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Toronto Notes 2019 Gastroenterology HIRSCHSPRUNG’S DISEASE (Congenital Aganglionic Megacolon)
• seeGeneralSurgery,GS64
OTHER ORGANIC DISORDERS CAUSING CONSTIPATION
• endocrine: hypothyroidism, DM, hypercalcemia
• neurologic:spinalcordabnormalities/trauma,NF
• anatomic:bowelobstruction,anus(imperforate,atresia,stenosis,anteriorlydisplaced) • drugs: lead, chemotherapy, opioids
• others
Abdominal Pain
ACUTE ABDOMINAL PAIN
History
• descriptionofpain(location,radiation,duration,constantvs.colicky,relationtomeals) • associatedsymptoms:N/V,diarrhea,fever
Pediatrics P39
Physical Exam
• abdominalexam,rectalexam,rash
Investigations
• CBC,differential,urinalysistoruleoutUTI
Table 18. Differential Diagnosis of Acute Abdominal Pain
Gastrointestinal
Gastroenteritis Appendicitis Mesenteric adenitis Constipation
Ileus
Abdominal trauma Intestinal obstruction (incarcerated hernia, intussusception, volvulus) Peritonitis
Peptic ulcer
Meckel’s diverticulum IBS
Food poisoning
Lactose intolerance
APPENDICITIS
Hepatobiliary Tract
Hepatitis Cholecystitis Cholelithiasis
Spleen – infarction, rupture
Pancreatitis
Genitourinary
UTI
Urinary calculi Dysmenorrhea Mittelschmerz
PID
Threatened abortion Ectopic pregnancy Nephrolithiasis Testicular torsion Ovarian torsion Endometriosis Hematocolpos
Hematologic
Sickle cell crisis Henoch-Schönlein purpura Hemolytic uremic syndrome
Metabolic
Diabetic ketoacidosis Hypoglycemia porphyria
Drug and Toxins
Erythromycin salicylates lead poisoning venoms
Pulmonary
Pneumonia Diaphragmatic pleurisy
Miscellaneous
Functional pain Infantile colic Pharyngitis Angioneurotic edema Mediterranean fever
• seeGeneralSurgery,G27
• mostcommoncauseofacuteabdomenafter5yrofage
• clinicalfeatures:lowgradefever,abdominalpain,anorexia,N/V(afteronsetofpain),peritonealsigns
(generalized peritonitis is a common presentation in infants/young children) • treatment: surgical
• complications:perforation(commoninyoungchildren),abscess
INTUSSUSCEPTION
• telescopingofsegmentofbowelintodistalsegmentcausingischemiaandnecrosis
Epidemiology
• 90%idiopathic,childrenwithCForGJtubeatsignificantlyincreasedrisk;M:F=3:1 • 50% between 3-12 mo, 75% before 2 yr of age
Pathophysiology
• usualsite:ileocecaljunction;jejunuminchildrenwithGJtubes
• leadpointoftelescopingsegmentmaybeswollenPeyer’spatches,Meckel’sdiverticulum,polyp,
malignancy, HSP, structural abnormalities
Clinical Presentation
• “classictriad”(<25%patients)-abdominalpain,palpablemass,redcurrantjellystools
• oftenprecededbyURTI
• suddenonsetofrecurrent,paroxysmal,severeperiumbilicalpainwithpain-freeintervals • latervomiting(maybebilious)andrectalbleeding(latefinding)
• shockanddehydration;lethargymaybeonlypresentingsymptom
Diagnosis
• U/S,airenema
Intussusception – Classic Triad
• Abdominal pain
• Palpable mass
• Red currant jelly stools