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Clinical Pathological Conference 2004-12-29


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Title: Clinical Pathological Conference 2004-12-29

Clinical Pathological Conference 2004-12-29
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Case Presentation Present Illness
  • This one-year-six-month-old boy came to our
    pediatric emergency department with the chief
    compliant of bilious vomiting and intermittent
    irritable crying since 4 hours ago.

Case Presentation Personal and Family History
  • Past history
  • Before this presentation,the child was in good
    condition without any compliant of abdominal

Case Presentation Physical Examination
  • Vital sign PR ? 136 /min (70-110),
  • RR 20 /min(20-30), BT 35.7 ºC
  • BP ? 112/70(90-105,50-70),
  • decreased urine output.
  • HEENT dehydration with dry lip.
  • Abdomen soft, neither sign of peritonitis nor
    hepatosplenomegaly .

Case Presentation Radiologic Lab Findings
  • Plain film of abdomen showed a nonspecific
    local ileus pattern over right upper quadrant.
  • Laboratory data
  • white blood count ? 25300/nl (6000-17500/nl)
  • with 75 segment(54-62) and
  • 18 lymphocyte(25-33).

Case Presentation Radiologic Lab Findings
  • Serum biochemistry
  • Sodium 145 (139-146)mEq/L
  • Potassium 4.5 (3.5-5.0)mEq/L
  • Chloride ? 130 (98-106)mEq/L
  • BUN 19 mg/dl,
  • Creatinene 0.4(0.2-0.4)mg/dl
  • C reative protein level 0.1mg/dl.

Case Presentation Radiologic Lab Findings
  • Abdomen sonography revealed a soft tissue mass
    over right lower quadrant, but no evidence of
    sign of target appearance besides, the
    relationship of superior mesentery artery and
    superior mesentery vein was in right position.

Case Presentation Hospital Course-I
  • Under the impression of intestinal obstruction,
    he was admitted to our pediatric department for
    further evaluation and management.
  • After admission, this patient had persistent
    bilious vomiting.

Case Presentation Hospital Course-II
  • Twelve hours later, heart rate increased to
    150-180 per minutes.
  • Meanwhile, decreased urine output and downhilled
    blood pressure happened to him despite of
    intravenous fluid supplement.
  • Under the impression of intestinal obstruction
    complicated with shock, our pediatric surgeon
    arranged emergency laparotomy.

Case Presentation Hospital Course-II
  • Post-operative course was relative smooth,and
    started feeding on the 4th day of lapatotomy
  • His condition was stable during the follow-up
    period at our out patient clinics.

Major Problems Minor Problems
  • Bilious vomiting
  • A soft tissue mass over right lower quadrant
  • Downhilled blood pressure(shock)
  • Intermittent irritable crying
  • Decreased urine output
  • Leukocytosis
  • Hyperchloremia
  • Local ileus pattern over right upper quadrant
  • Tachycardia
  • Hypertension

Questions about past, personal, family history
  • Birth history?
  • History of trauma? Child abuse?
  • Operation history? foreign body aspiration?
  • Drug history? Food history?
  • Family history about tumor? About cystic

Questions- about Physical Examination and
laboratory data
  • Anemic conjunctiva? Lymphoadenopathy?
  • RLQ soft tissue mass movable or non-movable?
  • Bowel sound? Hyperactive to be replaced with
    hypoactive bowel sounds?
  • Stool rontine examination? occult blood? WBC?
  • Blood smear? blast cell?

Questions-about radiologic finding
  • Plain film of abdomen further finding? Foreign
  • Abdomen Sonography further finding? Appendix?
    Ascites?Kidney? Any finding about tumor?

Bilious vomiting
  • Vomitus or nasogastric aspirate containing bile
    which in children almost always indicates bowel
    obstruction distal to the sphincter of Oddi.
  • By contrast, infants with pyloric stenosis have
    non-bile-stained vomiting.

Intestinal obstruction
  • Intraluminal polyp, mass, parasites,
  • and tumor.
  • Intramural stricture, tumor,
  • hematoma.
  • Extrinsicpostoperative adhesion, adhesion from
    peritonitis, hernia, volvulus,and tumor.

