1. Feedback: Q6
A 4 week old child is brought to your emergency department with a distended abdomen.

3. Marking
What six (6) questions would you ask to aide you with your diagnosis? (6 marks)
passage meconium first 48 hours; vomiting history ? bilious; bowel opening history; tolerating feeds/ passing urine; distressed/ unwell; premature; significant PMH eg bowel surgery
Needed to ask about passage meconium to get 6/6 question
Not about Dx but about approach
One point for Dx

4. Marking
State two (2) positive and two (2) relevant negative findings on the AXR. (4 marks)
XR +ve:
dilated bowel loops (large and small)
paucity of air in rectum
XR-ve:
No free air (football sign, rigler’s/ double wall sign)
No pneumatosis intestinalis
No double bubble sign

5. Marking What is the most likely diagnosis? (1 mark)
Hirschsprungs
Name two (2) differential diagnosis.(2 marks)
causes bowel obstruction
malrotation, imperforate anus, constipation, meconium plug/ ileus, incarcerated hernia, NEC

6. Marking State three management steps. (3 marks)
Surgery referral, NBM, NGT on free drainage, iv access and fluids, analgesia if distressed

7. Hirschsprung Disease
Absence of ganglion cells in bowel wall from anus proximally
Delayed passage meconium (99% full term infants pass meconium in 48 hours)
Chronic constipation
Risk of enterocolitis if not Dx early
AXR- obstruction and paucity gass rectum
Rectal suction biopsy for Dx then definitive surgery

9. Malrotation Incomplete rotation of intestine as foetus
Mesentery (including SMA) tethered by narrow stalk which can twist producing midgut volvulus
Can also cause duodenal obstruction (Ladd bands)
Present 1st year of life with about 40% presenting first week and 50% by first month
Bilious emesis, bowel obstruction and significant abdominal pain (especially with volvulus)

11. Necrotizing Enterocolitis
Newborn emergency- disease of the NICU
Multifactorial
Mucosal/ transmural necrosis of intestine
Incidence and mortality increase with decreasing BW and GA
90% in premature infant
Can be secondary disease- including Hirschsprung!
Usually 2nd-3rd week of life but can be as late as 3 months in VLBW infants
AXR- pneumatosis intestinalis

12. Hirschsprungs with pneumatosis intestinalis

13. Intussusception 2 months to 2 years (can occur any age)
Peak incidence 5 to 9 months (weaning)
Intermittent severe colicky abdo pain
Typically 2-3/ hour and at least 1/hour
Usually assoc with vomiting, pallor, lethargy
Blood in stool is late sign
Mass hard to feel

14. Intussusception: Imaging
diagnostic investigation of choice
Air enema:
diagnostic and therapeutic
AXR:
only if concerned perforated or obstructed
Target sign- 2 concentric circular radiolucent lines usually in RUQ
Crescent sign- a crescent shaped lucency usually LUQ with a soft tissue mass

16. Perforation
If suspected consider left lateral decubitus film

17. Rigglers sign/ double wall sign

18. Football sign

20. Small Bowel vs Large Bowel Obstruction
Small bowel tends to be central

21. Normal large bowel distribution with haustral folds