Volvulus

Volvulus is a type of bowel obstruction, in which the loop of the bowel whose nose has
completely twisted around its site of mesenteric attachment.
This may occur at any time from utero to adulthood but most cases are seen within the first
month of life.
There is a congenital abnormality of the fixation of the mesentery (Ladds bands) and in normal,
bowel migration leading to intestinal malrotation.
Signs and Symptoms
Bowel obstruction manifested as abdominal distension and vomiting
Ischemia
Bilious vomiting
Volume depletion/signs of shock
Grunting respirations
Jaundice (1/3)
Bloody stools (late)
Constipation
Diagnosis and Labs
X-ray plain films dilated stomach and proximal duodenum with no gas distal to the obstruction
Air contrast may reveal the double bubble sign
More useful than BE as 10% will have high cecum
Reveals narrowing at the site of obstruction
Spiraling of the small bowel above the superior mesenteric artery = corkscrew appearance
Complications
Secondary peritonitis
Short bowel syndrome (after removal of a large part of the small bowel)
Treatment
ABCs
Fluid resuscitation
NPO/NG tube
Sigmoidoscopy
Surgery and resection
Antibiotic coverage
o Ampicillin
o Clindamycin
o Gentamycin

Pyloric Stenosis
Is narrowing (stenosis) of the opening from the stomach to the first part of the small intestine
known as the duodenum, due to enlargement of the muscle surrounding this opening, which
spasms when the stomach empties.
Unknown etiology 4-5/1000 births
More common in males (5:1) with familial predilection
Frequently occurs in first born males
Signs and Symptoms
Vomiting (+/- projectile)
Hungry, healthy appearing infant who vomits soon after eating
Bilious vomiting is very rare
Peristaltic waves after feeding
Eventual dehydration and constipation
May palpate an olive mass in right upper to mid quadrants, net to right border of rectus muscle
(85%) of patients
Diagnosis and Labs
Volume depletion (BUN)
Hypokalemic, hypochloremic metabolic alkalosis
From emetic losses of H+ and Cl-
Ultrasound
o Increased diameter >17mm
o Increased muscle thickness >4mm
o Indeterminate ULTZ consider UGI, string sign from narrow pylorus
Complications
Failure for the baby to gain weight
Treatments
ABCs
NPO/NG suction
Fluid resuscitations as needed
Surgery
May delay in repair in 24-26 hrs to rehydrate

Necrotizing Enterocolitis
Medical condition primarily seen in premature infants where portions of the bowel undergo
necrosis. Occurs postnatally and is the second most common cause of morbidity in premature
infants.
25% mortality rate
Risk factors
o High tonicity feedings
o UVC
o Hypoxia
o Infection
o Polycythemia
Signs and Symptoms
Afebrile
Tachypneic, tachycardic, cap refill 3 seconds
Grunting
Abdomen distended, tender
Grossly bloody stool
Distention
Reflux often bile stained
Bloody diarrhea
Tender abdomen
Thromobocytompenia
Metabolic acidosis
DIC
Pathophysiology intestinal wall necrosis resulting in air in bowel wall, air in biliary tree, portal
vein, and pnemoperitoneum
Diagnosis and Labs
Abnormal gas pattern on X-ray with bubbly appearance, large veins of liver
Complications
Intestinal perforation
Intestinal stricture
Peritonitis
Sepsis
Treatments
Blood culture VBG, DIC, CMP, CBC
Rehydration
Antibiotics
Surgery

Intussusception
Caused by part of the intestine being pulled inward into itself. This can block the passage of food
through the intestine. If the blood supply is cut off, the segment of the intestine pulled inside can
die.
Pressure created by the walls of the intestine pressing together causes: decreased blood flow,
irritation, and swelling.
The intestine can die, and the patient can have significant bleeding.
Signs and Symptoms
Bloody, mucus like bowel movement, sometimes called a currant jelly stool
Fever
Shock
Stool mixed with blood and mucus
Vomiting
Diagnosis and Labs
Physical examination revealing a mass in the abdomen
Abdominal x-ray
Air or constrast enema
Complications
Perforation
Risk of infection
Fatal if not treated
Treatments
IV fluids and feeding
Surgery