Clinical Classification of Shock
  • Septic shock bacterial,Viral,Fugal..
  • Cardiogenic shock ischemia, cardiomyopathy
    ,congestive heart failure
  • Distributive shocktoxins,anaphylaxis
  • Hypovolemic shock enteritis,hemorrhage,
  • Obstructive shock tension pneumothroax

  • Pathophysiology
  • Metabolic Acidosis with a normal Anion Gap
  • Causes
  • Artifact (low Anion Gap)
  • Metabolic and Endocrine
  • Hyperparathyroidism, Renal Tubular Acidosis,
  • Bromide intoxication
  • Nervine, Sominex
  • Acetazolamide
  • Carbonic anhydrase inhibition
  • Boric acid , Triamterene ,Ammonium Chloride
  • Excess IV Normal Saline

  • Gastrointestinal
  • Dehydration
  • Prolonged Diarrhea
  • Loss of pancreatic secretion
  • Ileal loops
  • Ureteral colonic anastomosis

Malrotation with volvulus Appendicitis Other
causes of intestinal obstrution Congenital
structural abnormalities Postsurgical
adhesions Foreign body/Bezoars Meckels
diverticulum Incarcerated inguinal
hernia Meconium ileus Intussusception Hirschsprung
s disease Superior mesenteric artery
syndrome Duodenal hematoma Testicular or ovarian
(From Pediatric Decision-making Strategies
accompanied by Nelson)
Surgery Consult
Signs or symptoms suggestive of an acute
History and physical exam
Sign or symptoms suggestive of increased ICP?
Sign or symptoms suggestive of increased ICP
Malrotation with volvulus Appendicitis Congenit
al structural abnormalities Postsurgical
adhesions Foreign body/Bezoars Meckels
diverticulum with bleeding Incarcerated inguinal
hernia Meconium ileus Intussusception Hirschsprung
s disease Superior mesenteric artery
syndrome Duodenal hematoma Testicular or ovarian
Abdomen US
(From Pediatric Decision-making Strategies
accompanied by Nelson)
Abnormal result
Perform abdomen US
Lower abdomen mass in female
History and physical exam
Normal result
Abdomen mass
Hepatomegaly or splenomegaly present
Perform Abdomen CT
Not neonate , Not female with lower abdomen
mass Splenomegaly Wilms tumor Adrenal cortical
neoplasms Pancreatic masses/cysts Neuroblastoma
Hydronephrosis Rhabdomyosarcoma Urinary retention
Hepatic lesion Teratoma Bezoar Appendiceal
abscess Intestinal tumor Mesenteric cyst
Omental cyst Lymphangioma Lymphoma Choledochal
cyst Constipation Inflammatory bowel
disease Retroperitoneal hematoma
Foreign body/Bezoars Meckels diverticulum Hirschs
prungs disease Appendicitis Intestinal
tumor Neuroblastoma Rhabdomyosarcoma Lymphoma C
ongenital structural abnormalities
Foreign body/Bezoars (bezôr)
  • An accumulation of exogenous matter in the
    stomach or intestine.
  • peak incidence between the ages of 6 mo and 3 yr
  • 90 of foreign bodies are opaque.
  • vomiting, anorexia, and weight loss.
  • An abdominal plain film may suggest the presence
    of a bezoar, which can be confirmed on ultrasound
    or CT examination.

Gastric trichobezoar Pediatric Emergency Care.
19(5)343-7, 2003 Oct.
  • On plain abdominal radiographs, the bezoar will
    appear as a mottled heterogenous mass that may be
    mistaken for a food-filled stomach.
  • The classic sonographic appearance is described
    as a band of increased echogenicity in the region
    of the stomach with complete loss of posterior

Small bowel obstruction and covered perforation
in childhood caused by bizarre bezoars and
foreign bodies.
  • Small bowel obstruction with perforation is an
    unusual and rare complication of bezoars.
  • Israel Medical Association
    Journal Imaj. 2(2)129-31, 2000 Feb.

Hirschsprungs disease
  • Abnormal innervation of the bowel .
  • Most common cause of lower intestinal obstruction
    in neonates .
  • Usually begin at birth with the delayed passage
    of meconium.
  • Some infants pass meconium normally but
    subsequently present with a history of chronic

Hirschsprungs disease
  • Failure to thrive, with hypoproteinemia from a
    protein-losing enteropathy, is a less common
  • Rectal examination demonstrates normal anal tone
    and is usually followed by an explosive discharge
    of foul-smelling feces and gas.

