intestinal obstruction in children

Intestinal Intestinal Obstruction in Obstruction in

ChildrenChildren

ObjectivesObjectives• Presentation of obstruction• To know different causes • A brief about each cause

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

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)

Enhanced CT Enhanced CT Intramural duodenal hematoma almost completely Intramural duodenal hematoma almost completely obscuring the lumenobscuring the lumen

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

• 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)

ImagingImaging• Radiography(mass effect with displacement of adjacent bowel

loops)• Ultrasound(simple hypoechoic cyst, Gut wall signature)

Hypoechoic cyst with double ‘gut wall Hypoechoic cyst with double ‘gut wall signature’(inner echogenic mucosa & outer signature’(inner echogenic mucosa & outer hypoechoic smooth muscle layerhypoechoic smooth muscle layer

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

Mesenteric/Omental Mesenteric/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

Mesenteric Cyst

Meckel ‘s DiverticulumMeckel ‘s DiverticulumPersistence 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

Supine & prone radiographs of the upper GI Supine & prone radiographs of the upper GI barium seriesbarium series

AppendicitisAppendicitis• Peak incidence 12-15 years

Presention• -ill defined abd. Pain in RIF• -fever and vomiting

IMAGINGIMAGINGRadiography•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

Right iliac fossa mixed echogenicity Right iliac fossa mixed echogenicity inflammatory mass and echogenic focus inflammatory mass and echogenic focus with acoustic shadowingwith acoustic shadowing

Hypoechoic tubular structure 7mm in Hypoechoic tubular structure 7mm in diameter adjacent to iliac vesselsdiameter adjacent to iliac vessels

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

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

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

HENOCH SCHONLEIN HENOCH SCHONLEIN PURPERAPURPERASmall bowel vasculitis•Jejunum most frequently involved•Unknown etiology/postinfectious/post drug therapy

Presentations with•Purpuric rash over the buttocks & legs•Abdominal pain•glomerulonephritis

Henoch schonlein pupura Henoch schonlein pupura Ultrasound & barium follow throughUltrasound & barium follow through

JejunalJejunal bowel wall thickening bowel wall thickening

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

OTHER OTHER INFECTIONS•(giardia,compylobacter,yersinia,salmonella etc)

GRAFT VERSUS HOST REACTION •(mostly effecting small bowel)

CROHN’S DISEASE•(mostly effecting terminal ilium & cecum)

Polyps and polyposis Polyps and polyposis syndromessyndromesIsolated 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

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

Barium enema showing a pedunculated polyp Barium enema showing a pedunculated polyp in the descending colonin the descending colon

Juvenile polyposisJuvenile polyposis• Positive family hx (most cases)• Five or more polyps• Associated with higher long term risk of colonic

carcinoma

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

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

• Familial polyposis coli• Gardner syndrome• Both are dominanly inherited• Multiple adenomatous polyps are found

(numerous in colon)• High malignant potential• Prophylactic proctocolectomy usually

recommended

TURCOT’S SYNDROMETURCOT’S SYNDROME• Autosomal recessive condition• Colonic adenomas associated with CNS glioma

Small bowel Small bowel malignanciesmalignancies

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

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

CAUSES OF COLITIS IN CAUSES 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

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

GI SYMPTOMS•Diarrhoea•Abdominal pain

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)

CT SCAN•transmural bowel wall thickening•creeping fat within the mesentery•strictures•fistulas•localised collectionMRI•assessment of disease extent

Innumerable aphthoid ulcer in crohn’s Innumerable aphthoid ulcer in crohn’s

diseasedisease

Enema in crohn’s disease showing extensive Enema in crohn’s disease showing extensive cobblestoning due to linear ulceration cobblestoning due to linear ulceration &mucosal edema. Rectum is spared&mucosal edema. Rectum is spared

ULCERATIVE COLITISULCERATIVE COLITIS• Relapsing and remitting proctits• Rectum is always effected• Effects young adults(15-25yrs) with second

smaller peak at approx 60yrs

CLINICAL FINDING•bloody diarrhoea•abdominal pain•failure to thrive

IMAGINGIMAGINGDouble contrast barium enemaProctosigmoidoscopy•loss of normal mucosal vascular pattern (earliest detectable change)•ulceration is continuous & superficial•(deep ulceration does occur)•haustral blunting

• Luminal narrowing• Colonic shortening(due to muscular abnormality

rather than fibrosis)

CT SCAN not for primary diagnosis once toxic megacolon is

established

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

Complication•Risk of colonic ca is high approx 20% per decade•toxic megacolon

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

Bowel wall thickening & fat strandingBowel wall thickening & fat stranding

HAEMOLYTIC URAEMIC HAEMOLYTIC 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

IMAGINGIMAGINGUltrasound•Association of colonic thickening &echogenic kidneys is highly suggestive of diagnosis•Doppler flow within the bowel wall is reduced (atleast in prodromal phase)

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

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

IMAGINGIMAGINGAbdominal 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

Paucity of bowel gas in the right iliac fossa Paucity of bowel gas in the right iliac fossa and soft tissue massand soft tissue mass

Transverse ultrasound showing multiple Transverse ultrasound showing multiple hypoechoic concentric rings, central hypoechoic concentric rings, central echogenic mesentery and few small echogenic mesentery and few small echogenic lymph nodesechogenic lymph nodes

• 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

TREATMENTTREATMENTRADILOLOGICAL REDUCTION•Absolute contraindications are peritonitis and perforation

PNEUMATIC REDUCTION(air enema)•Replaced the barium in most paediatric centres(70-90% success rate)

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