1. IntestinalIntestinal
Obstruction inObstruction in
ChildrenChildren

2. ObjectivesObjectives
• Presentation of obstruction
• 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
•( 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. Enhanced CTEnhanced CT
Intramural duodenal 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 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. ImagingImaging
• Radiography
(mass effect with displacement of adjacent bowel
loops)
• Ultrasound
(simple hypoechoic cyst, Gut wall signature)

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

11. Differentials
•-mesenteric
•-omental
•-choledochal
•-renal
•-ovarian

12. 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

13. Mesenteric Cyst

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 & prone radiographs of the upper GI barium seriesSupine & prone radiographs of the upper GI barium series

16. AppendicitisAppendicitis
• Peak incidence 12-15 years
Presention
• -ill defined abd. Pain in RIF
• -fever and vomiting

17. 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

18. Right iliac fossa mixed echogenicity inflammatoryRight iliac fossa mixed echogenicity inflammatory
mass and echogenic focus with acousticmass and echogenic focus with acoustic
shadowingshadowing

19. Hypoechoic tubular structure 7mm in diameterHypoechoic tubular structure 7mm in diameter
adjacent to iliac vesselsadjacent to iliac vessels

20. CT findings are
•--localized or multi-focal abscess

21. ComplicationComplication
• Appendicolith
• Pelvic abcess
• Generalized peritonitis
• Portal vein thrombosis
• Multiple hepatic abcess ( rare)

22. Differential
•-- mesenteric adenitis
•--Crohn’s disease
•--Infection
•--ovarian torsion/cyst

23. 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

24. Henoch schonlein pupuraHenoch schonlein pupura
Ultrasound & barium follow throughUltrasound & barium follow through

25. JejunalJejunal bowel wall thickeningbowel wall thickening

26. Complications
•Transient small bowel intussusception(rare)
•Echogenic kidney suggest renal involvement

27. OTHEROTHER
INFECTIONS
•(giardia,compylobacter,yersinia,salmonella etc)
GRAFT VERSUS HOST REACTION
•(mostly effecting small bowel)
CROHN’S DISEASE
•(mostly effecting terminal ilium & cecum)

28. 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

29. • Double contrast barium enema
• Endoscopy
• A pedunculated polyp with a long stalk is seen

30. Barium enema showing a 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 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

33. Complications
•Intussusception around polyps(usually transient)
•Small bowel obstruction
•Gastrointestinal adenocarcinoma & non GI neoplasm
involving pancreas, breast or reproductive organs

35. • Familial polyposis coli
• 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 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

38. ULTRASOUND
•Thickened hypoechoic bowel loops are seen often
forming adherent masses with infiltration of adjacent
omentum & mesentery
•Hepatospenomegaly
•Retroperitoneal lymphadenopathy

39. CAUSES OF COLITIS INCAUSES 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

41. GI SYMPTOMS
•Diarrhoea
•Abdominal pain

42. 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)

43. CT SCAN
•transmural bowel wall thickening
•creeping fat within the mesentery
•strictures
•fistulas
•localised collection
MRI
•assessment of disease extent

44. Innumerable aphthoid ulcer in crohn’s diseaseInnumerable aphthoid ulcer in crohn’s disease

45. 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

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
•abdominal pain
•failure to thrive

48. 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

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 barium enema shows granularDouble contrast barium enema shows granular
mucosa (changes of early disease)mucosa (changes of early disease)

51. Complication
•Risk of colonic ca 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 colonic thickening &echogenic
kidneys is highly suggestive of diagnosis
•Doppler flow within the bowel wall is reduced (atleast
in prodromal phase)

56. 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

57. Classic presentation
•Episodic abdominal pain
•Screaming episodes associated with passage of
blood & mucus(current jelly)
•Haemodynamic instability due to considerable fluid
shift

58. 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

59. Paucity of bowel gas in the right iliac fossa andPaucity of bowel gas in the right iliac fossa and
soft tissue masssoft tissue mass

60. 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

61. • 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

62. TREATMENTTREATMENT
RADILOLOGICAL REDUCTION
•Absolute contraindications are peritonitis and
perforation
PNEUMATIC REDUCTION(air enema)
•Replaced the barium in most paediatric centres(70-
90% success rate)

63. THANKSTHANKS