Hirschsprungs disease
  • Rectal manometry and rectal suction biopsy are
    the easiest and most reliable indicators of
    Hirschsprung disease.
  • Barium enema examination is useful in determining
    the extent of aganglionosis.
  • Sonography may also help in determining the
    dynamic or adynamic state of fluid-filled or
    solid-filled bowel loops.

Meckels diverticulum
  • Remnant of the embryonic yolk sac
  • Arise within the 1st 2 yr of life .
  • Intermittent painless rectal bleeding by
    ulceration of the adjacent normal ileal mucosa.

Meckels diverticulum
  • Brick colored or currant jelly colored.
  • Obstruction occurs when the diverticulum acts as
    the lead point of an intussusception.
  • A Meckel diverticulum may occasionally become
    inflamed (diverticulitis) and present similarly
    to acute appendicitis.
  • The most sensitive study is a Meckel radionuclide

Meckel's diverticulum. Internal hernia and
adhesions without gastrointestinal
bleeding--ultrasound and scintigraphic findings.
  • US study was particularly helpful in this case
    because it shows a nonperistaltic region, which
    is consistent with a diverticulum or an internal
  • Clinical Nuclear
    Medicine. 21(12)938-40, 1996 Dec.

Meckel's diverticulum mimicking infantile colic
sonographic detection.
  • Abdominal sonography at 6 months of age
    demonstrated an abdominal mass with an anechoic
    center and a double-layered wall, surrounded by
    bowel loops.
  • Histologic examination of the resected mass
    revealed a Meckel's diverticulum with a
    perforation sealed off by the neighboring bowel
    and mesentery to form an inflammatory mass.
  • Journal of Clinical
    Ultrasound. 28(6)314-6, 2000 Jul-Aug

Gastrointestinal bleeding in infants and
children Meckel's diverticulum and intestinal
duplication. Seminars in Pediatric Surgery.
8(4)202-9, 1999 Nov.
  • Meckel's diverticula and intestinal duplications
    may cause gastrointestinal bleeding in almost any
    age group and require a high index of suspicion
    for diagnosis.

  • The risk of perforation is greatest in 1- to
    4-yr-old children (7075) and is lowest in the
    adolescent age group (3040) .
  • The classic triad consists of pain, nausea with
    vomiting, and fever.
  • The progression from onset of symptoms to
    perforation usually occurs over 3648hr.

  • History included onset of pain before vomiting or
    diarrhea, loss of appetite, migration of pain
    from periumbilical to right lower quadrant.
  • Auscultation may reveal normal or hyperactive
    bowel sounds in early appendicitis, to be
    replaced with hypoactive bowel sounds as it
    progresses to perforation.

  • Findings of appendicitis on abdominal films
    include calcified appendicolith, small bowel
    distention or obstruction, and soft tissue mass
  • Graded compression ultrasonography is a
    noninvasive study with false-negative and
    false-positive rates of 810 .
  • CT is more sensitive and specific than
    ultrasonography and more likely to change patient

Pediatric appendicitis in "real-time" the value
of sonography in diagnosis and treatment.
Pediatric Emergency Care. 17(5)334-40, 2001
  • The natural progression in appendicitis from
    initial symptoms to perforation is about 36 to 48
    hours . However, perforation may occur more
    rapidly in the younger child, sometimes within 6
    to 12 hours .
  • Extensive necrosis of the appendix may render it
    difficult to visualize .

Pediatric appendicitis in "real-time" the value
of sonography in diagnosis and treatment.
Pediatric Emergency Care. 17(5)334-40, 2001 Oct.
  • We may have to rely on the other ultrasound
    features of peri-appendiceal inflammation.
  • Studies have shown that the presence of loculated
    pericecal fluid, prominent pericecal fat, atonic
    bowel loops, thickened bowel walls, and the
    circumferential loss of the appendiceal
    submucosal layer on ultrasound were the
    significant predictive factors for perforation .

