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Digestive System in the

Pediatric age group

4th session

Topics:
 Meconium Ileus and Peritonitis

 Acute Appendicitis

 Necrotizing enterocolitis

 Anus and rectum

 Imperforate anus

 Anal fissures

 Pruritus ani

 Rectal prolapse

 Hemorrhoids

vomiting  Diagnosis:  Palpation of doughy or cordlike mass of intestines  Xray: loops vary in width and not evenly filled with gas. associated with Cystic fibrosis: absence of fetal pancreatic enzymes limits normal digestive activities of the intestines  meconium becomes viscid and mucilaginous clings to intestinal wall  inspissated and impacted meconium fills intestinal canal (lower part of the ileum)  abdominal distention. granular appearance  Genetic testing – to r/o CF . with contrast: bubbly.Meconium ileus  Impaction of meconium.

 Treatment:  Gastrografin enema (high osmolality 1.900mOsm/L) – draws fluid into the intestinal lumen (need to dilute with equal part of water to prevent DHN and shock)  Laparotomy  Complication: meconium peritonitis (treat by elimination of intestinal obstruction. drainage of peritoneal cavity) .

epidermidis. Clostridium perfringens. multifactorial  Distal ileum and proximal colon  Risk factor: prematurity  Pathophysiology: intestinal ischemia. coli. Klebsiella. rotavirus) . S. norovirus.Neonatal Necrotizing Enterocolitis  Most common life threatening emergency in the NB  Mucosal or transmural necrosis of the intestines  Cause: unclear. bacterial translocation  Agents: E. enteral nutrition (metabolic substrate). astrovirus.

 Intestinal ischemia leads to loss of bowel integrity  inflammatory response  development of necrotic segment  gas accumulates into the submucosa of the bowel  pneumatosis intestinalis necrosis to perforation. hepatic UTZ – portal venous gas . temperature instability. abdominal distention. sepsis and death  Onset: 2nd or 3rd week of life or late (3mos) in VLBW infants  Clinical manifestations: nonspecific: lethargy. peritonitis. gastric retention  Diagnosis: plain abdominal radiographs (ant-posterior cross table lateral or lateral decubitus).

short bowel syndrome . start antibiotics  Surgery: Explorative laparotomy  Peritoneal drainage (cautiously considered but has complications – death or neurodev. administration of IVF. blood cultures. NG decompression. Outcome)  Pot-op complications: wound dehiscence. Treatment: no definitive treatment  Cessation of feeding (NPO). stomal problems. intestinal strictures.

nausea and vomiting. low grade fever to severe manifestations (24-48hrs. perforation (beyond 36-48 hrs.Acute Appendicitis  Pathophysiology: bacterial invasion of appendiceal wall  Luminal obstruction  increase intraluminal pressure from bacterial proliferation and mucus secretion  leads to lymphatic and venous congestion and edema  impaired arterial perfusion  ischemia . Rovsing’s / Psoas/ Obturator/Guarding) or variable. later). inflammation. necrosis  12-18 yrs. abdominal pain. Old  Signs and symptoms: classic or atypical (absence of fever.)  Localized abdominal tenderness – single most reliable finding (McBurney’s) .

perforated (Ampicillin. metronidazole or Ticarcillin-clavulanate plus Gentamicin)  HIGH LEVEL OF SUSPICION + COLLECTIVE REVIEW OF LABS + SURGICAL REFERRAL . laparoscopic appendectomy.Diagnostic findings  CBC. UTZ. CT scan (gold standard imaging study)  Complications: wound infection and intraabdominal abscess  Treatment: Appendectomy. C-reactive protein  Radiologic studies: Plain films. antibiotics and interventional radiology (drainage)  Antibiotics: Cefoxitin (nonperforated). interval appendectomy. UA. Gentamicin and Clindamycin or Metronidazole) or (Ceftriaxone.

Surgical conditions of the Anus and Rectum .

levator ani. internal and external sphincter and superficial external sphincter)  1/3.000 live births  Concerns on bowel control. urinary and sexual function .Anorectal Malformations  Defined by the relationship of the rectum to the sphincter complex (mass of muscle fibers: puborectalis.

covered by a cloacal membrane  7th week AOG – urorectum septum descends and form lateral ridges to divide the cloaca into ANTERIOR and POSTERIOR  8TH week AOG – Posterior portion OPENS (anal membrane)  Associated anomalies: VATERR and VACTERL . urinary and intestinal tubes empty).Embryology of Anorectal malformations  2nd week AOG – hindgut forms as part of the primitive gut  Day 13 – hindgut  ventral diverticulum (allantoin or primitive bladder)  junction of the hindgut and allantoin become the CLOACA (where genital.