Mickels Diverticulum
Is a pouch on the wall of the lower part of the intestine that is present at birth. The diverticulum
may contain tissue that is the same as tissue of the stomach or pancreas.
A Meckel's diverticulum is tissue left over from when the baby's digestive tract was forming
before birth. A small number of people have a Meckel's diverticulum, but only a few develop
symptoms.
Rule of 2s 2% of population, 2 feet ileocecal valve, 2 years of age, 2 cm long, 4% develop
complications
Signs and Symptoms
Pain in the abdomen that can be mild or severe
Blood in the stool
Diagnosis and Labs
Hematocrit
Hemaglobin
Stool smear for invisible blood
Technetium scan
Complications
Excess bleeding from diverticulum
Folding of the intestines (intussusception)
Peritonitis
Perforation of bowel at the diverticulum

Treatments
Surgery
Correct anemia
Blood transfusion if a lot of bleeding

Hitschsprungs Disease
Hirschsprung's disease is a blockage of the large intestine due to improper muscle movement in
the bowel. It is a congenital condition, which means it is present from birth.
During normal fetal development, cells from the neural crest migrate into the large intestine
(colon) to form the networks of nerves called Auerbach's plexus and Meissner's plexus. In
Hirschsprung's disease, the migration is not complete and part of the colon lacks these nerve
bodies that regulate the activity of the colon. The affected segment of the colon cannot relax and
pass stool through the colon, creating an obstruction.
Signs and Symptoms
Difficulty with bowel movements
Failure to pass meconium shortly after birth
Failure to pass a first stool within 24 - 48 hours after birth
Infrequent but explosive stools
Jaundice
Poor feeding
Poor weight gain
Vomiting
Watery diarrhea (in the newborn)
Diagnosis and Labs
Abdominal x-ray
Anal manometry (a balloon is inflated in the rectum to measure pressure in the area)
Barium enema
Rectal biopsy
Complications
Inflammation and infection of the intestines (enterocolitis) may occur before surgery, and
sometimes during the first 1-2 years afterwards. Symptoms are severe, including swelling of the
abdomen, foul-smelling watery diarrhea, lethargy, and poor feeding.
Perforation or rupture of the intestine
Short bowel syndrome, a condition that can lead to malnourishment and dehydration
Treatments
Surgery serial rectal irrigation

Acute Appendicitis
Acute appendicitis is sudden inflammation of the appendix, usually caused by obstruction of the
lumen resulting in invasion of the appendix wall by the gut flora. If the appendix ruptures,
infected and faecal matter enter the peritoneum, producing life-threatening peritonitis
Signs and Symptoms
Pain:
o Early periumbilical pain moves after hours or sometimes days to the right iliac fossa as
the peritoneum becomes involved. Pain which wakes the patient or keeps a child awake
is significant.
o Movement and coughing aggravate pain. The patient may lie still with shallow breathing,
and coughing hurts.
Nausea, vomiting, anorexia. The patient is usually constipated but may have diarrhoea. Rapidly
progressive cases may have marked vomiting without fever and diarrhoea, which may be marked
in post-ileal appendix (which is rare).
Temperature and pulse are normal at first. Low-grade pyrexia then develops. A rising pulse rate
may be an indication of peritonitis.
Localised tenderness, guarding and rebound tenderness in the right iliac fossa.
o A retrocaecal or pelvic appendix may be missed.
o Rectal examination: localised tenderness and this may be the only sign of an inflamed
retrocaecal or pelvic appendix.
o Other methods to demonstrate an inflamed appendix include: the psoas test (extend
the hip and abduct the thigh with the patient on the left side) and the obturator test
(flex the right thigh and internally rotate the hip).
o Right iliac fossa peritonism:
o Can be demonstrated by percussion tenderness or rebound tenderness.
o Rovsing's sign: pain in the right iliac fossa induced by palpation of the left iliac fossa.
Stage of illusion: just after perforation, a child may sit up in bed apparently better. A rising pulse
rate may be the only indication of perforation, before the obvious signs of peritonitis develop.
Atypical presentations include:
An infant with watery diarrhoea and vomiting.
A child with vague abdominal pain and anorexia.
Diagnosis and Labs
Urinalysis
Blood count
Raised inflammatory markers C-reactive protein
Ultrasound
CT scan
Diagnostic laparoscopy
Complications
Perforation
Wound infection
Appendix abscess
Pelvic abscess
Subphrenic abscess
Paralytic ileus
Treatments
Surgery appendectomy