Distal Intestinal Obstruction Syndrome
  • In the older child or young adult with CF, the
    distal small bowel may by obstructed by thick
    stool. This condition was called "meconium ileus
    equivalent" by Jensen in 1962 .
  • Palpable mass in the right lower abdominal
    quadrant. Bilious vomiting as a result of the
    intestinal obstruction

Distal Intestinal Obstruction Syndrome
  • Radiographs of the abdomen demonstrate dilated
    small bowel loops and a bubbly ileocecal
    soft-tissue mass .

Carcinoid tumor
  • About 85 of carcinoid tumors develop in the
    gastrointestinal tract, usually the appendix.
  • Carcinoid syndromeflushing,diarrhea,
  • wheezing.
  • Carcinoid crisisgeneralized flush,
    tachycardia, severe diarrhea with abdominal pain,
    hypotension converting to hypertension, and
    central nervous system changes leading to coma
    and then death.

Carcinoid tumor
  • Approximately 40 of the tumors occurred within 2
    feet of the ileocecal valve, with very few in the
    proximal small intestine.
  • These tumors frequently elicit a mesenteric
    fibrosing reaction, in which the bowel becomes
    shortened and kinked, frequently causing partial
    small bowel obstruction.

Carcinoid tumor
  • On CT, the mesenteric extension from carcinoid
    will usually appear as a soft tissue-density
    mesenteric mass .
  • Calcification can be seen in up to 70 of cases .

Lymphoma from manual of pediatric hematology and
oncology ,3rd edition
  • Non-Hodgkins lymphoma
  • peak age 5-15 years ,rick factor including
    genetic and poettransplantation
  • Clinical featureHead and neck(13),

Non-Hodgkins lymphoma
  • The ileum is mostly involved due to a higher
    number of lymphocytes in the distal gut,
    accounting for about 50 of small bowel lymphomas
  • Present with abdomen pain, vomiting and diarrhea,
    abdominal distension, palpable mass,
    intussusception,peritonitis, ascites, GI
    bleeding, hepatosplenomegaly.

Multidetector-row computed tomography and
3-dimensional computed tomography imaging of
small bowel neoplasms current concept in
  • Lymphoma can appear as a single mass lesion,
    which varies in size.These can lead to
    intussusception, but rarely will result in
    obstruction because the masses are typically
    pliable and soft.
  • Again, because the masses are characteristically
    soft, it is rare that the mesenteric vasculature
    is compromised.

  • Journal of
    Computer Assisted Tomography. 28(1)106-16, 2004

Neuroblastoma from manual of pediatric
hematology and oncology,3rd edition
  • Give rise to adrenal medulla and the sympathetic
  • Most common tumor in infancy ,peak incidence is 2
    years of age
  • Clinical finding related to anatomic site of
    abdomen anorexia ,vomiting,abdomen pain,massive
    involvement of the liver with metastasis
    (especially in the newborn)

  • Paraneoplastic manifestations
  • excessive catecholamine secretion
    (sweating,flushing, paller,palpitation,
    hypertension) ,VIP secretion (watery
    diarrhea,abdomen distension, hypokalemia) ,and
    acute myoclonic encephalopathy.

Neuroblastoma Grainger Allison's Diagnostic
Radiology A Textbook of Medical Imaging, 4th
  • A neuroblastoma is usually solid with a
    heterogeneous echotexture. Calcification is
    evident by the presence of echogenic foci with
    posterior acoustic shadowing.
  • Anterior displacement and encasement of the aorta
    and inferior vena cava (IVC) by this
    retroperitoneal tumour is characteristic.

Rhabdomyosarcoma from manual of pediatric
hematology and oncology,3rdedition
  • Two age peaks2-6 years and 15-19 years.
  • Rare primary sites for rhabdomyosarcoma include
    the GI-hepatobiliary tract(3), where in presents
    with obstructive jaundice and a large abdomen
  • These tumors arise in the common bile duct and
    may extend into both lobes of the liver.

Final diagnosis
  • 1.Meckels diverticulum with diverticulitis or
    congenital structural abnormalities
  • 2.Ruptured Appendicitis


Mesenteric cyst / Omental cyst
  • They ranged in age from 1 month to 14 years 75
    were younger than 5 years.
  • The main presenting symptom is abdominal pain,
    followed by nausea and vomiting.
  • Some mesenteric cysts may present as an acute
    abdomen due to a possible complication, such as
    hemorrhage, rupture, or torsion of the cyst.

