All about ultrasound

1. Paulo B.S. Tugbang

2. A three-month-old male with Down
Syndrome (T21) presents with passage of
bloody stools. Physical examination showed a
sausage-showed mass on the abdomen upon
palpation.

3.  AM is a three-month-old male baby boy,
seen for the first time on August 26, 2014,
accompanied by mother, presenting to the
emergency department with a 36-hour
history of non-bilious vomiting after every
feed and one episode of blood-tinge per
rectum.

4. AM, a known Down Syndrome baby, was previously
healthy until 36 hours prior to consult, when his
mother noted him to vomit all previously
breastfed milk. This was accompanied by
intermittent crying spells, decrease in appetite,
decreased activity, and decreased sleep.
The infant was taken to a local clinic, and was
treated as a case of gastroenteritis, and oral
rehydration therapy was started. He was reported
to be passing urine but less than usual.
When the symptoms did not improve, AM was
brought to our institution for further
management.

5.  No other relevant illnesses past or present
 No recent history of abdominal trauma

6.  Family Hx is positive for history of DS on
mother’s side (uncle)

7.  Born term via CS to a G2P0 mother
 Regular prenatal checkup during pregnancy
 Congenital scan at 6 months revealed DS
 No maternal complications during childbirth

8. (-) head lag
(+) rolls side to side
(+) able to follow objects/turns head toward
sound source
(+) reacts to sound occasionally
(-) no vocalizations
(-) eye fixation
(-) smile
(+) Primitive reflexes (Moro, Babinski)

9.  Pure breastfeeding
 Fed per demand
 Weaning not started

10.  VS 37.6, 158, 36, 85/55, 4kg
 CBG 6,7mmol/L, O2 Sat 99%
 Not in CP distress
 Awake, but lethargic, carried by mother
 Pale, listless
 Generally normal PE
 Abdominal exam showed AM disliking the test
 Draws up legs and crying while being examined
 Abdomen is tender and distended, with a
sausage shaped mass noted on the R
hypogastrium
 (+) passage of fresh mucousy blood per rectum
resembling red currant jelly

12.  Intussusception prob. idiopathic

13.  Down syndrome (T21) is
characterized by a variety of
dysmorphic features,
congenital anomalies, and
associated medical
conditions such as
respiratory and
cardiovascular system
anomalies, GI anomalies,
and lymphatic anomalies
 Appropriate radiologic
imaging with prompt,
accurate interpretation
plays an important role in
the diagnosis and
management of this
diseases

14.  First described by Barbette of Amsterdam in
1674
 The commonest cause of acute intestinal
obstruction in children below 2 years of age
 Has a male predominance with a ratio of 4:1
 If left untreated may be fatal in two to five
days

15. Any other part Ileocolic

16.  Idiopathic in most cases
 Two main theories: dietary theory and infective
theory
 May also occur in starvation, dehydration 2 to
severe GE, cystic fibrosis, and sickle cell crisis
 A lead point in the intestine allows the
telescoping of the intussusceptum (proximal
segment) into the intussuscipiens (adjacent distal
segment), obstruction, strangulation, and
mucosal bleeding occurs
 A specific lead point is not found in 90% of cases

17.  Classic triad of acute abdominal pain, currant
jelly stools or hematochezia, and palpable
abdominal mass
 History: infant, has had URTI presents with
vomiting (initially non bilious and reflexive, with
obstruction becomes bilious), abdominal pain
(colicky, severe, intermittent), passage of blood
and mucus (may also present with diarrhea),
lethargy, and abdominal mass
 PE: RHyp sausage-shaped mass and emptiness in
the RLQ (Dance sign) (Abdominal distention when
obstruction is complete)

18. Red currant jelly Stool

19. Target sign Pseudokidney sign

21. Gas-filled area Mass

22. Target sign (PR) Meniscus sign

23. Target sign (BE) Coiled spring sign

24.  Usually not helpful in evaluation
 WBC count – leucocytosis may be an
indication of gangrene
 Electrolyte count – with persistent vomiting
and sequestration of fluid in the obstructed
bowel

25.  Division by age (by lead points) indicate
treatment
 Operative reduction
 Non-operative reduction

26.  Not standard of care
 Use of opioid analgesics and NSAIDs for pain
control post operatively