Imperforate Anus  Inspection of the perineum of the NB  Normal position of the anus: approx. LOW lesion – rectum has descended into the sphincter complex B.5 ratio)between the coccyx and scrotum or introitus A. HIGH lesion – rectum has not . halfway (0.

rectovesicular) (girls: rectovaginal fistula)  PERSISTENT CLOACA – treatment is repositioning the urethra. rectal temperature: obstruction 2 cm above skin level: protective colostomy . rewuire a COLOSTOMY before repair  RECTAL ATRESIA – features a normal anal canal and anus. rectoprostaticurethral. thisckened raphe or “bucket handle”  HIGH lesion – associated with fistula (boys: retrobulbaurethral. vagina and rectum. LOW lesion – associated with perineal fistula or if no fistula.

Approach to patients with Anorectal Malformations Clues:  Failure to pass meconium  Perineal inspection .Do prone cross table lateral films  Plain xray of the entire sacrum  Abdominal-pelvic UTZ and VCUG  Other anomalies: pass NGT (esophagus). 2-D-echo .

Operative Repair  LOW lesion – if < 1cm from the skin – minor perineal procedure or do simple perineal anoplasty . ACE or antegrade continence enema .dilatation with HEGAR DILATORS .if with fistula: posterior approach of PENA ffed by post-op dilation  HIGH lesions – colostomy 1st then do PSARP (posterior sagittal anorectoplasty) at 1 year old. close colostomy 6 wks later or Laparoscopic technique  OUTCOME: ability to achieve rectal continence (low > high).

Anal Fissures  Minor lacerations of the anal mucocutaneous junction  Unknown but usually due to forceful passage of a hard stool in < 1yr old infants  Inspection of perineal area  skin tags (epithelialized granulomatous tissue formed because of chronic inflammation)  Goal: ensure soft stool (avoid overstretching of anus) dietary and behavioral modification stool softeners (water intake and oral polyethylene glycolate) surgical intervention – not indicated or supported by scientific evidence (internal and sphincterotomy or excision of the fissure) .

pneumoniae. antibiotics are not useful except for systemic illness . mild rectal pain. S. K. coli.Perineal Abscess and Fistula  Unknown etiology  Mixed aerobic (E.extreme patient discomfort – abscess is drained under LA. Veillonella) or associated with IBD. Fistulotomy (unroofing or opening). aureus) and anaerobic (Bacteroides. immunocompromised states  Ssx: low grade fever. Fistulectomy or placement of SETON . Clostridium. areas of perianal cellulitis  Treatment: self limiting condition – conservative mgt. leukemia.

THROMBECTOMY – excruciating pain.Hemorrhoids  Does not occur in children and adolescent  Related to a diet deficient of fiber and poor hydration  If present in younger children: portal HPN  2 types: EXTERNAL – below the dentate line. avoid straining/prolonged sitting) discomfort (hot SITZ baths. prolapse and occ. bleeding. Incarceration  Treatment: conservative mgt (diet. open excision and use of transanal stapling device (painful internal hemorrhoids) . rubber band ligation. extreme pain and itching due to acute thrombosis INTERNAL –above the dentate line. topical analgesics).

chronic constipation. onset: 1-5 yrs (standing) resolves in 3-5yrs. Ehlers-Danlos syndrome  Occurs during defecation . CF. diarrhea. UC. meningocoele.  Other predisposing factors: intestinal parasite. pertussis. malnutrition.Rectal Mucosal Prolapse  Exteriorization of rectal mucosa through the anus  PROCIDENTIA – all layers of the rectal wall  Idiopathic.

 Treatment: reduction of protrusion – push it back into the rectum. aided with warm compress  Conservative management: careful manual reduction avoid excessive pushing during BM. others: sclerosing injections. linear cauterization . use of laxatives or stool softeners. surgical treatment (insertion of a Theirsch wire or Altemeir perineal rectosigmoidoscopy). treatment of intestinal parasites.

Pruritus Ani  Enterobiasis .nocturnal perianal pruritus (Mebendazole100mg/day/Albendazole 400mg/day/Pyrantel pamoate 11 mkd)  Cholestasis – xanthomas (accumulation of cholesterol bile acids (Urodeoxycholic acid 15mkd)  Liver disease  Opioid use .

End of 4th session .