Mesenteric cyst / Omental cyst Mesenteric cysts
in children Surgery 1994115571-7
  • Acute symptoms are related to compression of
    intra-abdominal organs or stretching of the
    mesentery by rapid expansion.
  • Among these categories, the cystic lymphangioma
    is differentiated from the others because it is
    far more common in children.

  • Five pathologic patterns account for most
    mesenteric cysts, namely, lymphangioma, enteric
    duplication cysts, enteric cysts, mesothelial,
    and nonpancreatic pseudocysts.

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    ???????,??????,??????????,???????????164 mg/dl
    (???lt50 mg/dl) ??????????????,????????????????????
    ?(???? 2004 54 189-93)

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Leiomyoma of the small bowel with hypercalcaemia
presence of a substance with parathormone
activity Nouvelle Presse Medicale. 8(40)3245-6,
1979 Oct 22.
  • A leiomyoma of the small bowel produced
    laboratory features of hyperparathyroidism which
    disappeared promptly after tumour resection.
  • Hypercalcaemia, hypophosphatemia,
    hyperchloremia, elevated chloride/phosphorus
    ratio, increased urinary cyclic AMP, and blood
    levels of immunoreactive parathormone were

Retroperitoneal hematoma
  • In the majority of cases there is an associated
    pathological condition of a viscus or vessel due
    to trauma, aneurysm, atherosclerosis, eroding
    primary or secondary tumors, or pancreatitis.
  • Furthermore, some have stated that hemophilia and
    anticoagulant therapy may be the cause in some

Retroperitoneal hematoma
  • These patients usually present with mild to
    severe abdominal pain, nausea and vomiting.
  • Physical examination reveals signs of shock,
    ileus and flank mass.
  • CT scans are used usually to establish the
    diagnosis of retroperitoneal hematoma.

Bilious vomiting intermittent irritable crying
Dehydration Hypertension Leukocytosis Hyperchlorem

one-year-six month-old boy
Decreased urine output and downhill BP in 16
Soft tissue mass over RLQ by Abdomen sonography
Wilms tumor
  • It may be associated with hemihypertrophy,
    aniridia, and other congenital anomalies, usually
    of the genitourinary tract.
  • Sign of Wilms tumorpalpable mass in abdomen
    (60),hypertension (25), hematuria(15),abdomen
    mass is the most common presenting symptom and
    sign ,occasionally there is abdomen
    pain,especially when hemorrhage occurs in the
    tumor following trauma.

Wilms tumor
  • Some patients may present with abdominal pain and
    vomiting and, infrequently, hematuria.
  • Occasionally, rapid abdominal enlargement and
    anemia may occur owing to bleeding into the renal
    parenchyma or pelvis.

Wilms tumor Grainger Allison's Diagnostic
Radiology A Textbook of Medical Imaging, 4th
  • On ultrasound examination the tumour appears as a
    well-defined, solid mass of mixed
    echogenicity.Areas of haemorrhage and necrosis
    can produce focal hypoechoic lesions within the
  • Ultrasound may be used for periodic surveillance
    of the opposite kidney.

Superior mesenteric artery syndrome
  • The classic example is an adolescent who starts
    vomiting after application of a body cast for
    orthopedic surgery. Other associated factors
    include anorexia, prolonged bed rest, weight
    loss, abdominal surgery, and exaggerated lumbar
  • The diagnosis is established radiologically with
    the demonstration of a cutoff of the duodenum
    just to the right of the midline.

Superior mesenteric artery syndrome
  • An extrinsic compression of the duodenum in
    children after rapid weight loss and in a supine
  • The compression is thought to occur as the
    mesentery loses its fat and allows the superior
    mesenteric artery to collapse on the duodenum,
    compressing it between the superior mesenteric
    artery anteriorly and the aorta posteriorly.

