplication • Appendicolith • Pelvic abcess • Generalized peritonitis • Portal vein thrombosis • Multiple hepatic abcess ( rare)
  21. 21. Differential •-- mesenteric adenitis •--Crohn’s disease •--Infection •--ovarian torsion/cyst
  22. 22. HENOCH SCHONLEINHENOCH SCHONLEIN PURPERAPURPERA Small bowel vasculitis •Jejunum most frequently involved •Unknown etiology/postinfectious/post drug therapy Presentations with •Purpuric rash over the buttocks & legs •Abdominal pain •glomerulonephritis
  23. 23. Henoch schonlein pupuraHenoch schonlein pupura Ultrasound & barium follow throughUltrasound & barium follow through
  24. 24. JejunalJejunal bowel wall thickeningbowel wall thickening
  25. 25. Complications •Transient small bowel intussusception(rare) •Echogenic kidney suggest renal involvement
  26. 26. OTHEROTHER INFECTIONS •(giardia,compylobacter,yersinia,salmonella etc) GRAFT VERSUS HOST REACTION •(mostly effecting small bowel) CROHN’S DISEASE •(mostly effecting terminal ilium & cecum)
  27. 27. Polyps and polyposisPolyps and 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
  28. 28. • Double contrast barium enema • Endoscopy • A pedunculated polyp with a long stalk is seen
  29. 29. Barium enema showing a pedunculated polyp in theBarium enema showing a pedunculated polyp in the descending colondescending colon
  30. 30. Juvenile polyposisJuvenile polyposis • Positive family hx (most cases) • Five or more polyps • Associated with higher long term risk of colonic carcinoma
  31. 31. Peutz jeghers syndromePeutz jeghers 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
  32. 32. Complications •Intussusception around polyps(usually transient) •Small bowel obstruction •Gastrointestinal adenocarcinoma & non GI neoplasm involving pancreas, breast or reproductive organs
  33. 33. • Familial polyposis coli • Gardner syndrome • Both are dominanly inherited • Multiple adenomatous polyps are found (numerous in colon) • High malignant potential • Prophylactic proctocolectomy usually recommended
  34. 34. TURCOT’S SYNDROMETURCOT’S SYNDROME • Autosomal recessive condition • Colonic adenomas associated with CNS glioma
  35. 35. Small bowel malignanciesSmall bowel 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
  36. 36. ULTRASOUND •Thickened hypoechoic bowel loops are seen often forming adherent masses with infiltration of adjacent omentum & mesentery •Hepatospenomegaly •Retroperitoneal lymphadenopathy
  38. 38. 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
  39. 39. GI SYMPTOMS •Diarrhoea •Abdominal pain
  40. 40. IMAGINGIMAGING • ENDOSCOPY • BARIUM ENEMA(largely replaced by endoscopy) • aphthoid ulceration • mucosal ulceration is deep, discontinuous & asymmetrical • generally have thicker colon than ulcerative colitis • LEUCOCYTE SCINTOGRAPHY(extent of disease)
  41. 41. CT SCAN •transmural bowel wall thickening •creeping fat within the mesentery •strictures •fistulas •localised collection MRI •assessment of disease extent
  42. 42. Innumerable aphthoid ulcer in crohn’s diseaseInnumerable aphthoid ulcer in crohn’s disease
  43. 43. Enema in crohn’s disease 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
  44. 44. ULCERATIVE COLITISULCERATIVE COLITIS • Relapsing and remitting proctits • Rectum is always effected • Effects young adults(15-25yrs) with second smaller peak at approx 60yrs
  45. 45. CLINICAL FINDING •bloody diarrhoea •abdominal pain •failure to thrive
  46. 46. IMAGINGIMAGING Double contrast barium enema Proctosigmoidoscopy •loss of normal mucosal vascular pattern (earliest detectable change) •ulceration is continuous & superficial •(deep ulceration does occur) •haustral blunting
  47. 47. • Luminal narrowing • Colonic shortening(due to muscular abnormality rather than fibrosis) CT SCAN not for primary diagnosis once toxic megacolon is established
  48. 48. Double contrast barium enema shows granularDouble contrast barium enema shows granular mucosa (changes of early disease)mucosa (changes of early disease)
  49. 49. Complication •Risk of colonic ca is high approx 20% per decade •toxic megacolon
  50. 50. 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
  51. 51. Bowel wall thickening & fat strandingBowel wall thickening & fat stranding
  52. 52. 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
  53. 53. IMAGINGIMAGING Ultrasound •Association of colonic thickening &echogenic kidneys is highly suggestive of diagnosis •Doppler flow within the bowel wall is reduced (atleast in prodromal phase)
  54. 54. INTUSSUSCEPTIONINTUSSUSCEPTION • Invagination of a 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
  55. 55. Classic presentation •Episodic abdominal pain •Screaming episodes associated with passage of blood & mucus(current jelly) •Haemodynamic instability due to considerable fluid shift
  56. 56. IMAGINGIMAGING Abdominal radiograph •Absence of bowel 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
  57. 57. Paucity of bowel gas in the right iliac fossa andPaucity of bowel gas in the right iliac fossa and soft tissue masssoft tissue mass
  58. 58. Transverse ultrasound showing multipleTransverse 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
  59. 59. • Small crescents of 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
  60. 60. TREATMENTTREATMENT RADILOLOGICAL REDUCTION •Absolute contraindications are peritonitis and perforation PNEUMATIC REDUCTION(air enema) •Replaced the barium in most paediatric centres(70- 90% success rate)