Two Causes of Bilious Emesis in Children

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Two Causes of Bilious Emesis in Children

• Patrick Basile
• 4/17/07

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General Information

• Bilious distal to ampulla of Vater
• Presence of abdominal distension can correlate
  with the level of obstruction
• Lower the obstruction the larger the distension
• Meconium
• Passed in first 24 hours in 94 first 48 hrs98
• In newborn, cannot differentiate small from large
  bowel by markings on plain abd film

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Case 1

• At 6 hours of age a newborn is noticed vomiting
  small amounts of mucus and bile stained fluid.
  Physical exam is normal. During delivery, the
  mother is noted to have large amounts of amniotic
  fluid upon rupture of her membranes.
• A plain abdominal film shows the following

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Case 1

• What is the most likely diagnosis?

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Duodenal Obstruction Ddx

• True atresia-Due to failure of recanalization of
  duodenum early in gestation Twice as common as
  atresia of jejunum of ileum (Papilla of Vater)
• 50 with multiple congenital anomalies
• Downs Syndrome 20-30
• CHD 20
• Ladds Bands-peritoneal bands
• Mucosal webs as often as pure atresia
• Annular Pancreas
• Ventral bud of pancreas malrotates and tissue
  persists

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Ladds Bands
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Duodenal obstruction- Clinical
Presentation

• Bilious vomiting without abdominal distension
• Hx of polyhydramnios in about 50
• Small for gestational age
• 50 with multiple congenital anomalies if true
  atresia
• Downs Syndrome 20-30
• CHD 20
• Others malrotation and esophageal atresia
• Meconium passed in 50 of cases

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Duodenal obstruction- Dx/imaging

• Plain abd radiograph- double bubble sign
• Gas in small/large intestine indicates incomplete
  obstruction
• Upper GI series to check for malrotation
• Surgical emergency if present

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Duodenal obstruction- Treatment

• Initial Tx
• Nasogastric/orogastric decompression with IV
  fluid replacement
• Treat co-existing life threatening anomalies
• Surgery
• Ladds Bands-division of band and correction of
  malrotation
• Atresia/annular pancreas-duodenoduodenostomy
• Web-excised with caution to not harm ampulla
• Exploration for concurrent distal obstruction and
  atresia (1-3)

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Atresia Surgery

• Side to side duodenoduodenostomy

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Further Distal Atresia

• Due to mesenteric vascular accident in-utero due
  to hernia, volvulus, intussusception
• Leads to aseptic necrosis and resorption of
  necrotic bowel.
• Prevalence duodenal, proximal jejunum and distal
  ileum respectively
• Colonic is rare
• Different types are present

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Case 2

• A 9 month old girl with a h/o intestinal polyps
  presents with intermittent colicky abdominal
  pain, appearing normal in between bouts of pain.
  The frequency has recently increased and she has
  begun to vomit bilious colored liquid. She also
  passes stool that looks dark and gelatinous in
  nature. Early PE was normal, but now a sausage
  shaped mass sits in the right upper quadrant.
• What is the most likely diagnosis?

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Intussusception

• Telescoping of one portion of bowel
  (intussusceptum) into an adjacent portion
  (intussuscipiens)
• Proximal portion into distal portion likely due
  to peristalsis
• Most common is ileocolic
• Terminal ileum into right colon 90

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Intussusception
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Epidemiology

• Incidence 1-41000
• Peak Incidence 5-12 months
• Range 2 mos- 5 years
• MF 2-41
• Most common cause of intestinal obstruction in
  children

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Causes

• Idiopathic
• Viral (enterovirus in summer and rotavirus in
  winter)
• link with rotavirus vaccine
• Lead points older children 2-10
• Meckels Diverticulum
• Polyps
• Lymphoma
• Henoch-Schonlein Purpura
• Cystic Fibrosis
• Hypertrophied Peyers patches

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Presentation

• Classic Triad (only 20 of time)
• Intermittent colicky abdominal pain
• Bilious Vomiting
• Currant Jelly Stool (absence doesnt exclude)
• Neurological signs (can delay dx)
• Lethargy, shock-like state, seizure-like
  activity, apnea
• RUQ mass
• Sausage shaped that
• Ill defined
• Dances Sign-absence of bowel in RLQ

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Diagnosis/Imaging

• AXR
• Lack of bowel gas
• Loss of visualization of liver
• Target sign-two concentric circles of fat
  density
• U/S
• Target or donut sign-single hypoechoic ring
  with hyperechoic center
• Pseudokidney sign- superimposed hypoechoic and
  hyperechoic layers
• Barium enema

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US target/donut sign
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Barium Enema
Cervix-like mass
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Non-surgical treatment

• Correct for dehydration
• NG tube for decompression
• Contrast enema dx and tx in 60-80
• Only after resuscitation
• Contraindications
• Peritonitis, perforation, profound shock
• Will not reduce gangrenous bowel

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Surgical Treatment

• Indications
• Unsuccessful enema reductions
• Signs of bowel perforation or peritonitis
• Laparotomy or Laparoscopically
• If non-gangrenous gentle retrograde compression
  of intussuscipiens (distal), not traction of
  intussusceptum
• If gangrenous or non-reducible resection with
  re-enastamosis.

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Recurrence

• Radiographic reduction
• 3-10 recurrence
• Surgical reduction
• 1-5 recurrence
• Death due to delay of treatment for gangrenous
  bowel