Inflammatory bowel disease
  • The most common time of onset of IBD is during
    adolescence and young adulthood. A bimodal
    distribution has been shown with an early onset
    at 1525 yr of age and a second smaller peak at
    5080 yr of age.
  • Nonetheless, IBD may begin as early as the 1st yr
    of life.
  • In developed countries, these disorders are the
    major causes of chronic intestinal inflammation
    in children beyond the 1st few yr of life.

Ulcerative colitis
  • Bloody stool and diarrhea are the typical
    presentation of ulcerative colitis. Constipation
    may be observed in those with proctitis.
  • Fever, severe anemia, hypoalbuminemia,
    leukocytosis, and greater than five bloody stools
    per day for 5 days is what defines fulminant

Ulcerative colitis
  • Extraintestinal manifestations that tend to occur
    more commonly with ulcerative colitis than with
    Crohn disease include pyoderma gangrenosum,
    sclerosing cholangitis, chronic active hepatitis,
    and ankylosing spondylitis.

Crohns disease
  • Crohn colitis may be associated with bloody
    diarrhea, tenesmus, and urgency.
  • Children with Crohn disease often appear
    chronically ill, weight loss linear growth

Crohns disease
  • The initial presentation most commonly involves
    ileum and colon (ileocolitis) but may involve the
    small bowel alone in about 30 or colon alone in
  • Children with ileocolitis typically have
    cramping, abdominal pain, and diarrhea, sometimes
    with blood. Ileitis may present as right lower
    quadrant abdominal pain alone.

Crohns disease
  • There may be abdominal tenderness that is either
    diffuse or localized to the right lower quadrant.
  • The diagnosis of Crohn disease depends on
    finding typical clinical features of the disorder
    (history, physical examination, laboratory
    studies, and endoscopic or radiologic findings).

Crohns disease
  • Plain films of the abdomen may be normal or may
    demonstrate findings of partial small bowel
    obstruction or thumbprinting of the colon wall.
  • An upper gastrointestinal contrast study with
    small bowel follow-through may show aphthous
    ulceration and thickened, nodular folds as well
    as narrowing of the lumen anywhere in the
    gastrointestinal tract.

  • Duplications can be classified into three
    categories localized duplications, duplications
    associated with spinal cord defects and vertebral
    malformations, and duplications of the colon.
  • Duplications may cause bowel obstruction by
    compressing the adjacent intestinal lumen, or
    they may act as the lead point of an
    intussusception or a site for a volvulus.

  • If they are lined by acid-secreting mucosa, they
    may cause ulceration, perforation, and hemorrhage
    of the adjacent bowel.
  • Patients may present with abdominal pain,
    vomiting, palpable mass, or acute
    gastrointestinal hemorrhage.

  • Radiologic studies such as barium studies,
    ultrasonography, CT, and MRI are helpful but
    usually nonspecific, demonstrating cystic
    structures or mass effects.
  • Radioisotope technetium scanning may localize
    ectopic gastric mucosa.
  • The treatment of duplications is surgical
    resection and management of associated defects.

Atypical presentation of an intestinal
duplication in a three month old child Journal
de Radiologie. 85(6 Pt 1)773-5, 2004 Jun.
  • Intestinal duplication is an uncommon congenital
    anomaly that often is diagnosed during childhood.
  • Ultrasound diagnosis is based on the presence of
    a characteristic double-walled cystic mass.
  • We report a case of duplication in a three Month
    old child presenting with small bowel

Intestinal duplication presenting as spontaneous
hemoperitoneum. Journal of Pediatric
Gastroenterology Nutrition. 31(2)181-2, 2000
  • In approximately 60 of the cases, the condition
    appears during the first year of life as a
    palpable abdominal mass or as complications such
    as intestinal obstruction due to extrinsic
    compression, volvulus, or intussusception.

Intestinal duplication presenting as spontaneous
hemoperitoneum. Journal of Pediatric
Gastroenterology Nutrition. 31(2)181-2, 2000
  • It was probably caused by erosion of a blood
    vessel adjacent to the perforation that had been
    sealed off at laparotomy.

Sudden infant death, large intestinal volvulus,
and a duplication cyst of the terminal ileum.
American Journal of Forensic Medicine
Pathology. 21(1)62-4, 2000 Mar.
  • If an intussusception or volvulus is identified,
    careful search for predisposing lesions or
    conditions such as duplication cysts, mesenteric
    cysts, mesenteric defects, Meckel's diverticula,
    mesenteric lymph nodes, polyps, neoplasms, mural
    hematomas, or cystic fibrosis should also be

Jejunal and Ileal Atresia and Obstruction
  • Jejunoileal atresias have been attributed to
    intrauterine vascular accidents leading to
    ischemic necrosis of the sterile bowel and
    resorption of the affected segments.

  • Most infants become symptomatic during the 1st
    day of life with abdominal distention and
    bile-stained emesis or gastric aspirate.

  • Plain radiographs demonstrate many air-fluid
    levels or peritoneal calcification associated
    with meconium peritonitis.
  • In meconium ileus, plain films of the abdomen
    show a typical hazy or ground-glass appearance in
    the right lower quadrant.

  • Pneumoperitoneum is most readily seen as free air
    between the liver and the diaphragm on an upright
    radiograph of the abdomen if there is a large
    amount of free air, the entire abdomen may look
    like a football from distention with air the
    ligamentum teres is sometimes clearly visible in
    the midline.

  • Incomplete rotation of the intestine during fetal
  • The majority of patients present within the 1st
    yr of life with symptoms of acute or chronic
    obstruction. Infants often present within the 1st
    wk of life with bilious emesis and acute bowel
  • An acute presentation of small bowel obstruction
    in a patient without previous bowel surgery is
    usually a result of volvulus associated with

  • The abdominal plain film is usually nonspecific
    but may demonstrate evidence of duodenal
    obstruction with a double-bubble sign.
  • Barium enema usually demonstrates malposition of
    the cecum but may be normal in 10 of patients.
  • Upper gastrointestinal series demonstrates
    malposition of the ligament of Treitz.

  • Ultrasonography demonstrates inversion of the
    superior mesenteric artery and vein. A superior
    mesenteric vein located to the left of the
    superior mesenteric artery is suggestive of
  • Surgical intervention is recommended for any
    patient with a significant rotational
    abnormality, regardless of age.

  • A portion of the alimentary tract is telescoped
    into an adjacent segment.
  • The most common cause of intestinal obstruction
    between 3 mo and 6 yr of age.
  • Sixty per cent of patients are younger than 1 yr,
    and 80 of the cases occur before 24 mo it is
    rare in neonates. The malefemale ratio is 41.
  • Most intussusceptions do not strangulate the
    bowel within the first 24hr but may later
    eventuate in intestinal gangrene and shock.

  • Sudden onset, severe paroxysmal colicky pain
  • Vomiting occurs in most cases and is usually more
    frequent early.
  • 60 of infants pass a stool containing red blood
    and mucus, the currant jelly stool.
  • Tender sausage-shaped mass, which may increase in
    size and firmness during a paroxysm of pain and
    is most often in the right upper abdomen, with
    its long axis cephalocaudal.
  • Plain abdominal radiographs may show a density in
    the area of the intussusception.

  • Neonate with abdomen mass
  • Neuroblastoma Congenital Hydronephrosis
  • Multiple cystic kidney
  • Infantile polycystic kindey disease
  • Neurogenic bladder Renal vein thrombosis
  • Collecting system duplication
  • Intestinal duplication Sacrococcygeal teratoma
  • Adrenal hemarrhage Mesoblastic nephroma
  • Pancreatic cyst Hepatoblastoma
  • Meconium ileus Hematoma(hepatic,splenic)
  • Magacolon(obstruction)
  • Anterior myelomenihgocele
  • Appendiceal abscess Intestinal tumor
  • Mesenteric / Omental cyst Choledochal cyst

  • Neuroblastoma
  • Congenital Hydronephrosis
  • Multiple cystic kidney
  • Infantile polycystic kindey disease
  • Neurogenic bladder
  • Renal vein thrombosis
  • Collecting system duplication
  • Intestinal duplication
  • Sacrococcygeal teratoma
  • Adrenal hemarrhage
  • Mesoblastic nephroma
  • Pancreatic cyst
  • Hepatoblastoma
  • Meconium ileus
  • Hematoma(hepatic,splenic)
  • Magacolon(obstruction)
  • Anterior myelomenihgocele
  • Appendiceal abscess Intestinal tumor
  • Mesenteric / Omental cyst

Renal Vein Thrombosis
  • In newborns and infants, RVT is commonly
    associated with asphyxia, dehydration, shock,
    sepsis, and infants born to mothers with diabetes
  • Sudden onset of gross hematuria and
    unilateral or bilateral flank masses, microscopic
    hematuria, flank pain, hypertension, or oliguria.

Renal Vein Thrombosis
  • RVT is usually unilateral. Bilateral RVT results
    in acute renal failure. Most patients also have a
    microangiopathic hemolytic anemia and
  • Ultrasonography shows marked enlargement, whereas
    radionuclide studies reveal little or no renal
    function in the affected kidney(s).
  • Doppler flow studies of the inferior vena cava
    and renal vein confirm the diagnosis.

  • The advent of technetium (Tc) 99m pertechnetate
    radionuclide scanning has greatly facilitated the
    diagnosis of Meckel's diverticula and may also be
    useful for intestinal duplications. A positive
    scan requires the presence of ectopic gastric
    mucosa, which may be identified in both Meckel's
    diverticula and intestinal duplications.

  • The significance of ectopic gastric mucosa is
    that it contains acid-secreting parietal cells,
    which may cause ulceration and bleeding. Only
    rarely are intestinal duplications diagnosed
    preoperatively. After initial fluid
    resuscitation, bleeding from Meckel's diverticula
    and intestinal duplications require surgical
    intervention. Resection is the treatment of

  • A barium enema shows a filling defect or cupping
    in the head of barium where its advance is
    obstructed by the intussusceptum (coiled-spring
    sign) .
  • Ultrasonography is a sensitive diagnostic tool in
    the diagnosis of intussusception.
  • The diagnostic findings of intussusception
    include a tubular mass in longitudinal views and
    a doughnut or target appearance in transverse
    images .

Posttraumatic retroperitoneal rupture of the
right colon simulating a retroperitoneal
hematoma. Journal of Trauma-Injury Infection
Critical Care. 42(4)741-2, 1997 Apr.
  • This case illustrates the diagnostic problems
    encountered in a patient with posttraumatic
    retroperitoneal abscess caused by perforation of
    the posterior wall of the cecum, simulating a
    retroperitoneal hematoma.
  • Blunt colonic injuries are rare and difficult to
    diagnose. Septic signs are unexpected in case of
    posttraumatic retroperitoneal hematoma and should
    suggest the diagnosis of retroperitoneal colonic

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Incarcerated inguinal hernia
  • An inguinal hernia appears as a bulge in the
    inguinal region that extends toward and possibly
    into the scrotum.
  • The hallmark signs of an inguinal hernia on
    physical examination are a smooth, firm mass that
    emerges through the external inguinal ring
    lateral to the pubic tubercle and enlarges with
    increased intra-abdominal pressure.
  • A quiet infant can be made to strain the
    abdominal muscles by stretching out supine on the
    bed with legs extended and arms held straight
    above the head. Most infants struggle to get
    free, thus increasing the intra-abdominal
    pressure and pushing out the hernia.

Incarcerated inguinal hernia
  • The infant or child with an incarcerated inguinal
    hernia is likely to have associated findings
    suggestive of intestinal obstruction such as
    abdominal distention, vomiting, and multiple
    air-fluid levels evident on plain radiographs.

Wilms tumor
  • The incidence is approximately 8 cases/million
    children younger than 15 yr of age.
  • It usually occurs in children between 25 yr of
    age, although it has also been encountered in
    neonates, adolescents, and adults.

Neonatal intestinal perforation caused by
congenital defect of the small intestinal
musculature report of one case. Acta Paediatrica
Taiwanica. 40(4)271-3, 1999 Jul-Aug.
  • Congenital defect of the small intestinal
    musculature is a rare cause of neonatal
    spontaneous intestinal obstruction or
  • Histology examination demonstrates multifocal
    deficiency of the inner circular muscle layer
    three cm around the perforation site. The
    clinical and histological characteristics are
    reviewed and discussed. We propose that the
    muscle defect of small intestine, especially
    ileum, is secondary to ischemic injury rather
    than an embryological malformation.